Three dimensional printed models of the airway for preoperative planning of open Laryngotracheal surgery in children: Surgeon's perception of utility.

BACKGROUND: Preoperative planning of open laryngotracheal surgery is important for achieving good results. This study examines the surgeon's perception of the importance of using life size 3D printed models of the pediatric airway on surgical decision making. METHODS: Life-size three-dimensional models of the upper airway were created based on CT images of children scheduled for laryngotracheal-reconstruction and cricotracheal resection with anastomosis. Five pediatric airway surgeons evaluated the three-dimensional models for determining the surgical approach, incision location and length, graft length, and need for single or double-stage surgery of seven children (median age 4.4 years, M:F ratio 4:3). They rated the importance of the three-dimensional model findings compared to the direct laryngoscopy videos and CT findings for each domain on a validated Likert scale of 1-5. RESULTS: The mean rating for all domains was 3.6 ± 0.63 ("moderately important" to "very important"), and the median rating was 4 ("very important"). There was full agreement between raters for length of incision and length of graft. The between-rater agreement was 0.608 ("good") for surgical approach, 0.585 ("moderate") for incision location, and 0.429 ("moderate") for need for single- or two-stage surgery. CONCLUSION: Patient-specific three-dimensional printed models of children's upper airways were scored by pediatric airway surgeons as being moderately to very important for preoperative planning of open laryngotracheal surgery. Large-scale, objective outcome studies are warranted to establish the reliability and efficiency of these models.

Combined trans-stomal endotracheal approach to peri-stomal tracheal pathologies in children.

IMPORTANCE: Peristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved. OBJECTIVE: We evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies. METHODS: The medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed. RESULTS: In total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure. CONCLUSION: Combined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies.

Decreased cerebral oxygen saturation levels during direct laryngoscopy with spontaneous ventilation in children.

INTRODUCTION: Direct laryngoscopy in children is usually performed with spontaneous ventilation and monitored by pulse oximetry. It is currently unknown if spontaneous ventilation has an effect on cerebral oxygenation. We hypothesized that cerebral oxygenation may be impeded during direct laryngoscopy with spontaneous ventilation in children. OBJECTIVE: Our objective was to determine if children who undergo direct laryngoscopy under general anesthesia with spontaneous breathing experience significant reductions in cerebral oxygen saturation levels, and whether or not these reductions are accompanied by decreases in peripheral oxygen saturation levels. METHODS: This pilot study included 16 consecutive children who underwent direct laryngoscopy under general anesthesia and spontaneous ventilation. The INVOS™ system, which is currently used to monitor cerebral oxygen saturation levels during neurosurgery and cardiothoracic surgery, consists of a processing unit and 2 sensors that are applied to the patient's forehead. We used it to record cerebral oxygenation levels throughout the procedure. Peripheral pulse oximetry was recorded simultaneously, and the results were compared to the levels recorded by the INVOS™ system. RESULTS: Cerebral oxygen saturation levels decreased by more than 20% from baseline in 7/10 children with tracheostomy and in 2/6 children without tracheostomy, while peripheral oxygen saturation levels remained intact in all the children. The mean time from induction of anesthesia to significant decrease in the cerebral oxygenation level (rSO2) was 14 ± 6 min for the tracheostomy group and 14.5 ± 1.5 min for the no tracheostomy group. CONCLUSIONS: Children who undergo direct laryngoscopy under general anesthesia with spontaneous ventilation may display reductions in brain oxygenation levels that are not detected by standard pulse oximetry, which reflects only peripheral oxygenation levels. Further study is required to explore the possible effect of this phenomenon in children who undergo direct laryngoscopy.

Parental concern as an indicator of the severity of Obstructive Sleep Apnea in children.

