Assessing Radiology Practice Patterns for Obtaining MRI in Pediatric Patients with MR-Conditional Tracheostomy Tubes.

OBJECTIVES: Silicone tracheostomy tubes are a popular choice for pediatric patients with chronic tracheostomies due to their pliability and increased comfort. However, the presence of wire reinforcement causes them to be labeled "MR-conditional." The objective of this study was to understand practice patterns across radiology departments for obtaining MRI in children with MR-conditional tracheostomy tubes. METHODS: A survey consisting of 7 questions aimed at determining a facility's protocol for obtaining MRI in children with tracheostomy tubes was developed and administered via telephone to MRI technologists at US children's hospitals. RESULTS: 182 children's hospitals were identified and 59 responses were obtained across 30 states (32.4%). 19 sites (32%) were excluded as they were unable to perform MRI. All 40 facilities reported that they have a standard questionnaire for medical implants, however only 20 reported that tracheostomy tubes are included on that questionnaire (50%). 6 (15%) reported all MR-conditional tubes are changed to MR-safe ones. Of the remaining 34, protocols were as follows: 1 (2.9%) scans patients with conditional tubes for a maximum of 15 minutes, 5 (14.7%) only use a 1.5T magnet, and 28 (82.3%) reported following the manufacturer conditions. In terms of artifact, 3 sites change MR-conditional tubes to MR-safe if scanning the head, neck, chest, or abdomen (8.8%), 6 (17.6%) change the tube if scanning the head or neck, 15 (44.1%) change the tube only if scanning the neck, and 10 (29.4%) were not aware of issues with artifact. CONCLUSION: Based on this survey of MRI technologists at US children's hospitals, there is no unified protocol for obtaining MRI in pediatric patients with MR-conditional tracheostomy tubes. A lack of standardized protocols may be contributing to unnecessary tracheostomy changes. Future research includes clearly defining the anatomical regions affected by wire-related artifact and developing a standardized MRI protocol for these patients.

Congenital Sensorineural Hearing Loss.

Congenital sensorineural hearing loss is highly prevalent in our population, with a wide variety of causes. The key to clinical management is early detection and intervention, to promote language and cognitive development. With expanding genetic knowledge about congenital sensorineural hearing loss, the indiscriminate approach in workup is no longer recommended. Comprehensive genetic evaluation and cytomegalovirus testing are key to identify the underlying cause of the hearing loss. Treatment and prognosis depend on age of hearing loss onset and detection; management plans will typically include audiology consultation, speech therapy, and various hearing amplification devices and technologies when applicable.

Laceration of Aberrant Internal Carotid Artery Following Myringotomy: A Case Report and Review of Literature.

INTRODUCTION: The presence of an aberrant internal carotid artery (ICA) in the middle ear is rare. Patients may be asymptomatic or complain of conductive hearing loss, otalgia, pulsatile tinnitus, or aural fullness. Otoscopic exam findings can include a pulsating erythematous lesion on the tympanic membrane (TM). It may be misdiagnosed as a glomus tumor, hemangioma, or serous otitis media, or go unrecognized until surgical exploration. Early recognition is important as intraoperative discovery carries risk of iatrogenic injury, hemorrhage and subsequent neurologic sequelae. Prevention requires adequate preoperative suspicion and can be confirmed with radiologic examination via computed tomography (CT) scan or magnetic resonance angiography (MRA). Management of iatrogenic injury of an aberrant ICA can include packing, vessel embolization and/or surgical ligation. PATIENT CASE: We report the case of an aberrant ICA injury in a pediatric patient undergoing a myringotomy with tube placement, who sustained neurologic deficits that eventually resolved following treatment with packing and coil embolization. DISCUSSION AND CONCLUSIONS: An aberrant ICA can cause life-threatening complications without prior diagnosis in a routine myringotomy. Suspicious exam findings should prompt temporal bone CT to rule out aberrant ICA or other vascular pathology of the middle ear prior to surgery. In the case of iatrogenic injury of an aberrant ICA, there is no consensus in existing literature on optimal management. We reviewed 37 studies to compare therapeutic options and subsequent outcomes. Though complications are rare regardless of management, cases in which solely packing was utilized demonstrated an increased incidence of hemiparesis, aphasia, hearing loss, re-bleeding, and delayed pseudoaneurysm, as compared to an approach coupling packing with embolization or ligation, both of which have comparable outcomes.

Analysis of polysomnogram findings in children with concurrent obstructive and central sleep apnea.

