The "Frankentower:" A clinician-driven approach to enhancing endoscopic data technology.

OBJECTIVE: To develop a more efficient endoscopy tower and evaluate its capability to improve retrieval and storage of videos across 6 clinical sites. METHODS: Descriptive study that took place at tertiary care Pediatric Otolaryngology Department over a 2 year period. In collaboration with our Information Services Department and Otolaryngology endoscopy vendors, we assembled our "Frankentower" endoscopy cart using components from 3 medical device manufacturers. RESULTS: It is feasible to create a functional composite endoscopic tower. Implementation of "Frankentower" improved overall management and retrieval of endoscopy video and images in our department which lead to better patient care and facilitated education for medical students, residents and faculty. CONCLUSIONS: The "Frankentower" is a feasible, cost-effective solution to streamline the capture, access and storage of patient endoscopy exams across our operating rooms, inpatient consult service, Emergency Department and outpatient clinics.

Differences in the Tensor Veli Palatini Muscle and Hearing Status in Children With and Without 22q11.2 Deletion Syndrome.

PURPOSE: To investigate the dimensions of the tensor veli palatini (TVP) muscle using high image resolution 3-dimensional magnetic resonance imaging (MRI) of the soft palate among children with normal velopharyngeal and craniofacial anatomy and to compare values to individuals with a diagnosis of 22q11.2 deletion syndrome (22q11DS). We also sought to determine whether there is a relationship between hypoplasia of the TVP and severity of middle ear dysfunction and hearing loss. METHODS: Three-dimensional MRI were used to collect and analyze data obtained across 53 children between 4 and 12 years of age, including 40 children with normal velopharyngeal and craniofacial anatomy and 13 children with a diagnosis of 22q11.2 DS. Tensor veli palatini muscle length, thickness, and volume as well as bihamular distance were compared among participant groups. RESULTS: A Welch's t-test revealed that the TVP in participants with 22q11DS is significantly shorter (P = .005, 17.3 vs 19.0 mm), thinner (P < .001, 1.1 vs 1.8 mm), and less voluminous (P < .001, 457.5 vs 667.3 mm3) than participants without 22q11DS. Participants with 22q11DS also had a greater (P = .006, 27.7 vs 24.7 mm) bihamular distance than participants without 22q11DS. There was an inverse relationship between TVP abnormalities noted above and the severity of audiologic and otologic histories. CONCLUSION: The TVP muscle is substantially reduced in volume, length, and thickness in children with 22q11DS. These findings serve as preliminary support for the association of patient hearing and otologic severity and TVP dysmorphology.

Clinical validation and reproducibility of endoscopic airway measurement in pediatric aerodigestive evaluation.

BACKGROUND: Endoscopic airway measurement (EAM) combines optical endoscopic instruments with open source image processing to accurately obtain airway dimensions. Preclinical models have demonstrated EAM as an accurate technique of airway measurement with the added advantage of characterizing multilevel stenosis, non-circular lesions, and distal obstruction. The aim of this prospective clinical study was to compare EAM to airway measurements obtained from endotracheal tube approximation (ETTA) during pediatric aerodigestive evaluation and to evaluate reproducibility of EAM across practitioners. METHODS: Thirty-seven pediatric patients undergoing routine microlaryngoscopy and bronchoscopy at a single tertiary care children's hospital were prospectively recruited. Patients undergoing emergent procedures were excluded. Two blinded reviewers performed airway measurements using ImageJ (NIH) as previously described and average values were compared to ETTA measurements. Additional EAMs were obtained from an ex vivo airway model by 28 separate clinicians and were analyzed by the same reviewers to evaluate reproducibility. RESULTS: EAM and ETTA measurements were themselves significantly different (p = 0.0003); however, the average absolute difference between the two methods was small (Mean: 0.5 mm, 95%CI: -2.6-1.6 mm). There were notable differences between raters such that estimates of raters with more experience were more similar to ETTA. Despite observed differences between EAM and ETTA, endoscopic airway measurement was highly correlated with ETTA (p = 0.0002, Spearman r = 0.4185), and strong agreement was observed (Bias: -0.4974 ±â€¯1.083 mm, 95% LOA: -2.62-1.625 mm). CONCLUSION: Clinical use of EAM is a valid and precise approach for quantification of airway luminal dimensions. This method may provide advantages over traditional ETTAs for evaluation of asymmetric airway morphology in the pediatric population.

