Surgical and audiologic outcomes following revision cochlear implantation in children.

INTRODUCTION: The incidence of cochlear implantation failure is rare; however, complications can arise in which revision surgery becomes necessary. The purpose of this study is to review our institutional experience with revision cochlear implantation to further understand the surgical and audiological outcomes after cochlear implant failure. METHODS: This is a retrospective review of patients who underwent revision cochlear implantation from 2014 to 2022 at a single institution. RESULTS: Twenty-one patients required reimplantation within the 8-year study period. During this time frame, a total of 202 cochlear implants were implanted in 171 pediatric patients, resulting in a reimplantation rate of 5.9 %. Our reimplantation patient population were majority white (61.9 %), female (52.4 %), and insured by Medicaid (61.9 %). The average age at implantation was 54.8 months ±47.5 months and the average age at reimplantation was 100.1 months ±55.9 months. The average time between initial implantation and reimplantation was 46.2 months ±30.2 months. The most common sign of failure was abnormal impedances (47.6 %). Reimplantation was required more often for hard failure (76.2 %), which occurred secondary to trauma in 56.3 % of patients, and occurred more frequently in those ages 5-7. Operative findings were unremarkable in 81 % of patients. Those with audiologic data were noted to have stable or improved thresholds after their revision surgery. Three of the 21 patients discontinued use of their processor on the revised ear. Of these, two had known trauma associated with implant failure that was not immediately addressed. CONCLUSION: We noted increased rates of hard failure, most commonly secondary to trauma. We noted that majority of those who discontinued use of their implant after revision surgery had associated traumatic injuries that ultimately delayed their presentation and surgery.

Direct Bluetooth connectivity results in better hearing aid compliance in children.

OBJECTIVE: To determine if hearing aid use in school aged children is impacted when upgraded to direct Bluetooth® enabled technology. We hypothesized that because children are better able to connect to their devices and headphones, they would be more inclined to use their hearing aids throughout the day, resulting in an increase in hearing aid compliance. METHODS: This retrospective analysis examined changes in datalogging of hours of usage per day in 51 school aged children who underwent an upgrade from non-direct Bluetooth® hearing technology to direct Bluetooth®-enabled hearing technology. RESULTS: Hours per day of hearing aid use in all hearing aid users significantly increased after upgrading to DBT enabled technology (6.82 vs 9.82, <0.001). There were no significant differences noted in hours before and after upgrade depending on race (p = 0.147), gender (p = 0.887), developmental delay (p = 0.749), type of hearing loss (p = 0.218), and degree of hearing loss (p = 0.551). However, when comparing private versus Medicaid insurance, there was noted to be a significant difference with the odds of an increase in hours of usage after upgrade being higher for those patients privately insured (OR = 1.247, p < 0.001, 95 % CI 1.093-1.422). CONCLUSION: Direct Bluetooth® enabled hearing technology positively impacts children's hearing aid compliance, which has the potential improve speech and language outcomes.

Oxymetazoline vs ofloxacin vs ciprofloxacin/dexamethasone- effects of drops on tympanostomy tube postoperative otorrhea.

OBJECTIVE: To assess for differences in postoperative otorrhea rates after tympanostomy with tube placement surgery comparing use of oxymetazoline, ofloxacin, or ciprofloxacin/dexamethasone drops prescribed in the postoperative period. METHODS: A retrospective review was conducted of 516 pediatric patients who had either bilateral or unilateral myringotomy with tube placement performed during the year 2018. Information collected from each surgery included whether there was effusion at time of surgery, type of effusion, whether an adenoidectomy was performed the same time or prior, prior history of tube placement, style of tube placed, type of drop given or prescribed on the day of surgery. Demographic information including age, sex, race, weight was recorded as well. Finally, the postoperative visit was analyzed for presence of otorrhea in the ears that had surgery. Univariate analysis was conducted to see if there was any association between the three different drops and presence of otorrhea postoperatively. RESULTS: Postoperative otorrhea was present in 50 of the 516 patients (9.7 %). We observed no significant difference between the type of drop used and postoperative otorrhea being present (p = 0.179), but prior placement of tubes was significantly correlated to postoperative otorrhea (p < 0.001). There was no relationship between type of tube used, prior tube placement, or history of adenoidectomy with type of ear drop used. CONCLUSION: Overall, there is no significant difference in the rate of postoperative otorrhea when choosing between oxymetazoline, ofloxacin, or ciprofloxacin/dexamethasone drops for use in the postoperative period after tympanostomy tube placement.

