Outcome Comparison of Functional Laryngectomy for the Dysfunctional Larynx to Salvage Laryngectomy.

OBJECTIVE: To compare functional outcomes of total laryngectomy (TL) with microvascular free tissue transfer (MVFTT) reconstruction in the treatment of dysfunctional larynx (DL) versus salvage therapy for locally recurrent disease in patients with a history of laryngeal squamous cell carcinoma (SCC). METHODS: Retrospective review from a tertiary medical center between August 2015 and August 2022. RESULTS: Sixty-nine patients underwent TL with MVFTT following primary laryngeal radiation or chemoradiation; 15 (22%) patients underwent functional laryngectomy (FL) and 54 (78%) underwent a salvage laryngectomy (SL). There were no total flap failures. Four (6%) patients developed a pharyngocutaneous fistula; one (7%) FL patient and 3 (6%) in the SL cohort. There was no significant difference in average hospital length of stay (LOS) between the cohorts (8.6 ± 3.0 days vs. 12.8 ± 10.1 days, p = 0.12). All patients (100%) in the FL cohort achieved a total oral diet compared to 41 (76%) in the SL cohort (p = 0.03). Two (13%) and 10 (19%) patients developed pharyngoesophageal stenosis in the FL and SL cohorts, respectively (p = 1.0). Nine (60%) and 23 (43%) patients in the FL and SL cohorts underwent tracheoesophageal puncture (TEP) placement, with 89% and 91% achieving fluency, respectively (p = 0.23). CONCLUSION: Although the role of TL for the definitive treatment of laryngeal SCC has decreased over the past 30 years, organ-preservation protocols can impact speech, swallowing, and airway protection with life-threatening consequences. The use of elective FL with MVFTT for the treatment of DL results in similar or better functional outcomes compared to SL for recurrent disease. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:222-227, 2024.

Local Allergen-Specific IgE Production in Turbinate Tissue of Pediatric Patients.

OBJECTIVES: The objective of this study is to compare serum allergen-specific IgE to IgE levels in nasal tissue taken from the inferior turbinates of pediatric patients undergoing turbinate reduction. METHODS: Twenty-six pediatric patients were recruited at the time of turbinate reduction surgery. At the time of recruitment, parents of patients completed the validated 22 item Sinonasal Outcome Test (SNOT-22) to describe symptoms prior to surgery. A sample of turbinate tissue was taken during turbinate reduction and blood was collected. Tissue and serum IgE were measured and differences in the group characteristics were evaluated using Chi-square tests for binary variables and Wilcoxon-Mann-Whitney tests for continuous variables. Student's t test was used to assess differences in means of total SNOT-22 scoring between the groups, and Wilcoxon-Mann-Whitney tests were used again for the rest of the SNOT-22 analysis. RESULTS: Levels of IgE in the serum were compared to levels in the turbinate tissue from all patients for each individual allergen. Every allergen except Alternaria displayed significant correlation between the serum and turbinate IgE levels. Additionally, each allergen except Alternaria and oak tree resulted in a strong correlation (r > .7) based on the correlation coefficients. Levels of Alternaria were found to be poorly correlative between serum and turbinate tissue, and significance was not achieved (r = -.346, P = .11). CONCLUSION: Certain allergen-specific IgE antibodies in the nasal mucosa seem to be highly associated with those in the serum, based upon the significant correlations we found between the two.

Management of infected nasal dermoid cysts and sinuses.

This study investigates outcomes of surgical management of pediatric patients with nasal dermoids with prior infection. A retrospective review at Nationwide Children's Hospital, a large free-standing pediatric hospital in the Midwestern USA, was performed. Patients were identified by the Current Procedural Terminology codes 30124 (simple excision of dermoid cyst) and 30125 (complex excision of nasal dermoid cyst) from 2011 to 2016. Demographic, imaging data, surgical findings, microbiological data and recurrence rates were collected for these patients. Descriptive statistical investigation was performed. In total, 14 patients were identified, 4 of the 14 patients (28.5%) had recurrent infection and required additional surgery. Three of seven patients required incision and drainage prior to definitive excision. One of seven patients in the infected group had recurrence. Prior infection does not increase the recurrence rate and almost half of the patients required I&D prior to definitive management.

Cephalometric and Functional Mandibular Reconstructive Outcomes Using a Horizontal Scapular Tip Free Flap.

Scapula tip free flaps (STFFs) have become an increasingly popular option for head and neck reconstruction. The aim of this study is to demonstrate the feasibility of using the STFF in a horizontal orientation to take advantage of the anatomy of the scapular tip bone to re-create a mandibular symphysis. Eight patients underwent oromandibular reconstruction with a horizontally oriented STFF between October 2016 and June 2020. Virtual surgical planning was used to design the bony reconstruction in 6 cases. Primary outcomes, including flap survival, complications, and return to oral diet, were collected. Cephalometric measurements were obtained to compare preoperative and postoperative mandibular projection and width. All flaps survived without compromise, and no fistulas developed postoperatively. Seven patients returned to taking an oral diet. Cephalometric analysis revealed comparable measurements between preoperative and postoperative mandibles and reconstructed mandibles, respectively. STFFs may be oriented horizontally to reconstruct large anterior mandibular defects with satisfactory results.