Endoscopic management of tissue-engineered tracheal graft stenosis in an ovine model.

OBJECTIVE: To evaluate the safety and efficacy of bronchoscopic interventions in the management of tissue-engineered tracheal graft (TETG) stenosis. STUDY DESIGN: Animal research study. METHODS: TETGs were constructed with seeded autologous bone marrow-derived mononuclear cells on a bioartificial graft. Eight sheep underwent tracheal resection and orthotopic implantation of this construct. Animals were monitored by bronchoscopy and fluoroscopy at 3 weeks, 6 weeks, 3 months, and 4 months. Bronchoscopic interventions, including dilation and stenting, were performed to manage graft stenosis. Postdilation measurements were obtained endoscopically and fluoroscopically. RESULTS: Seven dilations were performed in six animals. At the point of maximal stenosis, the lumen measured 44.6 ± 8.4 mm2 predilation and 50.7 ± 14.1 postdilation by bronchoscopy (P = 0.3517). By fluoroscopic imaging, the airway was 55.9 ± 12.9 mm2 predilation and 65.9 ± 22.4 mm2 postdilation (P = 0.1303). Stents were placed 17 times in six animals. Pre- and poststenting lumen sizes were 62.8 ± 38.8 mm2 and 80.1 ± 54.5 mm2 by bronchoscopy (P = 0.6169) and 77.1 ± 38.9 mm2 and 104 ± 60.7 mm2 by fluoroscopy (P = 0.0825). Mortality after intervention was 67% with dilation and 0% with stenting (P = 0.0004). The average days between bronchoscopy were 8 ± 2 for the dilation group and 26 ± 17 in the stenting group (P = 0.05). One hundred percent of dilations and 29% of stent placements required urgent follow-up bronchoscopy (P = 0.05). CONCLUSION: Dilation has limited efficacy for managing TETG stenosis, whereas stenting has a more lasting clinical effect. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:2219-2224, 2017.

Routine Bronchoscopy and Fogarty Catheter Occlusion of Tracheoesophageal Fistulas.

INTRODUCTION: Use of a Fogarty catheter for emergent occlusion of tracheoesophageal fistulas (TEFs) has been described for use in unstable neonates. Our purpose was to describe a case series of elective Fogarty catheter occlusion of the TEF. MATERIALS AND METHODS: A formal operative laryngoscopy and rigid bronchoscopy were performed with Fogarty catheter placement into the fistula before surgical intervention. The balloon was inflated and gentle traction provided occlusion of the tract. An endotracheal tube was then placed in a midtracheal location irrespective of fistulous tract location. The Fogarty catheter was removed at the time of fistula ligation. RESULTS: Six patients underwent Fogarty catheter occlusion of the TEF at the time of repair. The average gestational age was 38 ± 2 weeks and birth weight was 2499 ± 399 g. Associated anomalies or comorbidities were present in 2 of 6 patients (33%). Five patients (83%) had an esophageal atresia with distal TEF, all of whom underwent surgical intervention before day of life (DOL) 2. Of these patients, 3 were performed thoracoscopically, 1 was converted from thoracoscopic to open, and 1 was initiated as an open procedure. One patient had an H-type fistula, which was repaired through a cervical approach on DOL 48. Average time required for both bronchoscopy and Fogarty placement was 10 ± 2 minutes. There were no complications associated with Fogarty catheter placement and catheter dislodgement did not occur during any of the procedures. CONCLUSION: Elective Fogarty catheter occlusion of TEF can be performed safely and expeditiously, alleviating many perioperative challenges of TEF.

