Prospective evaluation of nasal septal perforation repair with absorbable plate and temporalis fascia in early adolescent patients.

OBJECTIVES: In the pediatric population, nasal septal perforations (NSP) are rare, and management is not well described. The use of various techniques has been reported in adults, including the use of interposition grafts, however this technique has not been described in the pediatric population. Our hypothesis is that the closure rate using absorbable d-lactide and l-lactide (each 50 %), polymer (PDLLA) plates as interposition grafts with temporalis fascia for NSP repair in the pediatric population will be an effective method compared to previous techniques. METHODS: Chart review was performed on patients who underwent NSP repair before June 2021, results were compared to a prospective evaluation of an interposition plate graft for repair at a tertiary care children's hospital. RESULTS: Fifteen patients via previous techniques and 5 patients via PDLLA and fascia graft were reviewed. Etiology of perforations included 45 % idiopathic, 25 % traumatic, and 15 % iatrogenic. In the previous techniques group, 10 were male, mean (median) age 14.4 years (15.2). Average size of NSP was 12.6 mm ± 6.6 mm (SD). 14/15 (93 %) patients had resolution of symptoms at 10-week follow-up, and 2/15 (13 %) required repeat repair. Five prospective patients were repaired with a PDLLA and fascia interposition graft, 4 were female, mean (median) age 14.6 years (Nassif and Scott, 2021 Feb 1) [14]. Average size of NSP was 11 mm ± 2.2 mm (SD). 100 % had resolution of symptoms at 10-week follow-up, 0 needed repeat surgery. No significant difference was found in size of NSP or in need for repeat procedure (p > 0.05) between the groups. CONCLUSION: Use of absorbable PDLLA interposition grafts with temporalis fascia for NSP repair in the pediatric population is effective at closing and resolving symptoms associated with NSP.

Overnight Monitoring Criteria for Children with Obstructive Sleep-Disordered Breathing After Tonsillectomy: Revisited.

OBJECTIVES: Previous studies indicate children who pass an Asleep Room Air Challenge (AsRAC) do not have significant postoperative adverse respiratory events after adenotonsillectomy (T&A). Subsequently, we revised our overnight monitoring (OM) criteria, allowing patients with an obstructive apnea/hypopnea index (OAHI) ≤20 or nonsevere obesity (Class I) to be considered for same-day surgery (SDS) if they passed an AsRAC. Our hypothesis is that our modified OM criteria would not increase the return visits or readmission rates for patients undergoing SDS within 48 h or 15 days of T&A. METHODS: A retrospective review of all children aged ≥3 and <21 years who underwent T&A at a tertiary children's hospital and its satellite locations was performed from January 2017 to September 2022. Descriptive statistics and outcome measures were compared using a 3% margin noninferiority test before and after the new criteria implementation. RESULTS: Before intervention, 3,266 (58%) T&As were performed as SDS. Afterward, 74% of T&As were performed as SDS (p-value <0.05). There was no difference in the ED revisit rate for SDS within the 3% noninferiority margin. Following intervention, 29% more children with Class I obesity (62% vs. 33%) underwent SDS (p-value <0.001). Afterward, 19% more children with polysomnography underwent SDS (39% vs. 20%), p-value <0.001. After intervention, within 48 h of SDS, six (0.9%) children had revisits for bleeding and seven (1.2%) for vomiting. There were no perioperative respiratory events. CONCLUSION: Our revised monitoring criteria did not demonstrate an increase in ED visit or readmissions rates within 48 h or 15 days of T&A. Additionally, we found a 29% increase in Class I obese children undergoing SDS T&A. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Sensorineural correlates of failed functional recovery after natural regeneration of vestibular hair cells in adult mice.

