Otology and Audiology: Complications, Challenges, and Concerns in the Patient With Cleft Lip and/or Palate.

Cleft lip and/or palate, a treatable congenital condition, affects around 1 in 700 births, placing a large burden of care on those affected. A multidisciplinary approach to treating the patient involves not only cleft surgery but also a wide array of treatments and preventative therapies to prevent further disease. In this review, the otolaryngology subspecialties, otology and audiology, are discussed in relation to orofacial clefts. As patients with clefts carry a higher risk of permanent hearing loss and speech complications caused by the pathology of their cleft, management of additional diseases such as otitis media with effusion, conductive hearing loss, or infections requires timely evaluation, treatment, and follow-up. The current practice in otology and audiology is discussed with the challenges faced in delivering timely care-in any setting, low or higher income. Lack of consensus and controversies surrounding the use and timing of tympanostomy tubes are reviewed, as well as the palatoplasty types that show significant benefit for otitis media with effusion, audiometry, and speech outcomes. Lastly, a call for further research in clefts and otology and the urgency for its awareness and advocacy in low and middle-income countries is imperative.

The racial pandemic experienced by Black American men: Cognitive-behavioral and structural implications.

Issues of systemic racism, mass incarceration, and cultural trauma (CT) are linked to emotional sequelae sufficient for treatment. However, attempts to explain the psychosocial reactions of Black American (BA) men to racial injustice and treat CT must be considered in the context of the current and past structural environments in which they live. The purpose of the present study was to obtain in-depth, thick description of two related factors: BA males' perceptions of injustice during the racial pandemic and the consequent psychosocial implications for theory and treatment. An interview guide addressing racial injustice, CT, and coping was used to conduct individual and focus groups' interviews with 20 BA men. The data were analyzed using thematic analysis. The qualitative analysis found five themes that collectively fulfilled the study's aims: (1) A violation of the social contract for Black American men, (2) Black American male distrust for police, (3) tripartite Black American male, police fear and heterogeneous emotions, (4) spiritual, technological, appraisal, and relational Black American male coping for racial injustice, and (5) Black American male resilience despite permanence of the racial status quo. As it pertains to BA male racial injustice and the residual CT, the qualitative data suggested multidimensional interventions that are cognitive-behavioral and structural in nature may be worthy of further empirical investigation. From a CT intervention perspective, the five emerging themes can be directly translated into cognitive-behavioral principles regarding therapeutic rapport, cultural adaptation, emphasis on positivity, and collaborative empiricism when working with BA men. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Intra-capsular complete tonsillectomy, a modification of surgical technique to eliminate delayed post-operative bleeding.

Pediatric tonsillectomy is a frequently performed procedure using a variety of surgical techniques. Despite decades of modern surgical experience and advances in tools and techniques, a consensus on which technique is superior for minimizing complications has not been established. In a 2014 study, the authors examined differing surgical techniques and devices to determine if there was a significant difference in the bleed rates based on technique and device [1]. In that study 7024 children were evaluated, of which a total of 1.4% (n = 99) of children experienced a postoperative hemorrhage that required a second surgery. There was no significant difference found between the four different techniques that were evaluated. Although the combined rates of post-operative hemorrhage requiring a second surgery was lower compared to many other published reports, we hypothesized that continued improvement in surgical techniques could eliminate post-operative hemorrhage completely. As follow up to that study, we decided on a collective change in technique, and subsequent analysis of our post-operative results with respect to only one outcome, post-operative hemorrhage requiring a second surgery. With a new standardized technique in place, we retrospectively evaluated one year of surgical outcomes. These procedures were performed using the technique of a modified and complete, intra-capsular Coblator tonsillectomy. Of the 783 tonsillectomies done in 12 months, we found there were 0 patients that had experienced a postoperative hemorrhage requiring a second surgery. Based on our previous study with a rate of 1.4% post-operative hemorrhage we would have expected to have 11 episodes of post-operative hemorrhage requiring a second surgery.

Post-tonsillectomy hemorrhage rates in children compared by surgical technique.

Despite the sheer number of pediatric tonsillectomies performed in the United States annually, there is no clear consensus as to which surgical technique is superior. One way to compare surgical techniques is to study the morbidity associated with each. We report postoperative hemorrhage rates, one of the frequently encountered major adverse events, as part of a retrospective chart review across four different surgical techniques. These surgeries involved either (1) Coblation, (2) Co-blation with partial suture closure of the tonsillar fossa, (3) diathermy, or (4) partial intracapsular tonsillectomy (PIT). Of the 7,024 children we evaluated, 99 (1.4%) experienced a postoperative hemorrhage that required a second surgery; hemorrhage occurred after 33 of the 3,177 Coblation-alone procedures (1.04%), 28 of the 1,633 Coblation with partial suture closure procedures (1.71%), 29 of the 1,850 diathermies (1.57%), and 9 of the 364 PIT procedures (2.47%). Statistical analysis of hemorrhage rates with each surgical technique yielded p values >0.05 in each case (Coblation alone and Coblation with partial suture closure: p = 0.29; diathermy: p = 0.47; PIT, p = 0.20). Based on these data, we conclude that none of these techniques is significantly superior in terms of decreasing the risk of post-tonsillectomy hemorrhage in children. Therefore, surgeons should continue to use the surgical procedure they are most familiar with to optimize recovery in the postoperative period.

