Assessment of children with speech sound disorders in otolaryngology outpatient clinics.

OBJECTIVE: To analyze the utility of Ankara Articulation Test (AAT) for the diagnosis of Speech Sound Disorders (SSD) in children by an Otolaryngologist independent of Speech-Language Pathologist (SLP). METHODS: In this prospective single-center study, 83 children comprising 45 boys (54.2%) and 38 girls (45.8%) were enrolled. AAT was applied to the children aged 3-12 years with primary SSD who presented to the otolaryngology outpatient service. Video recording was carried out while testing and the responses to the test were evaluated by another otolaryngologist and SLP. RESULTS: A perfectly significant agreement was found between the speech-language pathologist and otolaryngologist's assessments (Cronbach's Alpha > 0.80). CONCLUSION: Otolaryngologists could evaluate SSD with the help of AAT as well as an SLP analysis. Standardized visual tests, such as the AAT, assist the otolaryngologist in the diagnosis of SSD in outpatient clinics.

Comparison of Voice Quality of Life in Early Stage Glottic Carcinoma Treated with Endoscopic Cordectomy Using Radiofrequency Microdissection Electrodes, Laser Cordectomy, and Radiotherapy.

PURPOSE: To compare the quality of life of patients with early glottic carcinoma who have been treated using three treatment modalities: endoscopic cordectomy using radiofrequency microdissection electrodes (ECRM), transoral laser cordectomy, and radiotherapy (RT). ECRM, transoral laser cordectomy, and RT can all be used as alternatives to invasive open surgery to treat the early stages of glottic cancer such as stage T1. Patients treated using these different modalities could have different outcomes with respect to voice quality of life. MATERIALS AND METHODS: The voice quality of life was measured in patients who underwent ECRM, transoral diode laser excision, or RT for early laryngeal cancer. Post-treatment quality of voice was assessed using the Turkish version of the Voice-Related Quality of Life questionnaire in all patients after 1 year of cancer-free survival. A comparison was then made between the outcomes of the three groups. RESULTS: The total score of the ECRM group, when compared independently to that of the laser and the RT groups, was found to be statistically higher in both cases. However, no statistically significant differences were found between laser and RT groups in terms of any parameters. There was a statistically significant difference between the RT group and the other groups in terms of percentage jitter, percentage shimmer, and fundamental frequency (F0) (P < 0.05). While the RT group had the longest maximum phonation time (P < 0.001), no significant differences were found between the maximum phonation time of the ECRM and the laser groups (P < 0.001). CONCLUSIONS: Overall, the worst outcome with respect to voice quality of life is seen with ECRM. Since there were no significant differences in quality of life between the other two treatment modalities, it is recommended to leave the choice between RT and laser surgery up to the patient.

Cerebrospinal Fluid Leak After Septoplasty in Crouzon Syndrome.

ABSTRACT: Crouzon syndrome presents with craniofacial deformities due to early fusion of cranial sutures. Deviation of the nasal septum could be seen clinically in Crouzon syndrome. Cerebrospinal fluid leaks (CSF) after septoplasty are extremely rare and typically present with simple rhinorrhea, meningitis, and pneumocephalus. Herein, we report an adult patient with Crouzon syndrome who experienced CSF complication after septoplasty surgery.Supplemental Video: CSF leak repair operation, http://links.lww.com/SCS/B930.

The Effect of Blood Loss on the Hemodynamics of Pediatric Patients Undergoing Simultaneous Bilateral Cochlear Implantation.

OBJECTIVE: Our objectives were to find the mean blood loss volume and the mean hemoglobin decrease in patients undergoing simultaneous bilateral cochlear implant surgery, to determine whether they had clinical effects, and to calculate a minimum weight for pediatric patients that is independent of any age criteria. METHODS: A retrospective chart review of the pre- and post-operative hemoglobin concentrations and mean blood loss volumes were calculated for children between 12-24 months of age who underwent cochlear implant surgery. RESULTS: A postoperative decline in hemoglobin concentration was found in 67 cases (92%), with a mean difference between the pre- and post-operative values measuring 1.9 g/dL. Preoperative hemoglobin concentrations decreased from 13.4 g/dL to 11.5 g/dL. Mean blood loss volume was 82.3±12 cc. CONCLUSION: Although simultaneous bilateral cochlear implant surgery is reimbursed by the state for those who are greater than one year of age and who meet the appropriate audiological criteria, our findings suggest that these patients should weigh ≥10 kg to prevent hemodynamic instability due to blood loss during surgery.

