Quality of Life Outcomes After Pediatric Otitis Media Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVES: Systematically review of literature characterizing health-related quality of life (HRQoL) impact of surgery in pediatric otitis media (OM) patients, and meta-analysis of studies using the OM-6 questionnaire. DATA SOURCES: Pubmed, EMBASE, Cochrane Library, Scopus. REVIEW METHODS: A systematic review of literature of studies evaluating HRQoL outcomes for OM patients managed by surgery. Two investigators independently reviewed abstracts and full-length articles. Risk of bias was assessed using the MINORS criteria and Cochrane Risk of Bias 2 tool. RESULTS: The search yielded 1272 studies, 50 underwent full-text review and 23 met inclusion criteria. Non-randomized studies were of moderate to good quality, while randomized trials had a high risk of bias. Age ranged from 6 months to 15 years. Race and socioeconomic factors were inconsistently reported. There were 11 HRQoL outcome measure instruments of which four were disease-specific. Eleven studies used OM-6 and nine were included in the meta-analysis. Pooled analysis of five studies showed a mean OM-6 change of 1.79 (95% CI: 1.53-2.06; 95% PI: 0.92-2.67; I2 = 68%) 4-6 weeks after surgery; a mean change of 1.87 (95% CI: 1.15-2.58; 98%) after 6 months across two studies; and a mean change of 1.64 (1.02 to 2.27; -6.35 to 9.64; 98%) after 9-13 months across three studies. CONCLUSIONS: There is no consistency in HRQoL instruments used to evaluate pediatric OM surgery outcomes in current literature with few RCTs. Meta-analysis showed a clinically significant large improvement in HRQoL 4-6 weeks after tympanostomy tube placement. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Multi-institutional Assessment of Otitis Media Epidemiology Using Real-world Data.

OBJECTIVES: To determine rates and risk factors of pediatric otitis media (OM) using real-world electronic health record (PEDSnet) data from January 2009 through May 2021. STUDY DESIGN: Retrospective cohort study. SETTING: Seven pediatric academic health systems that participate in PEDSnet. METHODS: Children <6 months-old at time of first outpatient, Emergency Department, or inpatient visit were included and followed longitudinally. A time-to-event analysis was performed using a Cox proportional hazards model to estimate hazard ratios for OM incidence based on sociodemographic factors and specific health conditions. RESULTS: The PEDSnet cohort included 910,265 children, 54.3% male, mean age (months) 1.3 [standard deviation (SD) 1.6] and mean follow up (years) 4.3 (SD 3.2). By age 3 years, 39.6% of children had evidence of one OM episode. OM rates decreased following pneumococcal-13 vaccination (PCV-13) and the COVID-19 pandemic. Along with young age, non-Hispanic Black/African American or Hispanic race/ethnicity, public insurance, higher family income, and male sex had higher incidence rates. Health conditions that increased OM risk included cleft palate [adjusted hazard ratio (aHR) 4.0 [95% confidence interval (CI) 3.9-4.2], primary ciliary dyskinesia [aHR 2.5 (95% CI 1.8-3.5)], trisomy 21 [aHR 2.0 (95% CI 1.9-2.1)], atopic dermatitis [aHR 1.4 (95% CI 1.4-1.4)], and gastroesophageal reflux [aHR1.5 (95% CI 1.5-1.5)]. CONCLUSIONS: Approximately 20% of children by age 1 and 40% of children by age 3 years will have experienced an OM episode. OM rates decreased after PCV-13 and COVID-19. Children with abnormal ciliary function or craniofacial conditions, specifically cleft palate, carry the highest risk of OM.

Recurrent missense variant identified in two unrelated families with MPZL2-related hearing loss, expanding the variant spectrum associated with DFNB111.