INTRODUCTION: An accepted screening question for Obstructive Sleep Apnea (OSA) in children is "Does your child snore". However, this has no correlation to severity. The purpose of this study is to evaluate a simple 2-item questionnaire that reflects the degree of parental concern to predict the severity of Obstructive Sleep Apnea (OSA) in children as measured by Polysomnography (PSG). METHODS: Prospective analysis of parental concern regarding their children referred for PSG due to suspected OSA. Parents of all study children completed the brief Parental Concern Scale (PCS) questionnaire that we devised and the validated Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder questionnaire (PSQ-SRBD). The PCS consisted of 1 question on the need for surgery and 1 question on concerns about the child's breathing. Both questionnaires were compared to PSG results. RESULTS: Ninety-five children (mean age 4.2 ± 2.5 years, 52% males, mean body mass index z score 0.45 ± 1.8) were recruited. Twenty-three children (24%) had moderate-severe OSA and were referred for adenotonsillectomy. Correlations were found between the need for surgery score and the apnea-hypopnea index (r = 0.22, P = .029), as well as the mean SpO2 levels (r = -0.24, P = .02). The likelihood for the diagnosis of moderate-severe OSA by PSG increased as parental ranking for the need for surgery increased (P = .003). The need for surgery score was the only predictor for moderate-severe OSA (P = .039). CONCLUSION: Querying parents on their perception of their child's need for surgery is a practical, and easy-to-use tool that can help the clinician in prioritizing referral to PSG.

Open Approaches to the Anterior Skull Base in Children: Review of the Literature.

Introduction Skull base lesions in children and adolescents are rare, and comprise only 5.6% of all skull base surgery. Anterior skull base lesions dominate, averaging slightly more than 50% of the cases. Until recently, surgery of the anterior skull base was dominated by open procedures and endoscopic skull base surgery was reserved for benign pathologies. Endoscopic skull base surgery is gradually gaining popularity. In spite of that, open skull base surgery is still considered the "gold standard" for the treatment of anterior skull base lesions, and it is the preferred approach in selected cases. Objective This article reviews current concepts and open approaches to the anterior skull base in children in the era of endoscopic surgery. Materials and Methods Comprehensive literature review. Results Extensive intracranial-intradural invasion, extensive orbital invasion, encasement of the optic nerve or the internal carotid artery, lateral supraorbital dural involvement and involvement of the anterior table of the frontal sinus or lateral portion of the frontal sinus precludes endoscopic surgery, and mandates open skull base surgery. The open approaches which are used most frequently for surgical resection of anterior skull base tumors are the transfacial/transmaxillary, subcranial, and subfrontal approaches. Reconstruction of anterior skull base defects is discussed in a separate article in this supplement. Discussion Although endoscopic skull base surgery in children is gaining popularity in developed countries, in many cases open surgery is still required. In addition, in developing countries, which accounts for more than 80% of the world's population, limited access to expensive equipment precludes the use of endoscopic surgery. Several open surgical approaches are still employed to resect anterior skull base lesions in the pediatric population. With this large armamentarium of surgical approaches, tailoring the most suitable approach to a specific lesion in regard to its nature, location, and extent is of utmost importance.

Changes in the epidemiology and clinical features of acute mastoiditis following the introduction of the pneumococcal conjugate vaccine.

OBJECTIVES: Seven years after the introduction of the pneumococcal conjugate vaccines (PCV) in Israel, its effect on the incidence and severity of episodes of acute mastoiditis (AM) remains unclear. The primary objective of this study was to determine the incidence of AM and describe its clinical features in children during the years that followed the introduction of the PCV13 in comparison with the pre-PCV period. METHODS: Included in this retrospective comparative case series were all pediatric patients diagnosed with AM between Jan. 2007 and Dec. 2015 in one tertiary medical center. The patients were divided into 3 groups: pre-PCV, post-PCV7 (July 2009 through Dec. 2010) and post-PCV13 (Jan. 2011 through Dec. 2015). The patients' medical records were reviewed, and data on age at presentation, gender, presenting signs, bacterial ear cultures, hospitalization course, complications, surgical interventions, inflammatory response and outcome were retrieved and compared between the groups. Comparison was made between the pre-PCV and the post-PCV13 groups. RESULTS: 216 children were identified for analysis, 80 children in the pre-PCV period, 31 in the post-PCV7 period and 105 in the post-PCV13 period. Their mean age was 2.6 years. The number of AM cases per 1000 visits at the emergency room decreased by 46% in the post-PCV13 period compared to the pre-PCV period. There was no difference in the rate of AM between the post-PCV7 and post-PCV13 periods. No differences were found in age, gender, hospitalization length, C-reactive protein level, white blood cell count, rate of surgical interventions (mastoidectomy and incision and drainage) and rate of complications between the 3 groups. CONCLUSION: The incidence of AM was lower in the post-PCV13 period compared to the pre-PCV period. The rate of AM complications, however, has not changed, nor has the number of mastoidectomies.

