Feasibility and Outcomes of an Active Osseointegrated Bone Conduction Implant in Children as Young as 5 Years of Age.

INTRODUCTION: This study reviews the feasibility of implanting active osseointegrated bone conduction devices in young children, below the prior age for FDA indication (<12 years), which has recently been reduced to 5 years. Outcomes included differences in adverse event rates and operative time between two groups (<12 and 12 years or older). MATERIALS AND METHODS: This study is a retrospective review of children receiving active osseointegrated bone conduction devices at a tertiary referral center academic hospital. One hundred and twenty-four children received 135 active osseointegrated bone conduction devices (May 2018-March 2024). RESULTS: Of 135 devices, 77 (57%) were in children <12 years (mean age (SD) = 7.9 (2.0) years, range = 4.9-11.9 years) and 58 (43%) were in 12 years or older (mean age (SD) = 15.1 (1.7) years, range = 12-18 years). Adverse events were significantly higher in the older group, occurring in 8 (10%) of 77 devices in children <12 years and 15 (26%) of 58 devices in children 12 years and older (26%) (Fisher's exact test = 0.0217 at p < 0.05). Major adverse events occurred in 5/124 (4%) patients, with 2 in patients <12 years (2/73, 3%) and 3 in children 12 and older (3/51, 6%). The proportion of major events between groups was not significantly different (Fisher's exact test = 0.4, p < 0.05). Mean surgical time was significantly less (t = -2.8799, df = 120.26, p = 0.005) in the children <12 years (mean (SD) = 66.5 (22.4) min) compared to those 12 and over (mean (SD) = 78.32 (23.1) min). CONCLUSIONS: Implantation of active osseointegrated bone conduction devices is feasible in children as young as 5 years and demonstrates low rates of complication. Further miniaturization may allow even earlier safe intervention.

Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal.

OBJECTIVE: Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies. METHODS: We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated. RESULTS: Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%. CONCLUSION: Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications. LEVEL OF EVIDENCE: Level 3 Case-series Laryngoscope, 2024.

Our experience and modification of the Antia-Buch flap for pinna reconstruction.

OBJECTIVE: The Antia-Buch flap technique is used for the reconstruction of pinna helical defects. We present our modification of this flap to reconstruct large defects (greater than 20 mm) with good outcomes. METHODS: A retrospective review was conducted on all modified Antia-Buch flaps performed in a single unit from January 2011 to April 2019. All adult patients (greater than 16 years of age) who underwent this method of reconstruction after surgical excision of a pinna lesion were included. Measurements of the excision specimens from the final histological reports were used to determine the defect size. The helical lengths of the defect were used for analysis. Medical records were reviewed to identify postoperative complications from the reconstruction. RESULTS: A total of 103 patients underwent the modified Antia-Buch flap reconstruction. All cases were performed by a single surgeon (senior author SA). Patients were 51-96 years of age (mean 76 years, SD±8.6), including 92 males and 11 females. The helical length of defects closed was between 12 and 42 mm (mean 26.7 mm, SD±6.46), and defect widths were 6-37 mm (average 14.5 mm, SD±5.28). There were 5 complications in our series (4.8% complication rate), with a revision rate of 2.9% (n = 3). CONCLUSIONS: Our case series is the largest in the literature. Our modification demonstrates that large pinna defects can be reliably repaired with modification of the Antia-Buch flap that gives patients the option of a single-stage reconstruction without added morbidity and a good cosmetic outcomes.

A Rare Case of Orbital Cellulitis with Progressive Calvarial Osteomyelitis.

Orbital cellulitis is a potentially sight and life-threatening complication of acute sinusitis, and the association with osteomyelitis is rare in the era of antibiotic-use. A 13-year-old girl presented with coryzal symptoms and severe headache, with a CT head being consistent with a diagnosis of pansinusitis and orbital cellulitis with abscess formation. She proceeded to have surgical drainage through a combined endoscopic and external approach to intraorbital abscess drainage with frontal trephine. She was also diagnosed with progressive calvarial osteomyelitis involving the right frontal bone, treated with a prolonged course of intravenous antibiotics. Our case highlights the importance of a high index of suspicion for complications of sinusitis. Multimodal imaging is essential to establish the extent of infection, and a multi-disciplinary approach is integral to manage this rare complication.