Effect of post-operative oral steroids on bleeding rate after pediatric tonsillectomy.

PURPOSE: In 2013, the FDA placed a black box warning on the usage of opioid pain medications in the post-operative setting after pediatric adenotonsillectomy. Since then, alternative pain management regimens have been employed. Some have advocated for post-operative oral steroids, in part due to the effectiveness of intraoperative intravenous steroids in reducing post-operative pain and nausea. The evidence regarding the efficacy and safety of post-operative oral steroids is not as clear. The purpose of this study was to examine whether post-tonsillectomy hemorrhage rates in pediatric patients were affected by post-operative oral steroid usage. MATERIALS AND METHODS: Case-control retrospective chart review using a deidentified data set of patients undergoing tonsillectomy with or without adenoidectomy at a single academic medical center between June 2012 and November 2015. RESULTS: A total of 1416 patients were included in the study, with 704 in the no post-operative oral steroids group and 712 in the group who did receive post-operative oral steroids. The rate of post-tonsillectomy hemorrhage in the post-operative oral steroid group was 3.1 % compared to 1.8 % in the group who did not receive post-operative oral steroids, however, this was not a statistically significant difference (P = .132). CONCLUSIONS: Our study suggests that post-operative oral steroids are safe and do not increase the risk of post-operative hemorrhage after pediatric tonsillectomy.

Cochlear implantation in a 16-month-old with Chudley-McCullough Syndrome.

OBJECTIVE: The purpose of this report is to describe a case of bilateral cochlear implantation (CI) in a pediatric patient with Chudley-McCullough Syndrome (CMS). By reviewing the literature, we hope to describe common clinical presentations to aid in early diagnosis and management of pediatric patients with CMS. METHODS: Case report with literature review. RESULTS: We present a case of a 16-month-old female with CMS who presented to clinic after a failed newborn hearing screen and was found to have bilateral sensorineural hearing loss. After a failed trial of hearing amplification, the patient underwent successful bilateral CI. The patient had no surgical complications, and her follow up visit showed satisfactory speech and language development. CONCLUSION: This case validates that cochlear implantation in pediatric patients who present with CMS is both safe and efficacious. It also demonstrates the importance of early detection and treatment of sensorineural hearing loss in CMS to prevent speech and language delay.

Cochlear implantation in patients with Pendred syndrome.

OBJECTIVE: To examine the outcomes of cochlear implantation in children with Pendred Syndrome. MATERIAL AND METHODS: A retrospective case series of nine pediatric patients with Pendred syndrome undergoing cochlear implantation at a tertiary academic medical center from 2003 to 2017. RESULTS: All patients were diagnosed with bilateral mild-to-profound to severe-to-profound sensorineural hearing loss and used hearing aids prior to implantation. Preoperative imaging results revealed that all patients exhibited bilateral enlarged vestibular aqueducts and 8 of 9 had cochlear dysplasia equivalent to Incomplete Partition II. Despite inner ear malformations, all electrodes were successfully implanted with minimal complications and favorable post-operative audiological outcomes. CONCLUSIONS: Cochlear implantation is an effective and successful treatment for severe-to-profound hearing loss in children with Pendred syndrome and for whom traditional amplification aids provide limited benefit. With early intervention, cochlear implantation allows speech and cognitive development in Pendred children comparable to that of normal hearing individuals, allowing patients to learn in a mainstream educational setting.

Effect of Graft Size on Air-bone Gap Closure in Cartilage Button Tympanoplasty.