Device failure in sialoendoscopy: Intraoperative practical decision-making.

Sialoendoscopy has recently emerged as an alternative to gland excision in management of recurrent sialoadenitis and sialolithiasis. This technique has both diagnostic and therapeutic purposes. We report a case of unusual device failure during removal of a submandibular stone from Wharton's duct, which ultimately led to ductal avulsion. Sialoendoscopy is safe and effective in management of non-neoplastic major salivary gland disorders. Ductal avulsion can happen during mechanical procedures like stone removal or dilation of strictures. Failing to release the stone from the basket is very rare but can be problematic and lead to major complications.

Radiographic Findings and Clinical Correlates in Pediatric Periorbital Infections.

OBJECTIVE: To review radiographic studies of pediatric patients presenting with periorbital infections and to evaluate sinonasal anatomical factors and clinical course related to this disease process. METHODS: Retrospective study review of computed tomography (CT) scans in 100 patients less than 18 years old, admitted to a tertiary children's hospital with the diagnosis of an orbital infection. CT scans were reviewed for anatomic variants and Lund-Mackay scores were calculated. An independent chart reviews of the treatment course and need for surgical intervention was performed. RESULTS: Of 100 patients, 67% were male, 60% had left-sided infections, and 30% of patients were treated with surgical drainage. Adenoid hypertrophy (61%), inferior turbinate hypertrophy (80%) and septal deviation (47%) were common, but did not show statistical correlation with the need for surgical intervention. Dehiscence of the lamina papyracea was identified in 21% of patients treated without surgery and in 76% of those requiring surgery (P 0.0048). The average overall Lund-Mackay score was 11.8 and did not correlate with the need for surgical intervention. CONCLUSIONS: To our knowledge, this is the first study to evaluate the incidence of sinonasal anatomic abnormalities in children presenting with periorbital infections. This study also demonstrated that lamina papyracea dehiscence is a common finding and is associated with higher rates of surgical intervention. Such findings may have an important role in the diagnosis, surveillance and management of sinus disease in the pediatric population.

Initial experience from a multidisciplinary pediatric salivary gland disorder clinic.

OBJECTIVE: This study is the first in the literature to characterize and detail the clinical and surgical experience of one of the few multidisciplinary salivary gland disorder clinics in North America. METHODS: This is a retrospective chart review of a descriptive nature, including patient information from February 2013 to August 2014. The Salivary Gland Disorder Clinic (SGDC) is located at Nationwide Children's Hospital, a public academic hospital. All patients seen at the SGDC were included in this study, 54 in total. Patients were seen for any salivary gland disorder presentation, ranging from sialorrhea to glandular masses. RESULTS: A total of 70.4% of patients presented to the SGDC with a chief complaint of sialorrhea. Nearly 28% had previously experienced documented aspiration, and drooling severity and frequency was 4.06 and 3.3 on the Thomas-Stonell and Greenberg Drooling Rating Scales. 50% of patients presented with neurologic comorbidities and 25.9% with aerodigestive tract anatomic defects. Over 35% of patients had previously attempted medical treatment and 31.5% had no prior treatment attempts. 87% of all patients were offered further treatment options, including interventional, surgical, medical, and conservative measures. CONCLUSIONS: Pediatric salivary gland disorders, especially sialorrhea, can profoundly impact overall health and quality of life. Appropriate management of this symptom requires expert training and knowledge of the upper aerodigestive tract anatomy and appropriate treatment modalities. Our study demonstrates that there is community need for a centralized salivary gland disorder clinic given the complex comorbidities and social challenges that face this population. Many patients present with great risk for aspiration-related complications and the vast majority are offered new treatment options.

Using the maxillary-nasal angle to evaluate congenital nasal pyriform aperture stenosis.