MPZL2-related hearing loss is a rare form of autosomal recessive hearing loss characterized by progressive, mild sloping to severe sensorineural hearing loss. Thirty-five previously reported patients had biallelic truncating variants in MPZL2, with the exception of one patient with a missense variant of uncertain significance and a truncating variant. Here, we describe the clinical characteristics and genotypes of five patients from four families with confirmed MPZL2-related hearing loss. A rare missense likely pathogenic variant [NM_005797.4(MPZL2):c.280C>T,p.(Arg94Trp)] located in exon 3 was confirmed to be in trans with a recurrent pathogenic truncating variant that segregated with hearing loss in three of the patients from two unrelated families. This is the first recurrent likely pathogenic missense variant identified in MPZL2. Apparently milder or later-onset hearing loss associated with rare missense variants in MPZL2 indicates that some missense variants in this gene may cause a milder phenotype than that resulting from homozygous or compound heterozygous truncating variants. This study, along with the identification of truncating loss of function and missense MPZL2 variants in several diverse populations, suggests that MPZL2-related hearing loss may be more common than previously appreciated and demonstrates the need for MPZL2 inclusion in hearing loss testing panels.

Nanoparticle Concentration in Surgical Plume During Tonsillectomy: A Comparison of Four Techniques.

OBJECTIVE: Surgical plume has known potential occupational health hazards. This study compares nanoparticle concentrations in surgical plumes generated between different pediatric tonsillectomy surgical techniques and assesses the efficacy of mitigation measures. METHODS: This is a cross-sectional study performed at a tertiary care academic center. Extracapsular or intracapsular tonsillectomy was performed in 60 patients using four techniques and in 10 additional patients using mitigation measures. Two nanoparticle counters were used to measure particulate concentrations: CPC™ and DiSCmini™. Tonsillectomy techniques included: (1) microdebrider (MD), (2) Bovie with manual suctioning by an assistant (B), (3) Bovie with built-in smoke evacuation system (BS), and (4) Coblator™ (CB). An additional Yankauer suction was used in the mitigation groups (BSY) and (CBY). Comparative analysis was performed using one-way ANOVA on ranks and pairwise comparisons between the groups. RESULTS: The mean concentrations (particles/cm3) and coefficient of variants for the DiSCmini particulate counter were MD: 5140 (1.6), B: 30700 (1.5), BS: 25001 (0.8), CB: 54814 (1.7), CBY: 2395 (1.3) and BSY: 11552 (1.0). Mean concentrations for the CPC particulate counter were MD: 1223 (1.4), B: 3405 (0.7), BS: 5002 (0.9), CB: 13273 (1.0), CBY: 1048 (1.2) and BSY: 3046 (0.6). The lowest mean concentrations were noted in cases using MD and the highest in cases using CB. However, after mitigation, CBY had the lowest overall levels. CONCLUSION: Tonsillectomy technique does impact the levels of nanoparticles emitted within the surgical plume, which may present an occupational hazard for operating room personnel. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2444-2448, 2024.

The qualitative experiences of otolaryngologists with genetic services in pediatric hearing loss evaluation.

Genetic testing is one of the most high-yield diagnostic tests in the evaluation of pediatric sensorineural (SNHL) hearing loss, leading to a genetic diagnosis in 40-65% of patients. Previous research has focused on the utility of genetic testing in pediatric SNHL and otolaryngologists' general understanding of genetics. This qualitative study examines otolaryngologists' perceptions about facilitators and barriers when ordering genetic testing in the workup of pediatric hearing loss. Potential solutions for overcoming barriers are also explored. Eleven (N = 11) semi-structured interviews were conducted with otolaryngologists in the USA. Most participants were currently practicing in a southern, academic, urban setting and had completed a pediatric otolaryngology fellowship. Insurance was one of the main barriers to testing, and increased genetics provider accessibility was the most frequently cited solution to increase utilization of genetic services. Difficulty acquiring insurance coverage and unfamiliarity with the genetic testing process were the most common reasons otolaryngologists referred patients to genetics clinics for genetic testing, as opposed to ordering testing themselves. This study suggests that otolaryngologists recognize the importance and utility of genetic testing, but a lack of genetics-specific skills, knowledge, and resources makes it difficult for them to facilitate testing. Multidisciplinary hearing loss clinics that include genetics providers may increase the overall accessibility of genetic services.