OBJECTIVE: Increasing evidence suggests overlap in mechanisms of obstructive and central sleep apnea. Our objective was to compare the patient characteristics and polysomnographic findings of children with concurrent obstructive and central sleep apnea (obstructive sleep apnea + central sleep apnea [OSA + CSA]), to those with OSA only. METHODS: A retrospective case series of polysomnogram (PSG) from 30 June 2013 to 30 June 2018 of patients 18 years and younger was performed. PSG parameters were analyzed per standard protocol. There were two groups, OSA only group and OSA + CSA group. OSA + CSA was subdivided into groups of central apnea index (CAI) ≤5, and CAI >5. Differences in the age, sex, body mass index (BMI) percentile, prevalence of medical conditions, and PSG parameters between OSA only and OSA + CSA were assessed for statistical significance. RESULTS: The mean age of the OSA only group was 8.2 years, significantly higher than that of the OSA + CSA group, 5.0 years, P < .00001. The proportion of underweight, normal weight, overweight, and obese patients according to BMI percentiles was not statistically significantly different between the two groups, P > .05. Most common comorbidity in the two groups was pulmonary conditions, which included asthma. Of the PSG parameters, arousals due to respiratory events and obstructive apnea hypopnea index of all OSA + CSA groups were significantly higher than those of the OSA only group, P < .05. Rapid eye movement (REM) sleep was significantly higher in total OSA + CSA group and OSA + CSA subgroup with CAI ≤5, P < .05, compared to OSA only. CONCLUSION: Children with concurrent OSA + CSA are younger, but there appears to be no difference in BMI percentiles between OSA only and OSA + CSA. Compared to OSA only group, children with concurrent OSA + CSA have significantly different sleep architecture-higher REM %-and experience significantly higher respiratory arousals and obstructive events, especially in the subgroup with CAI >5. There appears to be overlap in mechanisms of CSA and OSA in this cohort. LEVEL OF EVIDENCE: 4.

Frailty as a Predictor of Postoperative Complications Following Skull Base Surgery.

OBJECTIVE/HYPOTHESIS: Frailty has emerged as a powerful risk stratification tool across surgical specialties; however, an analysis of the impact of frailty on outcomes following skull base surgery has not been published. The aim of this study was to assess the validity of the 5-factor modified frailty index (mFI-5) as a predictor of perioperative morbidity and mortality in patients undergoing skull base surgery. METHODS: A mFI-5 score was calculated for patients undergoing skull base surgeries using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2018. Multivariate logistic regression analysis was used to evaluate the association of increasing frailty with complications in the 30-day postoperative period, with a subanalysis by operative location. RESULTS: A total of 17,912 patients who underwent skull base procedures were identified, with 45.5% of patients having a frailty score of one or greater; 44.9% were male and the mean age was 52.0 (±16.1 SD) years. Multivariable regression analysis revealed frailty to be an independent predictor of overall complications (odds ratio [OR]: 1.325, P < .001), life-threatening complications (OR: 1.428, P < .001), and mortality (OR: 1.453, P < .001). Higher frailty also correlated with increased length of stay. When procedures were stratified by operative location, frailty correlated significantly with overall complications for middle, posterior, and multiple-fossae operations but not the anterior fossa. CONCLUSIONS: Frailty demonstrates a significant and stepwise association with life-threatening postoperative morbidity, mortality, and length of stay following skull base surgeries. mFI-5 is an objective and easily calculable measure of preoperative risk, which may facilitate perioperative planning and counseling regarding outcomes prior to surgery. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1977-1984, 2021.

Expanded Carrier Screening in Chinese Population - A Survey on Views and Acceptance of Pregnant and Non-Pregnant Women.