IMPORTANCE: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of nasal airway obstruction in newborns. The decision to operate is made clinically. Although pyriform aperture width is used for diagnosing CNPAS, it does not fully characterize stenosis of the nasal cavity. OBJECTIVE: To determine the utility of additional metrics for evaluating CNPAS. DESIGN, SETTING, AND PARTICIPANTS: The medical records of 13 patients with CNPAS treated from 2007 through 2012 at a single tertiary pediatric facility were retrospectively examined. Data on patient demographic characteristics, known genetic abnormalities, and hospital courses were extracted. Computed tomographic images were evaluated for pyriform aperture width; maxillary-nasal angle (MNA), defined as the angle between the anterior maxilla and anterior-posterior nasal axis; and choanal width. INTERVENTIONS: Medical management and surgical management. MAIN OUTCOMES AND MEASURES: Pyriform aperture width, MNA, and choanal width. RESULTS: Six of 13 patients underwent medical management, and 7 patients underwent surgical treatment. For patients who were managed medically as compared with those managed surgically, the evaluation revealed a larger pyriform aperture width (median [interquartile range {IQR}], 5.6 [5.4-6.1] vs 4.6 [4.5-4.7] mm; P = .03) and MNA (median [IQR], 70° [63°-73°] vs 59° [59°-64°]; P = .048) but no significant difference in choanal width (median [IQR], 11.0 [9.6-12.2] vs 11.9 [10.3-11.9] mm; P = .76). CONCLUSIONS AND RELEVANCE: The MNA, when used in conjunction with pyriform aperture width, provides additional pertinent information to supplement clinical decision making in the evaluation of patients with CNPAS. These measurements may be helpful in identifying patients who should undergo surgical intervention, although additional studies would be required to allow predictive use of the MNA.

Conservative management of iatrogenic membranous tracheal wall injury: a discussion of 2 successful pediatric cases.

IMPORTANCE: Management of pediatric tracheal injuries is a controversial topic not well documented in the otolaryngology literature. OBJECTIVES: To present our case outcomes in 2 pediatric patients with tracheal injury and to review the literature on surgical vs conservative management of tracheal injuries in the pediatric age group. DESIGN: Case series and literature review. SETTING: Tertiary referral pediatric hospital. MAIN OUTCOME MEASURES: Morbidity and mortality outcomes. RESULTS: The 2 tracheal injuries in the case studies were successfully managed with intubation, antibiotics, and careful monitoring without morbidity related to the tracheal injury. CONCLUSIONS AND RELEVANCE: A high level of clinical suspicion is necessary for the diagnosis of tracheal injuries. Both conservatively and surgically managed patients require serial chest and lateral neck plain radiographs to follow resolution of pneumomediastinum and pneumothorax. Both require surveillance of the airway with operative laryngoscopy and bronchoscopy, in addition to long-term follow-up. Surgical repair of trachea rupture, although resulting in shorter intubation, may require tracheotomy. Promising results have been reported in the literature for conservative management with a relatively small risk of airway stenosis without the complications associated with intrathoracic repair. Conservative management should be considered in the management of tracheal injuries in the pediatric population.

Recurrent unilateral periorbital cellulitis in a pediatric patient--an anatomic abnormality.

A 2-year-old male, otherwise healthy, suffered a total of 7 episodes of recurrent right-sided periorbital celluitis (POC) which began at 11 months of age. Five of the 7 episodes of right eye swelling/erythema required hospital admission for intravenous antibiotics. Imaging studies demonstrated a well-defined dehiscence in the lamina papyracea. Endoscopic sinus surgery was performed and an abnormal uncinate process was visualized, fused to the lateral nasal wall and ethmoid bulla. Post-operatively, the patient had no further infections. Nasal endoscopy and high-resolution imaging in pediatric patients with recurrent POC could identify those who would benefit from early surgical intervention.