Challenges in the Management of Ectopic Parathyroid Pathologies: A Case Series of Five Patients.

In primary hyperparathyroidism (PHPT) the diagnosis and treatment of ectopic parathyroid adenomas (EPTA) is a challenging process for head and neck surgeons. We present five patients with EPTA in different locations, along with an in-depth discussion of imaging modalities. We used sestamibi scintigraphy (MIBI) and ultrasound as first line imaging tools in asymptomatic hypercalcemia and PHPT. Single photon emission computed tomography (SPECT) was combined with MIBI or computed tomography (CT) if a parathyroid pathology was not localized initially. Four-dimensional parathyroid CT (4D-CT) was the last imaging modality preferred to localize the ectopic parathyroid gland. We performed focused unilateral neck exploration (FUNE) with intraoperative frozen section analysis as a routine procedure for imaging-detected lesions. Bilateral neck exploration was performed for re-exploration cases and imaging-negative cases. Histopathology confirmed EPTA and postoperative serum calcium normalized in all cases. 4D-CT is promising for ectopic parathyroid gland localization if all other imaging modalities fail. Despite the advancements in imaging, surgical experience continues to play the central role in the management of ectopic parathyroid pathologies.

Single Center Experience in the Surgical Management of Primary Hyperparathyroidism.

OBJECTIVES: As calcium included as a part of routine laboratory screening early diagnosis of primary hyperparathyroidism (PHPT) has been increased. Surgical resection of parathyroid adenoma or hyperplasia still is the mainstay of the treatment for most PHPT patients. The aim of this study was to evaluate of the surgical outcomes of patients with PHPT that referred to our ENT department of our University Hospital for the last 6 years. METHODS: One hundred thirty-seven patients with PHPT who underwent parathyroid surgery in our clinic between October 2011 and January 2018 included in this retrospective study. Data on demographics, clinical findings, past medical history, preoperative laboratory values in 3 months, preoperative localizing imaging studies including ultrasonography (USG) and 99mTc-sestamibi (methoxyisobutyl isonitrile, [MIBI]) scan, operative findings, postoperative laboratory values, and pathology reports were recorded. MIBI scan and USG are used as the first-line modalities in our center. Single-photon emission computed tomography was used for challenging situations of re-exploration and ectopic parathyroid pathology. Four-dimensional computed tomography scanning is was preferred as the last imaging modality. Focused unilateral neck exploration (FUNE) was performed with intraoperative frozen section analysis as a routine procedure. Bilateral neck exploration (BNE) was used only in re-exploration, ectopic parathyroid, and with high suspicion of multigland disease. RESULTS: Totally 137 patients (female:male, 3:3; mean age, 54.6±13.2 years) included in the study. Single parathyroid adenoma was found in 108 patients (78.8%). Most common adenoma localization was left inferior parathyroid gland (46.7%). FUNE was performed in 89.8% of the patients and BNE for 10.2% of the patients. Postoperative normocalcemia was reached in 132 patients and permanent hypocalcemia was observed in two patients. Persistence hypercalcemia observed in three patients. Postoperative pathology reports revealed three patients have parathyroid carcinoma. CONCLUSION: Preoperative imaging modalities is very important in parathyroidectomy surgery. Routine use of preoperative imaging modalities reduced the risk of complications in our clinic.

The utilization of Chronic Otitis Media Questionnaire-12 in chronic otitis media with or without cholesteatoma.