OBJECTIVE: To study the effect of graft size on postoperative air-bone gap in children undergoing butterfly inlay cartilage tympanoplasty using circular punch grafts. STUDY DESIGN: Retrospective case review. SETTING: Tertiary, academic children's hospital. PATIENTS: Children less than 16 years old undergoing circular butterfly inlay tympanoplasty using 4, 5, or 6 mm round grafts. INTERVENTION: Butterfly inlay tympanoplasty using circular punch graft harvest technique. MAIN OUTCOME MEASURES: Postoperative pure-tone average and air-bone gap. RESULTS: Fifty-two children were included in the analysis: 18 in the 4 mm group, 28 in the 5 mm group, and 6 in the 6 mm group. There was no significant difference in either postoperative pure-tone average or air-bone gap among the three groups. Closure rates for the 4, 5, and 6 mm graft groups were 94, 96, and 67%, respectively, for an overall rate of 92%. CONCLUSIONS: Cartilage button butterfly inlay tympanoplasty with punch graft is an effective method for tympanic membrane repair with similar hearing results among various graft diameters but may have diminished success with perforations requiring grafts larger than 5 mm. Larger case series are necessary to determine if larger defects are best managed with other repair techniques.

Characteristics and considerations for children with ankyloglossia undergoing frenulectomy for dysphagia and aspiration.

OBJECTIVE: The purpose of this study is to analyze the basic demographics of patients who underwent frenulectomy at our institution as well as additional considerations regarding age, location of procedure, and possible effects on aspiration. METHODS: A retrospective chart review was performed based on CPT codes for frenulectomy and basic demographic data was collected. Other information such as presenting symptoms, type of ankyloglossia, location of the procedure, and modified barium swallow study (MBSS) information were also obtained. RESULTS: A total of 226 (66.4% male) patients underwent frenulectomy in the study time frame. Younger patients underwent frenulectomy for feeding symptoms (average age 6.5 months) and older children typically presented with speech related symptoms (average age 3.8 years). Of patients who had MBSS before and after the procedure, 5/11 (43%) had improvement of their aspiration after frenulectomy. CONCLUSIONS: Symptomatic ankyloglossia is more common in boys. Two age groups typically present for frenulectomy, infants for feeding difficulties and toddlers/preschoolers for speech related difficulties. Children with aspiration may benefit from frenulectomy, though aspiration is unlikely to resolve if other comorbidities are present. Proper evaluation and documentation of anatomy and functional tongue movement is important for future studies and decision-making regarding frenulectomy.

Does intravenous acetaminophen reduce perioperative opioid use in pediatric tonsillectomy?

OBJECTIVE: Postoperative pain control is of significant interest in pediatric otolaryngology given the safety concerns with opioid use. We sought to determine if addition of intraoperative intravenous acetaminophen decreases perioperative morphine use in pediatric tonsillectomy. METHODS: This study is a retrospective cohort study performed at a tertiary care academic children's hospital. 166 pediatric patients (aged 1-16 years) who underwent tonsillectomy with or without adenoidectomy were for review. Seventy-four patients received intraoperative intravenous acetaminophen (intervention cohort), while ninety-two patients served as our control and did not receive any intraoperative intravenous acetaminophen. Perioperative (intraoperative and postoperative) morphine use was our primary outcome measure. Rate of adverse events in the post anesthesia care unit and time for discharge readiness were secondary outcome measures. Wilcoxon two-sample t-test approximation and Fisher's exact test were used for data analyses. RESULTS: Patients in the intravenous acetaminophen cohort received less morphine (mg/kg) intraoperatively (0.058 versus 0.070, p = 0.089) and in the post anesthesia care unit (0.034 versus 0.051, p = 0.034) than the control cohort. The median time to discharge readiness for the intravenous acetaminophen and control groups was 108.5 versus 105 min (p = 0.018). There was no adverse respiratory event (oxygen desaturation <92% lasting more than a minute, requiring bag mask ventilation or reintubation) in either group in the post anesthesia care unit. There were 5 (7%) episodes of postoperative vomiting in the IV APAP, while 2 (2%) were recorded in the control cohort (p = 0.244). CONCLUSION: Our findings suggest intraoperative intravenous acetaminophen use in pediatric tonsillectomy can decrease the perioperative use of opioid for optimal pain management.