Association of Diet Patterns and Post-Operative Tympanostomy Tube Otorrhea: A Pilot Study.

OBJECTIVE: The objective of this study was to explore diet patterns in children with tympanostomy tube placement (TTP) complicated by postoperative tympanostomy tube otorrhea. STUDY DESIGN: Cross-sectional survey and retrospective cohort study. METHODS: Caregivers of children (0-12 years old), at a tertiary-care pediatric hospital who underwent TTP within 6 months to 2 years prior to enrollment were included. Children with a history of Down syndrome, cleft palate, craniofacial syndromes, known immunodeficiency, or a non-English-speaking family were excluded. Our primary outcome variable was the number of otorrhea episodes. The primary predictor was diet patterns, particularly dessert intake, which was captured through a short food questionnaire. RESULTS: A total of 286 participants were included in this study. The median age was 1.8 years (IQR, 1.3, 2.9). A total of 174 (61%) participants reported at least one episode of otorrhea. Children who consumed dessert at least two times per week had a higher risk of otorrhea compared to children who consumed one time per week or less (odds ratio [OR], 3.22, 95% Confidence Interval [CI]: 1.69, 6.12). The odds ratio increase continued when considering more stringent criteria for otorrhea (multiple episodes or one episode occurring 4 weeks after surgery), with a 2.33 (95% CI: 1.24, 4.39) higher odds of otorrhea in children with dessert intake at least 2 times per week. CONCLUSIONS: Our pilot data suggest that episodes of otorrhea among children with TTP were associated with more frequent dessert intake. Future studies using prospectively administered diet questionnaires are necessary to confirm these findings. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3575-3581, 2023.

The cost-effectiveness of targeted screening for congenital cytomegalovirus in newborns compared to clinical diagnosis in the US.

OBJECTIVE: Congenital cytomegalovirus (cCMV) is the leading environmental cause of hearing loss (HL) among children, affecting four in one thousand newborns. cCMV testing in the US is currently based on clinical diagnosis which does not consistently identify cCMV cases and precludes early intervention to prevent and reduce the severity of HL. We estimated the cost-effectiveness of targeted newborn screening and cCMV testing among newborns compared to clinical diagnosis. METHODS: We use a decision-analytic model to estimate the costs of preventing HL progression, of additional cases of severe HL, of identifying a case of HL one year earlier, and of identifying an additional case of cCMV, through targeted screening and cCMV testing for infants failing two newborn hearing screens with follow-up to age five. We also estimate the costs of nationwide implementation of a newborn screening and testing program. Model pathways were based on best practices for screening, testing, and treatment. Probabilities were drawn from the published literature; costs were estimated based on Medicare reimbursement rates. Probabilistic and scenario analyses were conducted to determine the robustness of results. RESULTS: Targeted testing and cCMV screening, compared to standard of care, cost an additional $2.96 (±2.26) per infant screened and identified 0.00038 (±0.00022) cases of HL, 3.8 in 10000 children, at a cost of $8197 (±4217) per case of HL identified. Implementing targeted screening for all children in the US was estimated to cost $193,229. CONCLUSIONS: Although cases numbers are small, our model shows that targeted newborn screening and cCMV testing reduced cases of HL progression. Adoption of newborn targeted screening as standard of care should be considered given it may prevent disability at very low cost.

Pediatric otolaryngology in the coronavirus disease 2019 pandemic: what have we learned?