OBJECTIVE: This study aimed to compare patients who had chronic otitis media with and without cholesteatoma in terms of the quality of life related to health. METHODS: The Turkish version of the Chronic Otitis Media Questionnaire-12 (COMQ-12) was completed by totally 100 healthy subjects and 100 patients who had chronic otitis media (COM). The COM group was divided into cholesteatoma and without cholesteatoma [dry tympanic membrane perforation (TMP) and draining ear] groups. RESULTS: COMQ-12 score = 3.6 for healthy people. The average scores of dry TMP, draining ear, and cholesteatoma groups were 32.90, 27.34, and 45.95, respectively. A significant difference was between the cholesteatoma and without cholesteatoma groups in total scores (p = 0.001). No difference was found between the groups in age (p = 0.518) and gender (p = 0.975). CONCLUSION: The COMQ-12 could be a useful tool to differentiate chronic otitis media with or without cholesteatoma.

Surgical complications of cochlear implantation: a 25-year retrospective analysis of cases in a tertiary academic center.

PURPOSE: Despite the advances made in cochlear implantation techniques, the associated complication rates are still high. Here, we aimed to analyze cases, with extensive follow-up data, associated with a large sample of patients to identify complications related to cochlear implants and to present our surgical experience and the technique that we used in order to follow surgical rules/medical purpose to avoid any complications. METHODS: We retrospectively examined cases involving 2597 patients (1342 males; 1255 females; age 1-88 years) who underwent cochlear implantation procedures between November 1995 and July 2019, and we classified complications as minor and major. RESULTS: The mean age at the time of implantation was 6.48 (Min: 1/Max: 88) years. The cause of deafness was congenital in 76.5% of the patients and acquired in 16.8%. The overall rate of complications in the study was 3.7% (n = 97). The minor and major complication rates were 3.0 and 0.7, respectively. Further, while the most common minor complication we encountered was vertigo, the most common major complication was implant extrusion. CONCLUSION: Fixing the cochlear implant receiver-stimulator with the bone-recess technique and sealing the posterior tympanotomy site with a piece of muscle in order to follow surgical rules/medical purpose to avoid any complications. Following the insertion of the electrode into the cochlea, the muscle closure of the cochleostomy site or the round window restores the original anatomy and in order to follow surgical rules/medical purpose to avoid any complications. We have developed this highly effective technique with years of experience and have not had a major surgical complication in 5 years.

Concentrations of Serum Cyclophilin A in Patients With Bell Palsy.

BACKGROUND: Cyclophilin A (CyPA) is the responder protein to stimuli that cause inflammation. To date, no association among CyPA and Bell palsy has been reported. METHODS: The concentrations of Serum CyPA were measured in 90 healthy participants and 92 patients with Bell palsy. Serum samples of patients and the control group were compared on the basis of CyPA levels. Facial latency and amplitude values on electromyography were evaluated and compared with serum CyPA concentrations. RESULTS: A total of 28, 37, 19, and 8 patients had grade 3, 4, 5, and 6 facial palsy cases, respectively. Comparing the control group and the patient group showed significant differences in CyPA values (P < 0.001). Cyclophilin A value can be evaluated as a marker with high disease discrimination capability. The results also showed that at low CyPA, the average recovery time was shorter than that of high CyPA (41.6 ±â€Š5.7 days vs 62.8 ±â€Š10.2 days, P = 0.036). We found no statistically significant relationship between electromyography parameters and CyPA level. (Facial latency: r: -0.014, P: 0.948; facial amplitude r: -0.081, P: 0.713). CONCLUSION: Serum CyPA concentrations increased in response to inflammation in Bell palsy patients. However, CyPA could not be used as an early prognostic marker in Bell palsy, low CyPA indicates the shorter average recovery time than that of high CyPA.

Bacterial cellulose tubes as a nerve conduit for repairing complete facial nerve transection in a rat model.