Vestibular hair cells (HCs) are mechanoreceptors that sense head motions by modulating the firing rate of vestibular ganglion neurons (VGNs), whose central processes project to vestibular nucleus neurons (VNNs) and cerebellar neurons. We explored vestibular function after HC destruction in adult Pou4f3+/DTR (DTR) mice, in which injections of high-dose (50 ng/g) diphtheria toxin (DT) destroyed most vestibular HCs within 2 weeks. At that time, DTR mice had lost the horizontal vestibulo-ocular reflex (aVORH), and their VNNs failed to upregulate nuclear cFos expression in response to a vestibular stimulus (centrifugation). Five months later, 21 and 14% of HCs were regenerated in utricles and horizontal ampullae, respectively. The vast majority of HCs present were type II. This degree of HC regeneration did not restore the aVORH or centrifugation-evoked cFos expression in VNNs. The failure to regain vestibular pathway function was not due to degeneration of VGNs or VNNs because normal neuron numbers were maintained after HC destruction. Furthermore, sinusoidal galvanic stimulation at the mastoid process evoked cFos protein expression in VNNs, indicating that VGNs were able to regulate VNN activity after HC loss. aVORH and cFos responses in VNNs were robust after low-dose (25 ng/g) DT, which compared to high-dose DT resulted in a similar degree of type II HC death and regeneration but spared more type I HCs in both organs. These findings demonstrate that having more type I HCs is correlated with stronger responses to vestibular stimulation and suggest that regenerating type I HCs may improve vestibular function after HC loss.

Beyond Laryngeal Clefts: Interarytenoid Injection Augmentation to Predict Success of Suture Augmentation in Children.

OBJECTIVE: To assess the efficacy of interarytenoid injection augmentation (IAIA) and the ability of IAIA to predict response to interarytenoid suture augmentation (IASA) based on diet advancement on video fluoroscopic swallow studies (VFSS). METHODS: Retrospective cohort analysis of patients with persistent pharyngeal dysphagia at a tertiary children's hospital with VFSS pre- and post-IAIA were included between March 2011 and June 2019. RESULTS: Median age of the 229 patients was 2.2 years (5.8 months-19 years). Interarytenoid mucosal height (IAMH) was found to be above the false vocal folds in 112 patients (53.4%) and at true vocal folds in 10 (4.9%) patients. On VFSS post-IAIA, 95 (41.5%) patients were successfully advanced in recommended diet consistency, 115 (50.2%) were stable, and 19 (8.3%) needed thicker consistency. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% confidence interval (CI; 0.50-0.85). Poisson regression found no covariates with significant association with improvement on IAIA. For IASA patients, 35/60 (58.3%) improved on post-op VFSS. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% CI (0.63-1.33). Positive predictive value for IAIA predicting response to IASA was 77% with positive likelihood ratio of 2.3. The response to IAIA versus no response to IAIA likelihood ratios were found to have a statistically significant difference (p < 0.05). CONCLUSIONS: Our study suggests IAIA yields objective improvement in swallow function on VFSS in nearly half of our patients and may be a reliable diagnostic tool to predict response to IASA in patients with persistent pharyngeal dysphagia with or without a laryngeal cleft. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1749-1756, 2023.

Current management of type III and IV laryngotracheoesophageal clefts: the case for a revised cleft classification.

PURPOSE OF REVIEW: This review summarizes the paediatric laryngotracheoesophageal cleft (LTEC) literature, with an emphasis on recent trends, evaluation and management, surgical techniques, postoperative care of Type III and IV LTECs, and to propose a revised cleft classification system that more accurately reflects our current understanding of these anomalies. RECENT FINDINGS: There are a number of techniques described to address Type III and IV LTEC, from endoscopic to open approaches with thoracotomy. The surgical approach should be tailored to the length of the cleft and its proximity to important anatomical structures. On the basis of review of the literature, we propose a modified Benjamin-Inglis classification (MBI) with subcategories to address this issue. Postoperative complications are common, namely, tracheoesophageal fistulae and tracheomalacia, which may necessitate subsequent procedures or prolonged tracheostomy dependence. SUMMARY: The medical and surgical management of Type III and IV LTEC is challenging with a high rate of morbidity and mortality. The rarity and difficulties in management of these malformations have made large cohort studies difficult, thus generalizable recommendations have been elusive. Experience and patient selection are critical for successful endoscopic repair. Anterior cervical approach, often with complete laryngofissure, appears to be the most common and preferred method for open repairs, though some use a lateral approach. The proposed MBI classification appears to be a useful adjunct to aid in surgical decision-making for deeper LTEC.

Parallel mechanisms suppress cochlear bone remodeling to protect hearing.