ENT Mentorship Program for Preclinical Medical Students.

OBJECTIVE: To provide preclinical medical students early access to otolaryngologists to learn about the specialty, facilitate acquisition of clinical skills, and provide one-on-one mentorship. METHODS: Students are matched with a single otolaryngology faculty mentor from The Ohio State University/Nationwide Children's Hospital and attend 8 hours per month in the clinic or operating room, monthly lectures, and rounds, and they give a final presentation. Mentors complete performance evaluations, and surveys are administered longitudinally until Match Day. RESULTS: Thirty-five students and 17 faculty members have participated in the program since 2015. All mentors and students found the program to be a valuable experience. When compared to nonparticipating students, participants had significantly higher confidence scores for clinical performance, knowledge of anatomy, and familiarity with the department of interest. All students felt the program prepared them well for third and fourth years, and all 8 of the initial program participants successfully matched into residency with 4 entering otolaryngology. DISCUSSION: Medical students face a competitive residency application process in otolaryngology with limited exposure, which creates an opportunity for guidance in the pursuit of matching into this field. This novel preclinical mentorship program prepares students for their clinical years and residency by facilitating acquisition of various competencies. Students gain hands-on clinical exposure in a field of interest and support for navigating the application process. IMPLICATIONS FOR PRACTICE: The structure of this program can be applied to other medical schools or specialties if the individual departments contain adequate resources of teaching faculty willing to participate.

Outcomes intensive care unit placement following pediatric adenotonsillectomy.

INTRODUCTION: Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care. METHODS: This is a retrospective chart review from the years of 2009-2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU. RESULTS: There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement. CONCLUSIONS: This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.

Treatment of Facial Dog Bite Injuries in the Emergency Department Compared to the Operating Room.

OBJECTIVE: To assess factors associated with repair of facial dog bites in the emergency department (ED) versus the operating room (OR) and to compare rates of surgical site infection and reoperation for each venue. STUDY DESIGN: Case series with chart review. SETTING: Single institution. SUBJECTS AND METHODS: All patients younger than 18 years of age who underwent surgical repair by a consulting surgical service within 24 hours of presentation for facial dog bites between 2010 and 2013 were included. Demographics, site of injury, associated evidence of complex injury, surgical site infections within 30 days, and reoperation within 2 years were compared between patients undergoing surgical repair in the ED versus the OR. RESULTS: One hundred sixty-five patients were evaluated; 75 patients underwent repair in the ED, and 90 patients were treated in the OR. Patients treated in the ED underwent surgery more promptly than patients treated in the OR (median time from arrival to procedure start 3.3 vs 6.8 hours, P < .001). Patients treated in the OR were more likely to have longer lacerations (3.0 cm vs 7.8 cm, P < .001), lacerations of the eyelid (17% vs 42%, P = .001), involvement of multiple regions of the face (11% vs 22%, P = .039), and multiple indicators of severe injury (3% vs 12%, P = .024). There were no differences in surgical site infections (1% vs 1%, P = .721) or reoperation rates (5% vs 13%, P = .071). CONCLUSIONS: Surgical management of pediatric facial dog bites may be successfully performed in both the ED and OR settings. Severity of the injury should dictate the choice for management.

Dog bite injuries to the face: Is there risk with breed ownership? A systematic review with meta-analysis.

INTRODUCTION: Dog bite injuries to the face are a serious, yet modifiable public health concern. This study explores the relationship between dog breed and the risk of biting and injury. The objective of this study is to determine the relative risk and severity of dog bite injuries to the face by breed. METHODS: Retrospective chart review of facial dog bite injuries presenting to the University of Virginia Health System and Nationwide Children's Hospital. Additionally, descriptive data was collected from 240 patients over the last 15 years. Bite risk by breed was assessed by a literature search from 1970 to current. A composite measure was used to determine the severity of injury, and characterize each patient into an ordinal scale of bite severity. An average of each breed bite rate within each study was calculated and combined to create an empiric bite risk by breed. Dog breeds were also further characterized morphologically. RESULTS: Bite risk by breed from the literature review and bite severity by breed from our case series were combined to create a total bite risk plot. Injuries from Pitbull's and mixed breed dogs were both more frequent and more severe. This data is well-suited for a bubble plot showing bite risk on the x-axis, bite severity on the y-axis, and size of the bubble by number of cases. This creates a "risk to own" graphic for potential dog owners. CONCLUSIONS: Breeds vary in both rates of biting and severity. The highest risk breeds had both a high rate of biting and caused significant tissue injury. Physical characteristics can also help determine risk for unknown or mixed dog breeds. Potential dog owners can utilize this data when assessing which breed to own.