PURPOSE: Functionality of the facial nerve is cosmetically important. While many techniques have been investigated, early and effective treatment for traumatic facial nerve paralysis remains challenging. Here, we aim to examine bacterial cellulose (BC) as a new tubularization material for improving facial nerve regeneration. METHODS: Our study was performed on 40 female Sprague Dawley rats. Rats were randomly divided into four groups, with 10 rats per group. In all rats, the main trunk of the facial nerve was completely cut 8 mm before the branching point. For repairing the facial nerve, in group 1, the nerve was left to recover spontaneously (control group); in group 2, it was repaired by primary suturing (8.0 Ethilon sutures, Ethicon); in group 3, BC tubes alone were used to aid nerve repair; and in group 4, both BC tubes and primary sutures (8.0 Ethilon sutures) were used. After 10 weeks, the facial nerve regeneration was evaluated by the whisker movement test and electrophysiologically (nerve stimulation threshold and compound muscle action potential). Nerve regeneration was assessed by calculating the number of myelinated nerve fibers, and by microscopically evaluating the amount of regeneration and fibrosis. RESULTS: No significant difference was observed among the groups in terms of whisker movement and electrophysiological parameters (P > 0.05). We found that the numbers of regenerating myelinated fibers were significantly increased (P < 0.05) when BC tubes were used as a nerve conduit. CONCLUSIONS: BC can be easily shaped into a hollow tube that guides nerve axons, resulting in better nerve regeneration after transection.

Outcomes of cochlear implantation in children with inner ear malformations.

PURPOSE: To evaluate the surgical experience and auditory functions and progress of speech development of cochlear implantation in malformed ears. MATERIALS AND METHODS: Between November 1995 and July 2017, thirty-seven patients (26 females and 11 males; mean age: 138.275 ± 96.24 months) with diverse anomalies of the inner ear were retrospectively examined for surgical and audiological results. Speech Intelligibility Rating (SIR), Categories of Auditory Perception (CAP), Pure Tone Average (PTA), Speech Intelligibility Rating (SRT), and Word Discrimination Score (WDS) were the audiological tests used to evaluate the efficacy of CI in the malformed inner ears. RESULTS: CSF gusher was experienced by six patients (three with LVA (large vestibular aqueduct), one with IP (incomplete partition) I, and two with both IP II Mondini malformations and LVA). Two patients had transient facial paresis after surgery. All patients fully recovered within 6 months. The postoperative PTA, SRT, and WDS test results showed significant differences between progressive and congenital sensorineural hearing loss (p values < 0.05 for all). On the other hand, the postoperative CAP and SIR test results revealed no significant differences between the two groups. According to etiology, the PTA and SRT values were significantly lower in common cavity patients than the LVA patients (p values < 0.01); no significant differences were found among the other etiological groups. CONCLUSIONS: Cochlear implantation is safe in children with inner ear malformations. However, the success rate is low compared to patients with normal anatomy in terms of audiological results; the most successful group of patients with inner ear malformation is large vestibular aqueduct.

Scar evaluation in subperiosteal temporal pocket versus the one-layer flap technique in cochlear implantation using the Patient and Observer Scar Assessment Scale.

PURPOSE: To compare the local and intracranial complications, migration of the IRS, surgical duration, and quality of life with the subperiosteal pocket technique and the one-layer flap (OLF) technique using the Patient and Observer Scar Assessment Scale (POSAS). METHODS: Eight patients who underwent cochlear implantation. The patients were applied subscales of the POSAS and were asked to respond to the questionnaire items via a telephone conservation conducted by a physician. Another researcher evaluated the patients' photographs using OSAS. POSAS was applied to the patients to compare the differences of scar assessment in subperiosteal pocket technique and the OLF technique. RESULTS: The surgical duration was 72.7 ± 12.3 min in the OLF group and 51.3 ± 11.7 min in the subperiosteal pocket group. The difference was statistically significant. No migration or intracranial complications were observed in either group. Patients in group 1 who underwent the subperiosteal technique were more satisfied than patients who received the OLF technique. However, there was no superiority between the two methods for the observer in scar assessment. CONCLUSION: Although the surgical time is longer, the lack of difference in terms of scar formation from smaller incisions, and few intra- and post-operative complications in experienced hands ensure that the OLF technique is a safe and reliable method in cochlear implantation surgery.

Could digital photography be an alternative to postoperative physical examination for pediatric tonsillectomy patients?