Bone remodeling, a combination of bone resorption and formation, requires precise regulation of cellular and molecular signaling to maintain proper bone quality. Whereas osteoblasts deposit and osteoclasts resorb bone matrix, osteocytes both dynamically resorb and replace perilacunar bone matrix. Osteocytes secrete proteases like matrix metalloproteinase-13 (MMP13) to maintain the material quality of bone matrix through perilacunar remodeling (PLR). Deregulated bone remodeling impairs bone quality and can compromise hearing since the auditory transduction mechanism is within bone. Understanding the mechanisms regulating cochlear bone provides unique ways to assess bone quality independent of other aspects that contribute to bone mechanical behavior. Cochlear bone is singular in its regulation of remodeling by expressing high levels of osteoprotegerin. Since cochlear bone expresses a key PLR enzyme, MMP13, we examined whether cochlear bone relies on, or is protected from, osteocyte-mediated PLR to maintain hearing and bone quality using a mouse model lacking MMP13 (MMP13(-/-)). We investigated the canalicular network, collagen organization, lacunar volume via micro-computed tomography, and dynamic histomorphometry. Despite finding defects in these hallmarks of PLR in MMP13(-/-) long bones, cochlear bone revealed no differences in these markers, nor hearing loss as measured by auditory brainstem response (ABR) or distortion product oto-acoustic emissions (DPOAEs), between wild type and MMP13(-/-) mice. Dynamic histomorphometry revealed abundant PLR by tibial osteocytes, but near absence in cochlear bone. Cochlear suppression of PLR corresponds to repression of several key PLR genes in the cochlea relative to long bones. These data suggest that cochlear bone uniquely maintains bone quality and hearing independent of MMP13-mediated osteocytic PLR. Furthermore, the cochlea employs parallel mechanisms to inhibit remodeling by osteoclasts and osteoblasts, and by osteocytes, to protect hearing. Understanding the cellular and molecular mechanisms that confer site-specific control of bone remodeling has the potential to elucidate new pathways that are deregulated in skeletal disease.

Comparison of W-Plasty vs Traditional Straight-Line Techniques for Primary Paramedian Forehead Flap Donor Site Closure.

IMPORTANCE: The paramedian forehead flap (PMFF) donor site scar is hard to disguise and may be a source of patient dissatisfaction. OBJECTIVE: To evaluate the aesthetic outcome of W-plasty vs traditional straight-line (SL) closure techniques of the PMFF donor site. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted at the University of California, San Francisco Medical Center. Clinical history and operative reports were reviewed for 31 patients who underwent a PMFF procedure performed between November 1, 2011, and May 29, 2014. Blinded photographic analysis of postoperative photographs was performed. INTERVENTIONS: The pedicled component of the PMFF was raised primarily with either a W-plasty or traditional SL design. MAIN OUTCOMES AND MEASURES: Standard photographs of the donor site, obtained at least 90 days after surgery, were reviewed and scored in a blinded fashion by 4 dermatologic surgeons using a 100-point visual analog scale (from 0 [worst possible outcome] to 100 [best possible outcome]) and a 5-point Likert scale (from very poor to excellent). Interrater reliability was assessed via Cronbach α testing. RESULTS: All 31 forehead flaps survived during this study period; 16 PMFFs were raised with the W-plasty technique and 15 were raised with the SL technique. The W-plasty and SL groups were similar in terms of age, sex, and race/ethnicity (mean [SD] age, 68.4 [12.4] vs 61.8 [11.6] years; 13 [84%] vs 9 [60%] men; and 15 [94%] vs 13 [87%] white). Patients undergoing W-plasty closure had significantly higher mean visual analog scale scores compared with those undergoing SL closure (72.8 [18.3] vs 65.6 [18.1]; P = .03). Mean Likert scale scores for W-plasty were higher than those for SL closure, but the difference was not significant (3.77 [1.02] vs 3.43 [0.98]; P = .08). Overall interrater reliability for the visual analog scale and Likert scale scores were 0.67 and 0.58, respectively. CONCLUSIONS AND RELEVANCE: Patients undergoing PMFF donor site closure using a primary W-plasty technique demonstrated better mean scar appearance of the forehead donor site compared with SL closure. The primary W-plasty technique did not result in any PMFF losses and should be considered for appropriate patients. LEVEL OF EVIDENCE: 3.