OBJECTIVE: Recessive genetic diseases impose physical and psychological impacts to both newborns and parents who may not be aware of being carriers. Expanded carrier screening (ECS) allows screening for multiple genetic conditions at the same time. Whether or not such non-targeted panethnic approach of genetic carrier screening should replace the conventional targeted approach remains controversial. There is limited data on view and acceptance of ECS in general population, as well as the optimal timing of offering ECS to women. This study assesses views and acceptance of ECS in both pregnant women and non-pregnant women seeking fertility counseling or checkup and their reasons for accepting or declining ECS. MATERIALS AND METHODS: This is a questionnaire survey with ECS information in the form of pamphlets distributed from December 2016 to end of 2018. Women were recruited from the antenatal clinics and the assisted reproductive unit at the Department of Obstetrics and Gynaecology, Queen Mary Hospital and the prepregnancy counseling clinic at the Family Planning Association of Hong Kong. RESULTS: A total of 923 women were recruited: 623 pregnant women and 300 non-pregnant women. There were significantly more non-pregnant women accepting ECS compared to pregnant women (70.7% vs. 61.2%). Eight hundred and sixty-eight (94%) women perceived ECS as at least as effective as or superior to traditional targeted screening. Significantly more pregnant women have heard about ECS compared with non-pregnant women (42.4% vs. 32.3%, P = 0.0197). Majority of women showed lack of understanding about ECS despite reading pamphlets that were given to them prior to filling in the questionnaires. Cost of ECS was a major reason for declining ECS, 28% (n = 256). Significantly more pregnant women worried about anxiety caused by ECS compared with the non-pregnant group (21.1% vs. 7.4%, P = 0.0006). CONCLUSION: Our study demonstrates that expanded carrier screening was perceived as a better screening by most women. Prepregnancy ECS maybe a better approach than ECS during pregnancy, as it allows more reproductive options and may cause less anxiety. Nevertheless, implementation of universal panethnic ECS will need more patient education, ways to reduce anxiety, and consensus on optimal timing in offering ECS.

Current Updates on Choanal Atresia.

Choanal atresia (CA) is a relatively uncommon but well-recognized condition characterized by the anatomical closure of the posterior choanae in the nasal cavity. Since the original description back in the early eighteenth century, there have been controversies regarding its exact pathogenesis, the optimal surgical approach, and the use of adjunct treatments such as post-surgical stenting and anti-neoplastic agents, despite of abundant literature available. The emergence and development of new technologies play a significant role in the management of this condition. This review provides a comprehensive clinical update on CA and identifies areas for future study based on the existing available literature.

Frequency of otitis media based on otoendoscopic evaluation in preterm infants.

OBJECTIVE: This study was conducted to determine the frequency of otitis media in preterm neonates using otoendoscopy and tympanometry. STUDY DESIGN: Prospective study. SETTING: Wayne State University, Hutzel Women's Hospital Neonatal Intensive Care Unit. SUBJECTS AND METHODS: Eighty-six preterm infants were included (gestational age <36 weeks). Otoendoscopy and tympanometry were performed to detect the presence of otitis media. Kappa statistic and logistic regression were used for statistical analysis. RESULTS: Otoendoscopy was performed in 85 patients. The frequency of otoendoscopy-diagnosed otitis media was 72.9% (62/85). Tympanometry could be performed on 69.76% of the ears. There was 73.5% agreement between the findings of tympanometry and those of otoendoscopy. The association between the presence of otitis media and gestational age at birth was statistically significant. The lower the gestational age, the higher the frequency of otoendoscopy-diagnosed otitis media (P = .001). CONCLUSION: Otoendoscopically diagnosed otitis media is frequent in preterm neonates. There was agreement between the results of tympanometry and those of otoendoscopy. The frequency of otitis media increased with lower gestational age.

Fat graft myringoplasty using umbilical fat.

BACKGROUND: Myringoplasty is a common procedure performed by otolaryngologists, particularly in the pediatric population. Tympanic membrane (TM) perforations can be caused by a variety of factors including retained tympanostomy tubes, infection and trauma. First described in 1878, myringoplasty has evolved to include many different materials for repair. Current materials used for myringoplasties include fascia, perichondrium, gelfoam, fat and paper. Multiple studies have looked at the success rates for these different materials. Fat graft myringoplasties in particular offer the advantage of a high success rate commonly reported in the range between 80% and 90%. Fat graft is classically harvested from ear lobe or post-auricular subcutaneous tissue. PURPOSE: In this study, we described the techniques and results of harvesting umbilical fat for the use in pediatric myringoplasty. METHOD: Twenty-eight cases of umbilical fat-graft myringoplasty performed between June 2008 and January 2011 was retrospectively reviewed and studied for rate of successful TM closure. RESULTS: Average length of follow up was 8 months ranging from 3 months to 26 months. Overall rate for successful TM closure of 100% was achieved. Literature review was performed to compare our results with those of studies using auricular fat graft. Furthermore, a review of existing literature on various properties of fat graft was done to explain the potential advantages of using umbilical fat for myringoplasty. CONCLUSION: Fat patch myringoplasty using umbilical fat is a safe and successful procedure for TM repair.

Recurrent croup presentation, diagnosis, and management.