OBJECTIVE: To evaluate and compare the efficacy of postoperative control with digital photographs and physical examination for children who underwent tonsillectomy? METHODS: In this prospective study, 86 children (46 boys (53.5%) and 40 girls (46.5%) were enrolled for postoperative clinical visit and for obtaining photographs of the tonsillar bed with a digital camera at clinic control. RESULTS: No difference in tonsillar fossa healing was observed between the two methods 2 weeks after surgery. CONCLUSIONS: Digital photographs proved to be a safe method for postoperative control of pediatric patients who underwent tonsillectomy. Adding control with outpatient follow-up will be useful for minimizing postoperative complications.

Comparison of pharyngocutaneous fistula closure with and without bacterial cellulose in a rat model.

OBJECTIVE: The present study aimed to compare the effects of bacterial cellulose used for closure of pharyngocutaneous fistulae, a complication of total laryngectomy, with those of primary sutures in a rat model. METHODS: Thirty female Sprague-Dawley underwent experimental pharyngoesophagotomy and were grouped depending on the material used for pharyngocutaneous fistula closure: group I, which received primary sutures alone, group II, which received bacterial cellulose alone; and group III, which received both. After 7 days, the rats were sacrificed. Pharyngocutaneous fistula development was assessed, the gross wound was inspected, and histological examination was conducted. RESULTS: Pharyngocutaneous fistulae developed in 12 rats (41%) in all: 6 from group I (21%), 4 from group II (14%) and 2 from group III (7%). CONCLUSION: Fibroblast density and inflammatory cell infiltration were significantly greater in group III than group I. We concluded that bacterial cellulose may be useful for pharyngocutaneous fistula closure.

Pycnodysostosis at otorhinolaryngology.

AIM: Pycnodysostosis is a rare autosomal, recessive, skeletal dysplasia caused by a mutation in the cathepsin k gene. Pycnodysostosis is characterized by short stature, characteristic facial appearance (delayed closure of fontanelles and cranial sutures, mandibular hypoplasia and angle disorder, blue sclera), and acroosteolysis of the distal phalanges. Our aim was to describe the otorhinolaryngologic findings, differential diagnoses, various treatment options, and followup in eight cases of pycnodysostosis. METHOD: This retrospective clinical study used data from eight patients diagnosed with pycnodysostosis by a single pediatric endocrinologist primarily based on clinical and radiographic findings. All patients were referred to the otorhinolaryngology outpatient clinic by the pediatric endocrinology unit of the Marmara University between February 2013 and March 2015. Detailed medical histories were obtained in all cases and otorhinolaryngologic physical examination, blood assays, electrocardiogram, lateral skull X-rays, chest radiograph, cephalometric investigations, tympanograms, and audiograms were also carried out. Sleep videos of patients were recorded and those with upper airway problems were evaluated for sleep apnea by polysomnography. Informed consent form was obtained from the parents of all patients. RESULTS: Eight patients (7 females and 1 male) displaying proportionate dwarfism were included in the study. They had a mean age of 14.7 years (range: 13-16 y), the mean height of 141.3 cm (range 132-155 cm), and mean weight of 44.4 kg (range: 39.6-49.3 kg). All patients had facial dysmorphism with frontal bossing and the hands and feet had short digits with overlying cutaneous wrinkles that tapered off with large overriding nails. Midfacial hypoplasia and malocclusion were observed in seven of the eight patients (87.5%), four (50%) had micrognathia, and five (62.5%) had proptosis. Tympanograms and audiograms of all patients were type A and normal, and the mean of the pure tone audiogram was 13.3 dB (range: 10-16 dB). All patients had a narrow and grooved palate with disturbed dentition; two of them (25%) had mild markedness of the tongue base, five (62.5%) had grade 3 and three (37.5%) had grade 2 tonsillar hypertrophy, and five (62.5%) had adenoid hypertrophy. One patient (12.5%) had grade 3 Mallampati, four (50%) showed grade 2 Mallampati while three (37.5%) patients displayed grade 1 Mallampati score. Further, while six (75%) patients had no uvular pathology, one (12.5%) patient presented with uvular elongation and another patient had a bifid uvula. Cephalometric measurements such as PAS-UP (mean 5.67 mm; range: 5.0-7.6 mm) and PAS-TP (mean 9.61 mm; range: 8.5-12.2 mm) were lower than that of normal subjects. Video recordings showed that six of the eight patients (75%) had respiratory distress and four (50%) had sleep apnea. Polysomnography in these patients with sleep apnea showed that two had mild OSA (AHI: 18.2 and 20.1 events/hour) and two had severe OSA (AHI: 53.4 and 62.8 events/hour). For upper airway problems, an adenotonsillectomy was performed in two (25%) patients while two others required an adenoidectomy. Positive pressure ventilation was recommended in two patients with persistent sleep apnea after adeno/adenotonsillectomy. However, because of the parental objections, the follow-up polysomnographs could not be obtained. CONCLUSION: Pycnodysostosis is a very rare form of bone dysplasia. Otorhinolaryngologically, proper follow-up of these patients and appropriate treatment of upper airway problems are important to achieve an acceptable quality of life. Adeno/adenotonsillectomy and positive pressure ventilation, used as conservative approaches in treating upper airway problems, are effective and could be used instead of an aggressive surgery such as tracheotomy or maxillomandibular advancement. This study, to the best of our knowledge, is the largest ENT case series on pycnodysostosis.