Novel Association of Odontogenic Myxoma with Constitutional Chromosomal 1q21 Microduplication: Case Report and Review of the Literature.

Odontogenic myxoma (OM) is a rare, benign, and locally aggressive tumor. It tends to occur in the posterior maxilla and mandible and is often associated with root resorption and perforation of cortex. Histopathologically, there is a proliferation of spindle, bipolar, and stellate cells, with bland nuclei within a myxoid to infrequently fibromyxoid extracellular matrix. Long, thin residual bony trabeculae are often seen floating within the spindle cell proliferation because of the infiltrating nature of this tumor, and these trabeculae impart a "soap bubble" or "tennis-racket" radiologic appearance. No syndromic association of OM has been reported. Although similar histopathologic features are shared with cardiac myxoma and soft tissue myxoma, mutations in the GNAS gene have not been identified in OM to date, and only 2 of 17 OMs showed mutations in the PRKAR1A gene. In this report, we describe a case of OM in a patient with constitutional 1q21 microduplication, a locus that harbors genes encoding certain proteins in the cAMP-dependent protein kinase A (PKA) signaling pathway, including G-protein-coupled receptors and 1 phosphodiesterase interacting protein. Review of the literature describes the key clinical features and molecular pathogenesis of 1q21 microduplication, as well as highlighting the role of PKA signaling pathway in the pathogenesis of myxomas in general.

Case series: A novel technique for the treatment of external auditory canal stenosis.

External auditory canal (EAC) stenosis can exist as an isolated problem, as a component of craniofacial disorders, or in association with genetic syndromes. We present five cases and demonstrate the efficacy of a minimally invasive way of opening the EAC, facilitating better hearing, easier office examination, and allowing for other necessary treatments such as ear tube placement or use of a hearing aid. Follow-up ranged from 1 to 19 months, with all patients demonstrating significant improvement. We believe this is a novel surgical approach which is easy to perform, cost effective, and may be applicable to a wide range of patients.

Pediatric recurrent laryngeal nerve reinnervation: A case series and analysis of post-operative outcomes.

OBJECTIVE: To provide detailed information about recurrent laryngeal nerve (RLN) reinnervation outcomes in children using objective measures. METHODS: The records of three pediatric patients with unilateral vocal cord paralysis that underwent RLN reinnervation were retrospectively reviewed. Fundamental frequency (F0), jitter, shimmer, noise-to-harmonic ratio (NHR), and voice phonation (sustained /s/, /z/, /a/) were measured preoperatively and post-operatively at 13, 9, and 33 months (each time period corresponding to one of the three patients). RESULTS: Mean preoperative and post-operative variables were as follows: shimmer, 9.65±1.02% vs. 4.46±0.71% (p=0.01); NHR, 0.296±0.063 vs. 0.127±0.011 (p=0.04); jitter, 3.57±0.89% vs. 1.46±0.54% (p=0.08); F0, 274.6±35.4Hz vs. 282.2±70.6Hz (p=0.44); maximum phonation time, 7.46±1.40s vs. 9.79±1.84s (p=0.22); /s:z/ ratio, 1.28±0.22 vs.1.07±0.09 (p=0.26). CONCLUSIONS: There was statistically significant improvement in shimmer and NHR. Jitter improvement approached statistical significance. All other variables failed to show significant improvement among this small sample size. RLN reinnervation for pediatric patients is an option for the treatment of vocal cord paralysis. Further studies with larger cohorts are needed to show the full benefits.

Sildenafil for microcystic lymphatic malformations of the head and neck: A prospective study.

BACKGROUND: Microcystic lymphatic malformations (LM) are congenital birth defects that can cause severe functional or esthetic deformity. At this time, several treatment interventions are possible, but there is no ideal therapy. A recently published article noted a coincidental improvement in microcystic LMs with the use of sildenafil for pulmonary hypertension, but conclusive and reproducible data is lacking regarding its efficacy. METHODS AND RESULTS: A prospective study was conducted to examine the subjective and objective results associated with sildenafil use in the treatment of microcystic LMs. Patients under the age of 18 were enrolled, and after evaluation with pre-intervention magnetic resonance imaging (MRI) studies, each was given a 6-week course of sildenafil. Subjective outcomes were obtained, and postoperative MRIs were used to objectively quantify changes. Five patients between the ages of 4 and 11 were enrolled in the study. All patients had microcystic LMs of the head and neck. All patients had undergone previous treatment interventions utilizing various modalities, and each was now seeking treatment for functional and cosmetic purposes. All patients had minimal to no response from a subjective standpoint. Comparison of pre- and post-treatment MRIs also demonstrated minimal to no response. CONCLUSIONS: The use of sildenafil for the treatment of microcystic lymphatic malformations did not have any appreciable effect on our selected population of pediatric patients who had been resistant to previous therapies. Further studies would be necessary to determine if other cohorts may benefit.