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID-19) has changed the face of healthcare. The current review is to discuss the major aspects that have changed in pediatric otolaryngology, from surgical operations management, to clinic workflow, to procedural precautions. RECENT FINDINGS: There have been many studies over the past year describing different ways to improve the safety of healthcare delivery in pediatric otolaryngology amidst a global pandemic, as well as ways to improve clinic and surgical logistics along with guidelines for telehealth of a surgical specialty. SUMMARY: COVID-19 has forever altered how healthcare is viewed and practiced, and pediatric otolaryngology was not exempt. With an increased focus on provider safety, as well as novel ways of utilizing changes in methods of communication, the practice of pediatric otolaryngology has evolved with the rest of healthcare to take on the new challenges brought on by this global pandemic.

Adenotonsillectomy in high risk patients: Hematologic abnormalities and COVID-19 considerations.

Adenotonsillectomy is one of the most common surgical procedures performed by otolaryngologists. It is vital that surgeons are aware of the risks in performing this surgery especially during the COVID-19 pandemic and in children with hematologic disorders. In this review we describe common hematologic disorders often noted in pediatric patients undergoing this procedure, as well as proper screening and management of these patients. In addition, we also address the impact of the COVID-19 pandemic and some measures to help mitigate the risks of this procedure during this time.

Radiologic Findings in Pediatric Sudden Sensorineural Hearing Loss.

OBJECTIVE: Pediatric sudden sensorineural hearing loss (pSSNHL) is a rare phenomenon. There is currently no consensus on the role of imaging in the work-up for this patient population. We aim to evaluate the efficacy of magnetic resonance imaging (MRI) and high-resolution computed tomography (CT) studies in determining the etiology of pSSNHL. STUDY DESIGN: Retrospective case review. SETTING: Tertiary Hospital and Ambulatory Otolaryngology Clinic. PATIENTS: Patients ≤18 years of age with sudden sensorineural hearing loss (SSNHL) and who had either MRI or CT imaging between January 2010 and May 2019 were included. INTERVENTION: Diagnostic imaging. MAIN OUTCOME MEASURES: Clinical characteristics and radiology impressions. RESULTS: A total of 11 patients were identified, and 10 had unilateral SSNHL. MRI was performed on all patients, five patients had additional CT imaging. Abnormal imaging findings relevant to SSNHL were observed in five patients (45.5%), which included enlarged endolymphatic duct and sac, labyrinthine ossification, apical petrositis, hypoplastic cochlear nerve, and arachnoid cyst in the internal auditory canal; one patient had unrelated findings (enlarged pituitary gland), all remaining imaging studies were normal. CONCLUSION: In our cohort, we found a higher imaging yield on pSSNHL than what has been reported for adult populations, indicating that the use of imaging in the diagnostic work-up is especially important in children.

Evaluating parental genetic knowledge of hearing loss with and without pre-test genetic counseling in a pediatric otolaryngology clinic.

This study evaluated parental knowledge of genetics of sensorineural hearing loss (SNHL) and satisfaction following pre-test consult with and without genetic counseling (GC). A survey evaluating parents' knowledge of genetics for SNHL with and without GC was administered to parents of children with SNHL who were offered genetic testing. The survey also inquired about satisfaction, and decision to pursue genetic testing. Statistical tests included Fisher-Freeman-Halton test and Mann-Whitney test. Forty-nine participants completed the survey and were seen by both otolaryngology and GC intern (ENT + GC) (n = 24) or by otolaryngology (ENT) only (n = 25). Participation groups were not randomized. There were no significant differences in demographics between groups. Participants in the ENT + GC group had higher average genetics knowledge score of 72% correct (range 22%-100%), compared to the ENT only group with 44% (range 22%-78%) (p < .001). Participants in the ENT + GC group were more likely to know the different test result possibilities (p = .002), the most common form and pathogenic variant associated with SNHL (p < .001), that only a subset of genes are evaluated (p = .004), and that genetic testing may not explain SNHL etiology (p = .013), in comparison with the ENT only group. There was no significant difference in parental satisfaction or ultimate decision to undergo testing between groups. Obtaining genetic testing plays an integral role in the diagnosis and management of SNHL in the pediatric population. Our results suggest that the addition of GC increases parent knowledge of genetics and SNHL. This knowledge allows the family to make a more informed decision as to whether or not to pursue genetic testing.