Analyzing complications of minimally invasive pediatric cochlear implantation: A review of 248 implantations.

PURPOSE: This study aims to report the postoperative complications and management of cochlear implantation in pediatric patients at our institution. All procedures were carried out by a single surgeon utilizing minimally invasive techniques. The impact of past surgical history of tympanostomy tubes was also reviewed to access association with postoperative complications. MATERIALS AND METHODS: All children receiving cochlear implants at our institution between April 2003 and October 2014 were reviewed. Complications were grouped into "major" and "minor" depending on degree of management and "immediate," "early," and "delayed" depending on time of presentation. RESULTS: In our series, 248 cochlear implants were placed into 141 children. The mean age at time of surgery was 4.8 years. The overall complication rate per ear was 16.5%, 5.2% being major and 11.3% being minor complications. Complications arose in the first 30 days following surgery in 8.4% of patients, with acute otitis media being the most common. A history of tympanostomy tubes did not impact complication rate. Excluding device failures, major complication rate was 2.4%. Hematoma was not encountered, and delayed seroma occurred in one patient. CONCLUSION: Minimally invasive cochlear implantation carries a low complication rate. The most common major complication was intrinsic device failure, and the most common minor complication was acute otitis media. Past medical history of chronic otitis media with tympanostomy tube placement prior to cochlear implantation did not have a statistically significant impact on postoperative complication rates. Given the rarity of hematomas and seromas, pressure dressings appear to be unnecessary with this approach.

Avoiding narcotic analgesics in young children.

Recent warnings regarding the use of codeine in young children have triggered changes in postoperative pain management with a trend toward over the counter pain medicines. A summary of the recent FDA warnings and current pain protocols is contained within.

Case presentation of soft tissue parapharyngeal chondroma in a pediatric patient.

Soft tissue chondromas are uncommon benign tumors found mostly in the hands and feet and rarely reported in the pediatric population. In this case presentation we describe a 10 year old boy who had an MRI for facial paralysis due to Ramsey Hunt Syndrome, which incidentally revealed a parapharyngeal mass. He underwent transoral resection of the mass without complication, and histopathology confirmed the diagnosis of soft tissue chondroma. This case is unique due to the unusual location of the tumor and its presentation in a child.

The use of cephalometric landmarks with 3-dimensional volumetric computer modeling to position an auricular implant surgical template: a clinical report.

The number of tools available to make a correctly positioned surgical guide for auricular implant placement is rapidly expanding as advances in 3-dimensional computer modeling continue. While the correct orientation of a missing auricle previously relied solely on soft tissue topography, computer modeling software now allows for navigational viewing of hard tissue and cephalometric landmarks. This clinical report describes a technique to establish the orientation of an auricular surgical guide incorporating the use of fundamental cephalometry. Cephalometry as a treatment planning tool has been limited to orthodontics and maxillofacial surgery. This article describes its use in a patient with a missing ear.

Low-grade nonintestinal sinonasal adenocarcinoma: a diagnosis of exclusion.

The World Health Organization classifies primary sinonasal adenocarcinomas (SNACs) into salivary and nonsalivary types. Salivary types are usually well-defined myoepithelial neoplasms, which closely resemble their salivary counterparts. Nonsalivary types are separated into intestinal-type SNAC (ITAC) and non-ITAC, and both have low- and high-grade categories. Intestinal-type SNACs are aggressive tumors that resemble intestinal epithelium and often arise in the ethmoid sinus. Non-ITACs are of presumed seromucous gland origin, have marked morphologic heterogeneity, and can arise anywhere in the sinonasal tract. Moreover, ITACs typically demonstrate an intestinal-type immunohistochemical profile (CK20+, CK7-, CDX2+, and villin+), whereas non-ITACs reveal a respiratory-type profile (CK20-, CK7+, CDX2-, and villin-). Here, we present a case of low-grade, nonintestinal SNAC in a 17-year-old African American man and a discussion of the classification and pathologic features of primary SNACs.