Informed consent for tonsillectomy: Do parents comprehend the information we provide?

OBJECTIVE: Informed consent is an important part of the surgical process. Based on our clinical experience, we hypothesized that parents providing consent for their children's tonsillectomy do not comprehend all the information that is given to them by the operating surgeon at the time of a conventional consent process. MATERIALS AND METHODS: Parents whose children were scheduled for tonsillectomy with or without adenoidectomy and/or tympanostomy tubes insertion were enrolled. Within one hour after the consent process, they were asked to complete a questionnaire designed to collect demographic data and to evaluate how much of the information that was given to them was actually understood. RESULTS: Ninety-seven parents were enrolled between October 2011 and March 2013. The average percentage of correct answers (score) for the 16 multiple-choice questions was 76.3%. The average scores were 84.8% for the native Hebrew-speaking parents and 71.9% for the parents whose first language was other than Hebrew (p < 0.01). The average scores were 83.3% for the parents who are healthcare system workers and 74.4% for those parents whose profession is not related to medicine (p < 0.05). Fifty parents (51.5%) responded incorrectly to at least one of two questions that we defined as essential: "What would you do if your child starts to bleed from the mouth" and "What kind of food is recommended for your child during the first week after the surgery". CONCLUSION: The current conventional method of obtaining informed consent for tonsillectomy is inadequate, as reflected by the low level of parental comprehension of essential information. Further studies which will evaluate methods for improving the consent process are highly warranted.

A Novel Radiographic Sign and a New Classifying System in Mastoiditis-Related Epidural Abscess.

OBJECTIVE: To describe a novel radiographic sign ("halo") and a new classification method of an evolving perisigmoid epidural abscess and present its correlation with intraoperative findings. STUDY DESIGN: Retrospective and prospective cohort study in a tertiary academic children's hospital. METHODS: The retrospective arm (15 children) was conducted between 1998 and 2007 and the prospective arm (11 children) between 2008 and 2013. The computerized tomographic appearance of the perisigmoid region was classified into four groups: Class I, normal; Class II, smooth halo; Class III, nodular halo 4 mm or less in diameter; and Class IV, gross nodular halo more than 4 mm in diameter. Intraoperative findings of the perisigmoid region were compared with the preoperative scan results. RESULTS: The correlation between preoperative imaging and intraoperative findings of the retrospective arm was highly significant (p = 0.007). The correlation between the preoperative imaging studies and intraoperative findings of the prospective arm was also highly significant (p = 0.005). The interobserver agreement for the proposed classification method was high (Cohen kappa score, 0.76; weighted kappa score, 0.84). CONCLUSION: A novel radiographic sign ("halo") and a new classification method for an evolving perisigmoid epidural abscess in acute mastoiditis are described. A thin and smooth halo sign is not indicative of a true abscess formation. Gross perisigmoid granular changes, however, are highly suggestive of an epidural abscess that warrants surgical intervention.

Outcomes of endonasal endoscopic dacryocystorhinostomy after maxillectomy in patients with paranasal sinus and skull base tumors.

Maxillectomy followed by radiotherapy and/or chemotherapy can result in lacrimal blockage and the need for subsequent dacryocystorhinostomy (DCR). Endonasal endoscopic DCR, as opposed to external DCR, allows better accuracy and leaves no scar. To date no report was published regarding the results of endoscopic DCR in these patients. The current study presents a retrospective review of all patients with paranasal and skull base tumors who developed nasolacrimal duct blockage after ablative maxillectomy with or without radiotherapy and/or chemotherapy and underwent endonasal endoscopic DCR between January 2006 and October 2012 in a tertiary reference medical center. According to our results, ten patients underwent 11 subsequent endonasal endoscopic DCR. There were 6 men and 4 women with a median age of 55 years (range, 19-81 years); four suffered from benign tumors and six had malignant tumors. All underwent maxillectomy. Six received high-dose radiotherapy. Time interval between primary ablative surgery and endonasal endoscopic DCR was 18 months (range, 7-118 months). Silicone stents were removed after median period of 11 weeks (range, 1-57 weeks). Nine out of ten patients experienced symptomatic improvement following one endonasal endoscopic DCR. One patient had recurrent epiphora and underwent a successful endonasal endoscopic revision DCR. In conclusion, endonasal endoscopic DCR in patients with paranasal and skull base tumors, who previously underwent maxillectomy, is generally successful and not associated with a high rate of complications or failure. Moreover, our findings may suggest that silicone stents can be removed shortly after the operation with high success rate.

Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: inter-observer correlation and comparison with awake endoscopy.

OBJECTIVE: Evaluate the inter-observer correlation of sleep endoscopy findings in children with persistent obstructive sleep apnea (OSA) with awake office fiber-optic endoscopy. DESIGN: retrospective case series; blinded review. SETTING: tertiary care children's hospital. PATIENTS: Children with persistent obstructive sleep apnea. INTERVENTIONS: Both awake and drug induced sleep endoscopy were performed. Endoscopy video recordings were mixed at random on a DVD. Two pediatric otolaryngologists and two pediatric pulmonologists independently scored each recording using an upper airway endoscopy scoring survey. MAIN OUTCOME MEASURES: reviewers scored the following parameters: each structure's contribution (nose, nasopharynx, lateral pharyngeal walls, tongue base, supraglottis) to the obstruction, the main site in which the obstruction occurs, the severity of OSA (mild, moderate, severe), the level of confidence of endoscopy findings (poor, fair, good). RESULTS: When reviewing sleep endoscopy recordings for the upper airway obstruction site, the highest correlation among the four observers was found for the nasopharynx and the supraglottis (Kappa score: 0.6 and 0.5, respectively). Compared to awake endoscopy, sleep endoscopy demonstrated more cases of airway obstruction caused by collapse of lateral pharyngeal walls and base of tongue (McNemar test for symmetry, P value<0.05). Level of confidence among the four observers was higher in older children and lower in children with severe OSA. CONCLUSIONS: Sleep endoscopy is a consistently reliable tool for identifying the site of obstruction in children with persistent OSA. Though anesthetic induced sleep is not a perfect model for real sleep, the technique demonstrably guides further therapy better than awake endoscopy.

Expression of Th17 and Treg lymphocyte subsets in hypertrophied adenoids of children and its clinical significance.

Adenoid hypertrophy is the most common cause of upper airway obstruction and sleep-disordered breathing in children, yet its pathogenesis remains unclear. The identification of the novel helper T cell subsets, Th17 cells and regulatory T cells (Tregs) could provide new insight into our understanding of the mechanisms involved in the development of this condition. The purpose of this study is to evaluate the adenoidal lymphocyte subsets to describe the percentage of various lymphocyte subsets in hypertrophied adenoids and correlate them with symptom severity. Twenty consecutive children undergoing adenoidectomy were included, and lymphocytes were isolated from their adenoids. T cell subpopulations were detected by flow cytometry using a fluoresceinated monoclonal antibody directed against a number of cell markers (CD4+, CD8+, CD25+, FOXP3 IL17+, and others). We found a significant negative linear correlation between the Th17/Treg ratio and the patients' clinical scores (R = -0.71 p < 0.005). The correlation was independent of age and gender. Decreased ratios of Th17/Treg subpopulations may play a role in the pathogenesis of adenoid hypertrophy.

[Postcricoid vascular lesion in an infant].

A 7-months-old female presented with coughing spells while feeding. Flexible laryngoscopy revealed a round bluish mass, emanating from the postcricoid area when the child cried or strained and disappeared when she relaxed. She was treated with systemic steroids for a month and was doing well. There was no change in the lesion. On examination at age 18 months the lesion disappeared. In a review of the literature, the authors found 6 articles describing 19 children with postcricoid vascular lesions. Seven children did not have significant related problems and did well without any treatment. Eight cases had significant co-morbidity. Treatment for symptomatic children included systemic or intralesion steroids, laser ablation and open resection. Postcricoid vascular lesion is a rare entity with a typical appearance. The recommended workup includes flexible laryngoscopy and videofluoroscopy. There are several treatment options for symptomatic children.

Multidisciplinary surgical approach for cerebrospinal fluid leak in children with complex head trauma.