Is endoscopic endonasal transsphenoidal surgery increases the susceptibility to rhinosinusitis.

The aim of the study was to analyze whether the measurement of changes in the anatomical position and volume of middle concha, the volume changes in the area between the middle concha and lamina papyracea, the evaluation of opacification in major paranasal sinuses, and osteomeatal complex occlusion in cases with middle concha by out-fracture technique during endoscopic endonasal transsphenoidal approach is a minimally invasive surgery, and also to find out whether these changes lead to the development of tendency to rhinosinusitis. It was a retrospective clinical study. Forty-five cases, between 2013 and 2015, planned for endoscopic endonasal transsphenoidal surgery due to hypophyseal pathology at the Neurosurgery Departments of Marmara University Hospital were evaluated retrospectively. The patients were evaluated for the changes in the anatomy of the middle concha and the effects of these changes to paranasal sinuses by paranasal computed tomographies were studied at the preoperative second week and postoperative 12 month. The Lund-Mackay scoring system was used for the evaluation of opacification in the five major paranasal sinuses and occlusion of the osteomeatal complex in the pre- and postoperative period. The Lund-Mackay scoring system was used to analyze the paranasal computed tomography of the patients at the preoperative 2 weeks and postoperative first year. According to the Lund-Mackay scoring system, no significant difference was detected between the preoperative and postoperative opacification of paranasal sinuses (p > 0.05). Besides, there was also no significant difference between the preoperative and postoperative osteomeatal complex occlusion (p > 0.05). Considering the distance between middle concha and lamina papyracea following the out-fracture of the middle concha, a significant lateralization of 0.5 mm between the preoperative and postoperative period was observed (p < 0.05). In addition, a significant change was also detected in the volume of middle concha (p < 0.05). The volume of the area between the middle concha and lamina papyracea was decreased with a statistical significance (p < 0.05). The endoscopic endonasal transsphenoidal surgery causes some variations in the structures of the middle concha, paranasal sinuses, and OMC, but these changes do not lead to significant rhinologic pathologies.

Circulating calprotectin as a biomarker of laryngeal carcinoma.