Syngnathia and obstructive apnea in a case of popliteal pterygium syndrome.

UNLABELLED: We describe an infant with popliteal pterygia, syngnathia, cleft lip and palate, and retrognathia diagnosed with popliteal pterygium syndrome (PPS). The neonatal course was complicated by severe obstructive apnea necessitating tracheostomy. CONCLUSION: This report illustrates the potential for airway compromise in PPS patients and the need for thorough neonatal airway assessment.

Laryngotracheal separation surgery for intractable aspiration: our experience with 12 patients.

OBJECTIVE: Laryngotracheal separation surgery (LTS) was performed as a treatment for recurrent or intractable aspiration pneumonia in 12 pediatric patients. The effectiveness of LTS surgery for preventing aspiration pneumonia, and the complications of this procedure were investigated. METHODS: A retrospective chart review, conducted at a tertiary academic hospital in conjunction with a private practice, was used to identify children who underwent Laryngotracheal Separation Surgery (LTS) from September 2001 to July 2007. The main outcome measure was the number of hospital admissions for pneumonia in the pre LTS and post LTS period. A student's t-test was used for statistical analysis. RESULTS: LTS surgery decreased the frequency of pulmonary infections and respiratory events in all patients, resulting in far fewer hospitalizations. These patients experienced an average of 5 hospital admissions for pneumonia in the 2 years prior to LTS surgery, and an average of 1.1 hospital admissions for pneumonia after the LTS surgery. There were no major complications related to the surgery. Several minor complications following surgery were easily and effectively dealt with in the perioperative period. CONCLUSIONS: LTS surgery is an effective and safe procedure in children with intractable aspiration. Parents do not perceive the care of the LTS stoma as burdensome. This procedure should be considered as an option in the surgical intervention for the management of chronic aspiration pneumonia in severely neurologically impaired children.

Surgical revision of vagus nerve stimulation electrodes in children.

Use of vagus nerve stimulation (VNS) has increased in the past decade, resulting in frequent revision cases for device failure. The authors report their series of children who underwent reimplantation of the VNS device after removal of old electrodes and leads. Patients with medically refractory seizures who underwent revision of VNS electrodes were included (n = 23). Twenty patients had high lead impedance and underwent removal of the device and replacement of the VNS electrodes during the same procedure. In 3 patients, electrodes and the device had been removed previously at an outside institution because of infection. None of the patients experienced any major complications. Mean operative time was 2.3 ± 0.9 hours. The reimplanted device worked well in all patients, and seizure control was similar to or better than that reported with the previous device. Thus, implantation of the VNS electrodes is reversible, and it appears that the electrodes can be removed or replaced safely if the device is not functioning properly.

Vagus nerve stimulation for drop attacks in a pediatric population.

A retrospective analysis of 43 patients with drop attack seizures who were treated with vagus nerve stimulation (VNS) was undertaken to determine the efficacy of VNS and to determine pre-implantation characteristics associated with VNS success. It was found that on last follow-up, 46% of patients had at least a 75% reduction in drops per day. Forty-six percent of patients had less than a 50% reduction in drops per day and were considered nonresponders. Univariate analysis failed to uncover significant associations between pre-implantation characteristics and VNS success. It was found that atonic head nods were more amenable to VNS treatment as compared with atonic or tonic drop attacks. In addition, patients with focal or lateralized epileptiform abnormalities responded better to VNS compared with those with more diffuse or poorly localized findings on ictal and/or interictal recordings. Our data suggest that VNS offers significant palliative benefit to many children with medically intractable drop attack seizures.

A modified technique for inferior turbinate reduction: the integration of coblation technology.