INTRODUCTION: Post-traumatic cerebrospinal fluid leak from the anterior cranial fossa in children may be isolated or combined with severe facial and calvarial injury. Untreated leak may result with meningitis, hydrocephalus, and abnormal neurocognitive development. PATIENTS AND METHODS: We present nine children, ages 4-16 years, with complicated craniofacial injury treated by a combined subcranial and intracranial approach. A continuous lumbar drainage was kept for several days, and prophylactic antibiotics and anti-convulsive medications were routinely given. A multidisciplinary approach including discussion before surgery about other surgical options (endoscopic extracranial and intracranial alone) were performed. RESULTS: None of the operated children had episodes of meningitis/leak after the combined approach, suggesting that appropriate sealing of the base of the skull has been achieved. There was no mortality, and the long-term follow-up showed good developmental and cosmetic results. Most of the children had significant brain contusions prior to surgery; however, these did not progress as minimal retraction was enabled by the extensive subcranial and intracranial approach. CONCLUSIONS: Child's age, anatomy of the bone, extent of cranial injury, and clinical parameters should be seriously considered when choosing the technical methods as for sealing base of skull and reconstruction of facial/cranial bones. Young age does not seem to be a contraindication to the combined approach, thus, we recommend considering it in extensive base of skull fractures when concomitant cranial, maxillofacial, and orbital fractures coexist, as alternative options may not suffice in these cases.

Conservative management of acute mastoiditis in children.

OBJECTIVE: To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy. DESIGN: A retrospective chart review. SETTING: Tertiary-care, university affiliated children's hospital. PATIENTS: One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002. INTERVENTIONS: All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call. MAIN OUTCOME MEASURES: Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions. RESULTS: Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR. CONCLUSIONS: These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

Fat graft myringoplasty: results of a long-term follow-up.

OBJECTIVE: To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. DESIGN: Prospective case series study. MAIN OUTCOME MEASURES: Patients with chronic tympanic membrane perforations were considered candidates for fat graft myringoplasty. Excluded were patients with purulent discharge, suspected ossicular disease, suspected cholesteatoma, or a perforation diameter greater than 6.5 mm. Fat was harvested from the ear lobule or subcutaneous tissue just posterior-inferior to the lobule. RESULTS: The study population comprised 27 adults and 11 children. Twenty-eight perforations were small (73.7%) and 10 were large (26.3%). Altogether, 31 of 38 perforations were successfully repaired (81.6%), including 22 of 28 small perforations (78.6%) and 9 of 10 large perforations (90%). Assessment by age showed that 23 of 27 perforations of the adults (85.2%) and 8 of 11 perforations of the children (72.7%) successfully closed (p = .648). Follow-up ranged from 25 to 53 months (mean 40.6 +/- 8.3 months). No recurrence of the perforation during the follow-up period was recorded if the initial results were successful. The speech reception threshold improved significantly (18.5 +/- 7.7 dB vs 23.5 +/- 8 dB; p = .043). No significant sensorineural hearing loss occurred. CONCLUSIONS: Fat graft myringoplasty is a reliable technique for the closure of small- and medium-sized perforations. The grafting results showed excellent long-term durability. Given the simplicity of the technique, its short duration, and the favourable hearing results, fat graft myringoplasty should be considered the procedure of choice in patients with suitable perforations and when not otherwise contraindicated.

Long-term outcome of atticotomy for cholesteatoma in children.

OBJECTIVE: To evaluate the long-term outcome of atticotomy (AT) surgery for cholesteatoma in children. STUDY DESIGN: Case series, retrospective chart review. SETTING: General otology practice in a teaching hospital. PATIENTS: Fifty-three children aged 5 to 16 years old with cholesteatoma limited to the attic and middle ear who underwent AT between the years 1979 to 1994. INTERVENTIONS: AT consisting of removal of cholesteatoma confined mainly to the attic. The procedure consists of removal of the lateral attic wall (scutum) and involved ossicles with excision of the cholesteatoma and tympanic membrane grafting with temporalis fascia, leaving a small attical cavity. The mastoid antrum was left intact. MAIN OUTCOME MEASURES: Disease recurrence, middle ear status, hearing results, and the need for further surgery. RESULTS: Mean follow up was 5.1 (+/-3.6) years. Eleven (21%) children required completion canal wall down tympanomastoidectomy because of residual disease or recurrence. The mean preoperative speech recognition threshold was 39.4 +/- 13.4 dB. The mean postoperative speech recognition threshold was 34.5 +/- 15.4, an improvement of 6.1 dB compared with the preoperative level. Last follow-up examination revealed a dry ear in all cases but one. CONCLUSIONS: In selected cases, AT can be a less invasive option in children with cholesteatoma limited to the attic and middle ear.