A Multidisciplinary Approach to a Pediatric Difficult Airway Simulation Course.

Objective To design and assess an advanced pediatric airway management course, through simulation-based team training and with multiple disciplines, to emphasize communication and cooperation across subspecialties and to provide a common skill set and knowledge base. Methods Trainees from anesthesiology, emergency medicine, critical care, pediatric surgery, and otolaryngology at a tertiary children's hospital participated in a 1-day workshop emphasizing airway skills and complex airway simulations. Small groups were multidisciplinary to promote teamwork. Participants completed pre- and postworkshop questionnaires. Results Thirty-nine trainees participated over the 3-year study period. Compared with their precourse responses, participants' postcourse responses indicated either agreement or strong agreement that the multidisciplinary format (1) helped in the development of team communication skills and (2) was preferred over single-discipline training. Improvement in confidence in managing critical airway situations and in advanced airway management skills was significant ( P < .05). Eighty-one percent of participants had improved confidence in following the hospital's critical airway protocol, and 64% were better able to locate advanced airway management equipment. Discussion Multiple subspecialists manage pediatric respiratory failure, where successful care requires complex handoffs and teamwork. Multidisciplinary education to teach advanced airway management, teamwork, and communication skills is practical and preferred by learners and is possible to achieve despite differences in experience. Future study is required to better understand the impact of this course on patient care outcomes. Implications for Practice Implementation of a pediatric difficult airway course through simulation-based team training is feasible and preferred by learners among multiple disciplines. A multidisciplinary approach exposes previously unrecognized knowledge gaps and allows for better communication and collaboration among the fields.

Low rate of positive bronchoscopy for suspected foreign body aspiration in infants.

OBJECTIVES: To describe our institution's low rate of positive bronchoscopy in infants suspected of inhaling a foreign body. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review was performed of patients at a tertiary children's hospital with suspected inhalation of a foreign body. Charts were reviewed for demographic information, radiologic findings, operative reports, and respiratory viral panels were reviewed. RESULTS: Sixteen pediatric patients under 12 months of age were identified from 2008 to 2016 with a diagnosis of possible airway foreign body inhalation who underwent emergent bronchoscopy. Of these patients, only one was positive for a foreign body present in the airway. The remaining 15 children were found to have a negative direct laryngoscopy and bronchoscopy evaluation for a foreign body. Of these fifteen patients, 14 were found to have structural airway abnormalities and 7 tested positive for a respiratory viral infection. CONCLUSIONS: Our institution has a low rate of positive bronchoscopy for highly suspected foreign body inhalation in a group of patients less than 12 months of age. Patients presenting with respiratory distress, stridor, or other airway symptoms were often found to have an underlying airway abnormality or viral infection, which coupled with an unclear history, would increase the suspicion for an airway foreign body and subsequent decision to perform bronchoscopy. In stable patients, diagnostic evaluation for an underlying respiratory infection should be performed in these cases. LEVEL OF EVIDENCE: Case Series.

Emergent sclerotherapy of a newborn with expanding lymphatic malformation causing respiratory distress.

The present report describes a case of acute airway obstruction in a newborn caused by an expanding hemorrhagic macrocystic lymphatic malformation (LM), which was successfully treated with emergent decompression and interventional radiology-guided sclerotherapy. The use of sclerotherapy for macrocystic LMs has been well described for various indications. The urgent interventional treatment obviated the need for a tracheostomy. This case describes the rapid diagnosis and use of sclerotherapy in a large expanding macrocystic LM.

Outcomes in pediatric patients with recreational vehicle related forceful head impact.

PURPOSE: To compare outcomes in pediatric patients suffering forceful head impact during recreational vehicle use to patients with forceful head impact from other mechanisms. METHODS: Retrospective cohort study of all patients 3-18 years old who suffered forceful head impact (any traumatic mechanism strong enough to result in a face or skull fracture) in our institutional trauma registry between January 2011 and September 2013. RESULTS: Out of 252 events involving forceful head impact, 64 events were a result of riding a recreational vehicle. Although there is no difference in rates of temporal bone fractures, recreational vehicle accidents have higher rates of otic capsule violation (21% vs. 5%) and higher rates of hearing loss (30% vs 16%) compared to patients with forceful head impact from other mechanisms. All incidents of otic capsule violation and sensorineural hearing loss in recreational vehicle accidents were associated with a temporal bone fracture. CONCLUSION: Despite the increasing use of head protective gear while operating a recreational motor vehicle there is still heightened risk for temporal bone fractures and subsequent hearing loss. The comparative associations in this study suggest that helmets used with recreational vehicles do not protect the temporal bone thus leaving vital structures within the otic capsule at risk for damage and long term consequences. When treating these patients Otolaryngologists should be aware of the elevated risk of otic capsule violation and late hearing loss with temporal bone fractures.