BACKGROUND: Many procedures have been described for the surgical management of inferior turbinate hypertrophy. Coblation is a relatively new technology that uses radiofrequency energy to ablate hypertrophied tissues. The standard method of using this technology has been shown to be effective; however, it only partially relieves symptoms of obstruction. The authors present a modified hybrid technique for the surgical reduction of inferior turbinate hypertrophy using a combination of coblation and turbinate outfracture to maximize the nasal airway patency. METHODS: A review was performed of operating room video files to evaluate the senior author's (J.L.E.) technique for performing inferior turbinate reduction using the modified coblation and outfracture technique. The videos were edited to present the technique. RESULTS: The senior author has found this modified hybrid technique to be both efficacious and safe. This Video Plus article presents both the operative technique and postoperative management for cases of inferior turbinate hypertrophy that fail medical management. CONCLUSION: This modified hybrid technique is the mainstay of the senior author's treatment of inferior turbinate hypertrophy reduction and can be a useful surgical tool to achieve adequate outcomes when dealing with patients who have hypertrophied inferior turbinates that fail medical management.

Lymphatic malformations: current cellular and clinical investigations.

OBJECTIVE: Summarize current knowledge of lymphatic malformation development, biology, and clinical outcome measures. METHODS: Panel presentation of lymphatic malformation biology and measurement of head and neck malformation treatment outcomes. RESULTS: Characterization of lymphatic malformation endothelial and stromal cells may lead to biologically based treatment. Traditionally, lymphatic malformation treatment outcomes have been measured according to reduction of malformation size. Currently, methods to measure functional outcomes following lymphatic malformation treatment are lacking. This is particularly apparent when the malformation directly involves the upper aerodigestive tract. CONCLUSIONS: The etiology and pathogenesis of head and neck lymphatic malformations are poorly understood, but understanding is improving through ongoing investigation. Reduction of lymphatic malformation size is generally possible, but further work is necessary to optimize methods for measuring therapeutic outcomes in problematic areas.

Lymphatic malformations: review of current treatment.

OBJECTIVE: Summarize current knowledge of lymphatic malformation medical, sclerotherapy, and surgical treatment; and highlight areas of treatment controversy and treatment difficulty that need improvement. METHODS: Panel presentation of various aspects of lymphatic malformation treatment. RESULTS: The mainstay of lymphatic malformation treatment has been surgical resection, which has been refined through lesion staging and radiographic characterization. Intralesional sclerotherapy in macrocystic lymphatic malformations is effective. Suprahyoid microcystic lymphatic malformations are more difficult to treat than macrocystic lymphatic malformations in the infrahyoid and posterior cervical regions. Bilateral suprahyoid lymphatic malformations require staged treatment to prevent complications. Lymphatic malformation treatment planning is primarily determined by the presence or possibility of functional compromise. Problematic areas include chronic lymphatic malformation inflammation, dental health maintenance, macroglossia, airway obstruction, and dental malocclusion. CONCLUSIONS: Lymphatic malformation treatment improvements have been made through radiographic characterization and staging of lymphatic malformations. Direct malformation involvement of the upper aerodigestive tract can cause significant functional compromise that is difficult to treat.

Anesthetic management of a young adult with complex congenital heart disease and bronchopleural fistula for rigid bronchoscopy.

The number of adults with congenital heart disease and those who require anesthetic care are increasing. We describe the anesthetic management of a young adult with palliated complex congenital heart disease and a chronic postsurgical bronchopleural fistula for rigid bronchoscopy. Perioperative considerations in the care of patients with single ventricle physiology for noncardiac procedures are reviewed. Specific requirements for rigid bronchoscopy are discussed in addition to the anesthetic implications of a bronchopleural fistula and particular concerns in the patient with single ventricle physiology.

The bacteriostatic properties of ear tubes made of absorbable polylactic acid.

OBJECTIVE: Tympanostomy tube placement remains the most common reason children are brought to the operating room. Of the known complications, transient, recurrent, and chronic otorrhea represent the most common and challenging sequelae of tube insertion. This study was performed to determine if the acidic nature of the polymer of lactic acid (PLA), a possible material for the construction of ear tubes, would have bacteriostatic properties. MATERIAL AND METHODS: Experimental PLA tubes and control fluoroplastic tubes were inoculated with a broth of Pseudomonas aeruginosa or Staphylococcus aureus and incubated. Fluid recovered from the tubes was plated and incubated again. Colony counts were recorded at 24 and 48 h. Two separate trials were conducted for each organism. Repeated measures analysis of variance (ANOVA) models were used to assess the effects of the type of tube, the experimental run, and the tube by run interaction on colony counts. RESULTS: In the Pseudomonas experiments, the mean colony count of the PLA tube group (Run 1: 1.0; Run 2: 26.6) was significantly lower than the mean colony count in the fluoroplastic tube group (Run 1: 132.6; Run 2: 122.2; p=0.0150). Similarly, in the S. aureus experiments, the mean colony count of the PLA tube group (Run 1: 88.2; Run 2: 92.6) was significantly lower than the mean colony count in the fluoroplastic tube group (Run 1: 335.0; Run 2: 325.8; p<0.0001). CONCLUSION: PLA has many properties including an apparent bacteriostatic quality, which may make it an attractive material for the construction of tympanostomy tubes.