Nitrous oxide-oxygen inhalation for outpatient otologic examination and minor procedures performed on the uncooperative child.

OBJECTIVE: Otomicroscopic examination with suctioning of ears or other procedures is frequently uncomfortable especially for children. Anxiety and pain with lack of cooperation may result in trauma to the ear, incompletion of the examination, delayed diagnosis and treatment and need for completion of the examination under general anesthesia. The purpose of this study was to evaluate the efficacy and safety of utilizing nitrous oxide-oxygen inhalation for sedation and analgesia in otologic examination and minor surgical procedures performed on the uncooperative child at the outpatient clinic. METHODS: In a prospective pilot case series study conducted at the Pediatric Otolaryngology outpatient clinic of a tertiary medical center, nitrous oxide-oxygen inhalation was administered by the examining otolaryngologist and the assisting nurse. The study group included children over 2 years old, for which an accurate diagnosis of ear pathology could not be made or a minor surgical procedure could not be tolerated because of anxiety and lack of cooperation. RESULTS: Completion of the indicated procedure was successful in 21 of 24 patients (88%). Full cooperation, where no restraint was necessary was achieved in 20 of 24 patients (83%). The mean rank pain scores, evaluated separately by the patient, parent and staff, were in the mild pain range using a 0-10 coding for Faces Pain Rating Scale. The mean procedure time was 8.9 min. An adverse reaction, vomiting, occurred in one patient. Twenty-one of 24 parents stated that they would repeat the procedure if necessary. CONCLUSION: This pilot study shows the potential usefulness of nitrous oxide-oxygen inhalation administered by an otolaryngologist in the outpatient clinic. Alleviation of pain and anxiety and avoiding the need for physical restraint is an important goal that can be achieved with this form of sedation.

The effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the Test of Variables of Attention (TOVA) in children with obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate children with obstructive sleep apnea syndrome (OSAS) for features of attention deficit disorder (ADD) using an objective test of inattention and impulsivity: Test of Variables of Attention (TOVA) and then to determine whether tonsillectomy and adenoidectomy (T+A) results in an improvement in TOVA scores. STUDY DESIGN AND SETTING: This study was a prospective interventional comparative trial in a tertiary care children's hospital. Nineteen children ages 5 to 14 years with OSAS, and otherwise healthy, with a clinical indication for T+A. Preoperative and 2 months postoperative OSA-18, CBCL questionnaires, and TOVA scores were evaluated. RESULTS: The preoperative TOVA scores were in the abnormal range in 12/19 (63%) of the children. The mean preoperative TOVA score was -2.9 (+/- 3.1). The mean postoperative TOVA score was -0.4 (+/-2.8). The improvement in the TOVA scores was significant ( P < 0.0001, t -test). CONCLUSION: This preliminary data suggests that treatment of OSAS with T+A results in significant improvement in objective parameters of inattention and impulsivity. Significance These findings may be important in understanding the impact of OSAS and therapeutic interventions on behavioral problems in children.

Inflammatory bowel disease and sclerosing cholangitis with ulcerative lesions on skin and soft palate.

Described is a 15-year-old boy who presented with an ulcerative destructive soft palate lesion, skin lesions, and prolonged history of weakness and abdominal pain associated with abnormal liver functions. A midline destructive lesion was considered. However biopsies revealed chronic inflammation. After thorough investigation including colon, liver, skin and uvular biopsies a diagnosis of Inflammatory Bowel Disease in association of Autoimmune Sclerosing Cholangitis was made. Treatment with steroids improved his symptoms, normalized liver functions and enhanced healing of the skin and palatal lesions. This case demonstrates the involvement of the palate in a rare systemic disease and to our knowledge is the first description of Sclerosing Cholangitis presenting as an ulcerative lesion of the soft palate.