PURPOSE: The lack of clinical insight into recurrent croup often leads to underdiagnosis of an upper airway lesion, and subsequently, inadequate treatment. This study examined the underlying etiology, diagnosis, treatment, and clinical outcome of patients with a history of recurrent croup identified at initial presentation. The aim was to present common diagnostic features and suggest new diagnostic and management recommendations. MATERIALS AND METHODS: A retrospective chart review of 17 children diagnosed with recurrent croup. Demographic, historical, and intraoperative data as noted in clinic charts were collected. Specific collected data included age, sex, chief complaint, presenting symptoms, past medical history, previous medication history, number of emergency room visits and inpatient admissions, tests/procedures performed and corresponding findings, current treatment given, and posttreatment clinical outcome. RESULTS: Six (35.3%) patients presented initially with a past medical history of gastroesophageal reflux disease. Fourteen (82.3%) patients had positive endoscopic evidence of gastroesophageal reflux. For these 14 patients, 44 laryngopharyngeal reflux lesions were noted, with 32 (72.7%) occurring in the subglottis. All 14 patients demonstrated various degrees of subglottic stenosis ranging from 30% to 70% (Cotton-Myer grade I-II). All 17 patients (100%) demonstrated subglottic stenosis ranging from 15% to 70% airway narrowing. CONCLUSIONS: History suggestive of recurrent croup requires close monitoring and expedient direct laryngoscopy/bronchoscopy for diagnosis. Long-term follow-up and antireflux treatment are necessary as well as endoscopic documentation of significant reflux resolution.

Effectiveness and efficiency of different guidelines on statin treatment for preventing deaths from coronary heart disease: modelling study.

OBJECTIVE: To examine the potential effectiveness and efficiency of different guidelines for statin treatment to reduce deaths from coronary heart disease in the Canadian population. DESIGN: Modelled outcomes of screening and treatment recommendations of six national or international guidelines--from Canada, Australia, New Zealand, the United States, joint British societies, and European societies. SETTING: Canada. DATA SOURCES: Details for 6760 men and women aged 20-74 years from the Canadian Heart Health Survey (weighted sample of 12,300,000 people) that included physical measurements including a lipid profile. MAIN OUTCOME MEASURES: The number of people recommended for treatment with statins, the potential number of deaths from coronary heart disease avoided, and the number needed to treat to avoid one coronary heart disease death with five years of statin treatment if the recommendations from each guideline were fully implemented. RESULTS: When applied to the Canadian population, the Australian and British guidelines were the most effective, potentially avoiding the most deaths over five years (> 15,000 deaths). The New Zealand guideline was the most efficient, potentially avoiding almost as many deaths (14,700) while recommending treatment to the fewest number of people (12.9% of people v 17.3% with the Australian and British guidelines). If their "optional" recommendations are included, the US guidelines recommended treating about twice as many people as the New Zealand guidelines (24.5% of the population, an additional 1.4 million people) with almost no increase in the number of deaths avoided. CONCLUSIONS: By focusing recommendations on people with the highest risk of coronary heart disease, the Canadian, US, and European societies guidelines could improve either their effectiveness (in terms of hundreds of avoided deaths) or efficiency (in terms of thousands of fewer people recommended treatment) in the Canadian population.

Polygenic control of hepatocarcinogenesis in Copenhagen x F344 rats.

Cop and CFF1 rats exhibit resistance to hepatocarcinogenesis, associated with high rates of remodeling of neoplastic lesions. We have mapped hepatocarcinogenesis susceptibility, resistance and remodeling loci affecting the number, volume and volume fraction of neoplastic nodules induced by the "resistant hepatocyte" model in male CFF2 rats. Three loci in significant linkage with the number or volume of nonremodeling lesions were identified on chromosomes 1, 4 and 18. Suggestive linkage with number or volume fraction of total, nonremodeling or remodeling lesions was found for 7 loci on chromosomes 1, 2, 13, 14 and 15. All of these loci showed significant allele-specific effects on the phenotypic traits. We also detected by analysis of variance 19 2-way interactions inducing phenotypic effects not predictable on the basis of the sum of separate effects. These novel epistatic loci were in significant linkage with the number and/or volume of total, nonremodeling or remodeling nodules. These data indicate that susceptibility to hepatocarcinogenesis in Cop rats is controlled by a complex array of genes with several gene-gene interactions and that different genetic mechanisms control remodeling and nonremodeling liver nodules. Frequent deregulation in human liver cancer of genes positioned in chromosomal segments syntenic to rat susceptibility/resistance loci suggests some similarities between the genetic mechanisms involved in hepatocarcinogenesis in rats and humans.