A Cross-Sectional Survey Evaluating Awareness of Congenital Cytomegalovirus Among Audiologists and Speech-Language Pathologists.

Purpose Congenital cytomegalovirus (cCMV) is the most common congenital infection worldwide and a leading environmental cause of pediatric hearing loss (HL). The objective of this study was to evaluate audiologists and speech-language pathologists (SLPs) on awareness and knowledge of cCMV. Method A multiple-choice survey assessing awareness, knowledge, and practice patterns was sent electronically to audiologists and SLPs of the American Speech-Language-Hearing Association. Results were compared between audiologists and SLPs and within stratified groups of audiologists. Data were collected, and descriptive analysis was performed. Results Ninety-four audiologists and 317 SLPs responded. Most audiologists were somewhat or very familiar with cCMV (85.9%), while only 26% of SLPs responded that they were at least somewhat familiar with cCMV (p < .0001). When comparing audiologists' and SLPs' knowledge of symptoms, transmission, and diagnostic age for cCMV, audiologists had higher scores in all categories (p < .0001). Audiologists were then stratified into subgroups to evaluate the association of the given subgroup with their overall knowledge. The more advanced audiology training, the more knowledgeable the respondent was regarding HL progression (p = .002). Audiologists who were more familiar with cCMV scored better in most categories compared to those reporting somewhat or less familiar; these findings were only significant for knowledge of symptoms (p < .0001). Audiologists who were sometimes or frequently evaluating children less than 5 years of age had a better understanding of HL presentation among cCMV patients than those who rarely saw this patient population. Those who were in practice for < 20 years frequently knew the time-sensitive age of diagnosis than respondents in practice longer. Conclusions As a leading environmental cause of pediatric HL, cCMV is frequently encountered by audiologists and SLPs. This study highlights knowledge gaps and areas where targeted education is needed for both groups.

Unilateral Facial Paralysis in the Pediatric Patient.

Unilateral facial paralysis (FP) in the pediatric population is a rare entity secondary to multiple etiologies including infectious, vascular, and neoplastic. In persistent or recurrent FP, imaging can demonstrate a peripheral facial nerve (FN) lesion. Given the rarity of FN lesions, however, there is limited literature regarding optimal management. In this case series, we describe the presentation, evaluation, and management of unilateral FP in three pediatric patients along with a review of the literature. All patients presented with complete FP due to a peripheral FN lesion or compression of the FN. A combined mastoid and middle cranial fossa approach was utilized for excision in two cases, and the other child underwent a translabyrinthine approach. The pathology of the lesions revealed a meningioma, an arachnoid cyst, and a hemangioma. Presentation, evaluation, post-operative outcomes, as well as final pathologies are discussed.

Considerations for povidone-iodine antisepsis in pediatric nasal and pharyngeal surgery during the COVID-19 pandemic.

PURPOSE: Surgeons resuming elective procedures during the COVID-19 pandemic should consider strategies to mitigate risk of exposure. For otolaryngologists performing surgery on children, unique vulnerability to SARS-CoV-2 results from a regular interface with the upper respiratory tract mucosa. A growing interest in perioperative application of povidone­iodine (PVP-I) to the nasopharynx and oropharynx has emerged. The purpose of this review is to provide an evidence-based assessment of PVP-I in pediatric oral, nasal and pharyngeal surgery. METHODS: A contemporary literature review with algorithmic approach to the potential use of PVP-I in pediatric mucosal surgery. RESULTS: Several formulations of PVP-I have shown rapid in vitro virucidal activity against SARS-CoV-2. Antisepsis using 1.0% PVP-I mouthwash and 0.45% PVP-I throat spray can occur after 30 seconds of contact time. To date, in vivo effectiveness of PVP-I against SARS-CoV-2 has yet to be established and possible risks of its direct use on upper aerodigestive mucosa of children must be weighed. CONCLUSION: Further research is required prior to strongly recommending PVP-I use in preparation for nasal, oral or pharyngeal surgery in children.