MedShr: improving patient care through clinical case discussion.

Case discussion is an essential part of clinical practice and medical education, and as part of patient care takes place both informally between medical staff and formally in case conferences and other meetings. Case presentations are often the most popular sessions at medical congresses and increasingly have moved to digital channels and social media. MedShr was developed to help doctors improve patient care: to empower doctors to use their own smartphones to share and discuss clinical cases, whilst protecting patient privacy and confidentiality. In this manuscript, we review the current climate of digital and social media networks used for clinical case discussion, and outline the importance of moving to a dedicated digital platform. We discuss the common drivers for digital case discussions which include multidisciplinary team groups, diagnostic doubt, new techniques, clinical equipoise and debate and case discussion amongst professionals from different training levels and specialties. One key observation is that if clinical guidelines and published evidence tell doctors what to do, case discussion shows them how to do it in terms of drugs, devices, procedures, techniques, and applying the evidence to individuals or patient groups. We explore how MedShr works and the range of features which promote professional compliance, protect privacy and enable case-based education. We also discuss example cases, case series and discussion themes from MedShr. In summary, the MedShr platform provides a trusted, secure environment for clinicians that uses state of the art social network technology to support case discussion whilst protecting patient privacy and confidentiality.

Unusual cause of airway obstruction: subglottic oncocytic cyst.

Oncocytic cysts are rare benign cystic lesions, which are usually seen in the supraglottic region. They usually present with symptoms of hoarse voice or the sensation of a lump in the throat. Management is with complete excision and follow-up to monitor for recurrence. In this unusual case, an elderly woman presenting with shortness of breath following recent treatment for pneumonia developed rapidly worsening stridor during admission. Flexible nasal endoscopy revealed a large pedunculated cystic lesion arising from the subglottic laryngeal mucosa. A tracheostomy was performed as an emergency and the lesion was then excised. Histology confirmed the diagnosis of a benign oncocytic cyst. Although oncocytic cysts are a recognised benign pathology of the supraglottic larynx, they should remain in the differential diagnosis for the subglottic larynx. Management is based on cases of supraglottic pathology, and we advise careful monitoring for this previously unreported pathology.

Spontaneous sphenopalatine pseudoaneurysm: recurrent epistaxis in a patient with cryptogenic vasculopathy.

We present a unique case of recurrent epistaxis secondary to a spontaneous sphenopalatine artery aneurysm in a young woman. This was investigated with an external carotid artery angiogram and subsequently treated successfully with endovascular embolisation of the aneurysm.

Systemic inflammatory response following acute traumatic brain injury.

The early, delayed, and systemic effects of acute traumatic brain injury (TBI) are the result of inflammatory mediators which initiate systemic inflammatory response syndrome (SIRS), subsequent complement deficits and coagulopathy. Once SIRS is triggered by acute inflammation, it can detrimentally self-propagate. Systemic inflammation causes tissue damage leading to further inflammation and damage, leaving the body in a vicious cycle of hyperinflammation. Therefore, important inflammatory mediators like interleukin (IL)-1 beta, IL-6 and tumour necrosis factor (TNF) alpha, are targeted in compensatory anti-inflammatory response syndrome (CARS) in an attempt to control the development of SIRS. The hypothalamus-pituitary (HPA)-axis and sympathetic nervous system (SNS) efferent limbs in CARS provide negative feedback for the production of inflammatory mediators. However, in the case of acute TBI, the activation of CARS often leads to the complication of immunosuppression which may result in multi-organ dysfunction syndrome (MODS) and mortality. In light of this, the activation of the SIRS following acute TBI does not bode well. If left uncontrolled, multiple systems will be implicated making it difficult to remedy.