Calprotectin is an S100 protein and marker of inflammation found in neutrophils and monocytes; S100 proteins are a family of calcium-modulated proteins. The aim of this study was to determine if the serum concentration of calprotectin is higher in patients with laryngeal carcinoma than in patients with benign laryngeal pathologies and controls. The study included 107 participants. The serum calprotectin concentration was analyzed using the calprotectin ELISA (enzyme-linked immunosorbent assay) kit (Calpo AS, Norway). EDTA-serum for analysis was collected prior to surgery from patients with laryngeal carcinoma (n = 41), those with a benign laryngeal pathology (Reinke's edema, vocal nodules, etc.) (n = 32), and healthy controls (n = 34). The median serum calprotectin concentration was significantly higher in the laryngeal carcinoma group (2179.6 µg L-1) than in the benign laryngeal pathology group (727.84 µg L-1) and control group (733.73 µg L-1) (P < 0.05). The median serum calprotectin concentration in patients with advanced-stage laryngeal cancer (5854.,4 µg L-1) was significantly higher than in those with early-stage laryngeal cancer (971.84 µg L-1) (P < 0.05); however, there was not a significant difference in the median calprotectin concentration between the control and benign laryngeal pathology groups (P > 0.05). Furthermore, the median serum calprotectin concentration in the patients with early-stage laryngeal cancer (n = 21) (971.84 µg L-1) was significantly higher than that in the benign laryngeal pathology and control groups (n = 64) (730.6 µg L-1) (P < 0.05). The serum calprotectin concentration was strongly correlated with poor survival and advanced-stage laryngeal carcinoma. Malignant laryngeal cancer patients (n = 4) that died during follow-up had a higher median serum calprotectin concentration (9468.4 µg L-1) than those that remained alive (n = 37) (857.78 µg L-1) (P < 0.05). The serum calprotectin concentration is higher in patients with laryngeal carcinoma than in those with benign laryngeal pathologies and healthy controls. The present findings show that the serum calprotectin concentration might be used as a marker to discriminate between laryngeal carcinoma and benign laryngeal pathologies. Additional research is needed to further assess the value of this parameter as a useful tumor marker for the diagnosis, treatment, and follow-up of laryngeal carcinoma.

A Challenge for Cochlear Implantation: Duplicated Internal Auditory Canal.

Duplication of the internal auditory canal is an uncommon, congenital malformation that can be associated with sensorineural hearing loss owing to aplasia/hypoplasia of the vestibulocochlear nerve. Only 14 such cases have been reported to date. We report the case of a 13-month-old girl with bilateral, congenital, sensorineural hearing loss caused by narrow, duplicated internal auditory canals and discuss the challenges encountered in the diagnosis and treatment of this condition.

Use of a Gelatin-Thrombin Hemostatic Matrix for Secondary Bleeding After Pediatric Tonsillectomy.

Importance: Secondary posttonsillectomy bleeding associated with oozing from multiple sites or overcauterized tonsillar bed deserves special evaluation. Objective: To evaluate the use of an absorbable, flowable gelatin-thrombin hemostatic matrix (GTHM) sealant for secondary bleeding after tonsillectomy. Design, Setting, and Participants: This was a retrospective data analysis, with information gathered from medical records of pediatric patients with secondary posttonsillectomy bleeding treated with the GTHM between 2012 and 2016 at a referral center and a local satellite facility. Forty-two pediatric patients admitted with secondary bleeding after tonsillectomy characterized by diffuse bleeding, multiple bleeding sites, or an overcauterized tonsillar bed, were treated with GTHM. Exclusion criteria were a bleeding disorder, genetic syndrome associated with abnormal oropharyngeal anatomy, and hemorrhage from a single site. Exposures: GTHM was used to treat posttonsillectomy secondary bleeding. Main Outcomes and Measures: Patient medical records were reviewed for information relevant to this study: (1) patient history, the tonsillectomy surgical technique used, and whether there were prior bleeding episodes (and if so, methods of treatment); (2) physical examination and laboratories on presentation, operative report details, and results of treatment; (3) hospital course and whether any further bleeding episodes occurred; and (4) hospital follow-up information (range, 3-20 months). Results: The study population comprised 22 boys (52%) and 20 girls (48%) (a total of 42 patients), and the mean (SD) age was 7 (2.7) years (range, 4-14 years). Two patients had presented with recurrent secondary bleeding necessitating multiple operations, but the others had only 1 episode. The mean day of occurrence of bleeding was on the eighth day (range, day 7-12; median, day 10). Only 2 patients required blood transfusions: they were the same patients who underwent multiple operations for recurrent episodes of secondary bleeding. All patients except for 1 (41 of 42) were discharged without further bleeding following treatment. No adverse effects were reported. Conclusions and Relevance: Results suggest that GTHM is generally simple, safe, and effective for use in the treatment of posttonsillectomy secondary bleeding types not associated with a direct vein or artery source but oozing from multiple sites and/or overcauterized tonsillar bed that cannot be stopped by traditional hemostatic methods.