Algorithm-Based Pediatric Otolaryngology Management During the COVID-19 Global Pandemic: A Children's Hospital of Philadelphia Clinical Consensus.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic requires clinicians to explore alternatives to routine patient management. Otolaryngologists caring for children commonly depend on physical examination, laboratory data, and ambulatory surgical procedures. Limiting patient care, mindful allocation of resources, and concern for safety have challenged all aspects of our health care system. This evidence-based clinical consensus is designed to guide practitioners of pediatric otolaryngology for common scenarios during this time. DATA SOURCES: Peer-reviewed literature, published reports, institutional guidelines, and expert consensus. REVIEW METHODS: A clinical consensus on 6 common scenarios in pediatric otolaryngology developed with evidence-based strategies. CONCLUSIONS: Providers should suspend all in-person nonessential office visits and elective surgical procedures. An emphasis on medical management and caregiver education will provide reasonable approaches to many of the common outpatient concerns. Surgery for chronic otitis media, obstructive sleep apnea, and acute rhinosinusitis should occur only in response to severe complications or failure of medical regimens. The approach to the pediatric neck mass focuses on timely management for oncologic etiologies and cautious surgical intervention for abscess drainage or tissue sampling. Finally, epistaxis and otorrhea must be triaged and addressed without the usual ambulatory procedures. IMPLICATIONS FOR PRACTICE: Adaptation of practice patterns during this unprecedented moment for our health care system requires thoughtful planning. The strategies described allow for safe handling of common pediatric otolaryngology diagnoses. Ultimately, otolaryngologists must be stewards of our global health community while advocating for the care of individual pediatric patients.

Congenital Cytomegalovirus and Hearing Loss: A Pilot Cross-Sectional Survey of Otologists' and Pediatric Otolaryngologists' Knowledge.

OBJECTIVE: To evaluate pediatric otolaryngologists, neurotologists, and otologists on awareness and knowledge of congenital cytomegalovirus (cCMV). STUDY DESIGN: Pilot cross-sectional online survey. SETTING: Otolaryngology practices. SUBJECTS AND METHODS: An electronic multiple-choice questionnaire was sent email listserv to physician members of the American Society of Pediatric Otolaryngology and American Otological Society. The survey assessed demographics, physician awareness, and practice patterns. Data were collected and analyzed. RESULTS: Seventy (14.5%) pediatric otolaryngologists and otologists responded. All responded that they are familiar with cCMV. Most were familiar with symptoms associated with cCMV with the exception of petechia/purpura. Less than 50% knew the incidence/natural history of cCMV-induced hearing loss. Only 63% knew that saliva or urine polymerase chain reaction/culture should be performed prior to 3 weeks of age. Less than half knew the indications for dry blood spot testing, and many incorrectly recommended serologic saliva or urine testing in a child >3 weeks old. Most respondents do not offer any diagnostic testing for cCMV or referral for antiviral therapy for those who may benefit from this treatment. Most either did not know the cCMV screening policy or did not have one at their institution. CONCLUSION: Despite a relatively low overall response rate, this study suggests several knowledge gaps and underutilization of cCMV testing by physicians who frequently encounter pediatric hearing loss. The findings from this pilot study demonstrate the need for further educational directives focused on cCMV to improve knowledge and incorporation of cCMV best practices.

Genetic testing for congenital non-syndromic sensorineural hearing loss.

INTRODUCTION: Approximately 60% of congenital pediatric hearing loss is of genetic etiology. To evaluate non-syndromic sensorineural hearing loss (NSSNHL), guidelines emphasize the use of comprehensive genetic testing (CGT) with next generation sequencing (NGS), yet these tests have limited accessibility, and potential CGT results may not be well understood. Thus, our objective was to analyze genetic testing practices and results for pediatric patients with NSSNHL. METHODS: This was a retrospective chart review of pediatric patients (<18 years) diagnosed with NSSNHL from 2014 to 2017 at a tertiary pediatric hospital. Demographics, clinical data, CGT results, genetic testing practices and referral patterns were recorded and descriptively analyzed. Logistic regression models identified patient characteristics associated with pathogenic variants (PV) and variants of unknown significance (VOUS). RESULTS: 430 patients with congenital NSSNHL were included in the study. Genetic testing was ordered for 28% (n = 122) and resulted for 16% (n = 68). Most of the ordered tests (89%, n = 109) were the CGT panel. A majority (62%, n = 97) of the time in which genetic testing was not ordered, a referral for genetics consultation was placed. Amongst those with CGT results, a definitive genetic etiology was identified in 25% (n = 13), with less than half due to variants of GJB2/6. At least one PV was identified for 33% (n = 18), while at least one VOUS for 93% (n = 51). There were no significant differences in PV presence or number of VOUS across any characteristic except race. When compared to Caucasians, African Americans had significantly higher rates of VOUS with a rate ratio and 95% CI of 1.61 [1.11-2.34], p = 0.01, and Asians trended towards higher rates (1.96 [0.95-4.05], p = 0.06). CONCLUSIONS: CGT is of high utility in the identification of relevant genetic variants and definitive genetic etiologies for pediatric patients with NSSNHL. Though guidelines recommend the early use of CGT, there are many barriers to appropriate testing and counseling, leading to low rates of CGT use at this single institution.

Hearing Loss and Failed Newborn Hearing Screen.

Hearing loss is the most common congenital defect. With early diagnosis and intervention, we are able to improve speech and language outcomes in this population. In this article, we discuss the implications of the newborn hearing screen, as well as diagnostic interventions, management, and intervention, and the increasing role of congenital cytomegalovirus screening.

External auditory canal: Inferior, posterior-inferior, and anterior canal wall overhangs.

OBJECTIVES: To characterize anatomic variants of the external ear canal (EAC), specifically canal wall overhangs. EAC overhangs are problematic since they obstruct the view of the tympanic membrane (TM) and middle ear, possibly creating diagnostic and surgical difficulties. METHODS: We reviewed pre-operative temporal bone CTs from children with cholesteatoma, and no history of EAC erosion or surgery. We measured the anterior canal wall overhang (ACOH), inferior (ICOH), and posterior-inferior (PICOH). A smaller angle means more EAC overhang. Angles >180° counted as 180° since they are non-obstructing. Analysis was performed between angular measurements and clinical and demographic data. RESULTS: 86 patients (88 ears total) were studied. Mean age was 8.3 years. Only obstructing angles were analyzed statistically (<180°). The ICOH was most severe and occurred in 72/88 (81.8%) ears with a mean of 145.9 ±â€¯12.8SD° (range 102-171°). ACOH occurred in 60/88 (68.2%) ears with a mean of 148.3 ±â€¯10.9SD° (range 120-169°). PICOH occurred in 59/88 (67%) ears with a mean of 150.4 ±â€¯9.2SD° (range 124-169°). Overall, ICOH was significantly more severe than PICOH (P = 0.026). ICOH had more Severe (142-102°) overhangs (27/88, 30.7%) than ACOH (17/88, 19.3%) or PICOH (11/88, 12.5%), but these were not significantly different. Analysis of clinical data showed that as the ICOH overhang became more severe, there was a history of significantly more (p = 0.039, r = -0.209) tympanostomy tubes placed. CONCLUSIONS: The greatest prevalence and severity of EAC overhang was the ICOH with a mean angle of 145.9°, compared with 148.3° and 150.4° for the ACOH and PICOH, respectively. This anatomic study demonstrates that ICOH and PICOH are prevalent anatomic variants and may possibly cause similar difficulties in otoscopic diagnosis and surgical TM and middle ear exposure as the well-known ACOH.