Feeding Issues in Infants Referred for Frenotomy.

INTRODUCTION: The diagnosis of ankyloglossia has increased significantly around the world over the last decade. Frenotomy is indicated in infants with ankyloglossia to improve breastfeeding, although there is little scientific evidence of its efficacy. The purpose of this study is to evaluate whether infants being referred for frenotomy had feeding issues prior to the procedure. METHODS: A retrospective chart review was undertaken for all infants under one year of age referred with ankyloglossia to a pediatric otolaryngology practice or a pediatric hospital between 2018 and 2020. Data included age at referral, gender, comorbidities, feeding issues, whether ankyloglossia was diagnosed, and whether frenotomy was done. Frequencies and non-parametric comparisons were calculated. RESULTS: Of the 646 consultations made for tongue tie, a diagnosis of ankyloglossia was made in 94.7% (N=612) of the patients based on clinical judgment. The most common feeding complaints were poor latch (57.1%, N=369) and painful latch (50.3%, N=325). Eighty one (12.5%) patients did not have a reported feeding difficulty. Most patients had an anterior tongue tie (85.8%, N=554), with some showing signs of restricted tongue movement (30.1%, N=184). Ankyloglossia was 4.03 times more likely to be diagnosed (p<.001) and frenotomy was 1.76 times more likely to be performed (p<.001) in the hospital setting compared to the clinic setting.  Conclusion: Children under the age of one referred to otolaryngology for ankyloglossia were often diagnosed concordantly, although some lacked feeding issues that would indicate frenotomy. There are still knowledge gaps about infantile ankyloglossia in referring medical personnel.

Does resident involvement in tonsillectomy affect outcomes?

OBJECTIVE: Tonsillectomy is essentially a solo surgery with a well-described complication profile. It may serve as a good benchmark to evaluate the resident-as-surgeon. This study examined complications such as post-tonsillectomy bleeding in children undergoing tonsillectomy by attending surgeons (AS) or pediatric otolaryngologist-supervised residents. METHODS: Charts were reviewed of all children aged 12 and under who had tonsillectomy +/- adenoidectomy at a children's hospital between Jan 2019 and Dec 2020. Patient age, gender, BMI, indication for surgery, surgical technique, presence of a resident surgeon, primary bleeding, secondary bleeding, treatment of bleeding, other Emergency Room (ER) visits, and clinic phone calls were recorded. Binary logistic regression was performed. RESULTS: 2051 total children (1092 (53.2 %) males and 956 (46.6 %) females) with a mean age of 6.1 years (95 % CI 6.0-6.2) were included. 1910 (93.0 %) underwent surgery for tonsillar obstruction. 1557 (75.9 %) underwent monopolar cautery tonsillectomy. 661 (32.2 %) had a resident surgeon. 274 (13.4 %) had a related ER visit within 15 days. 18 (0.9 %) had a primary bleed and 155 (7.6 %) had a secondary bleed. Binary logistic regression showed that significant predictors of postoperative ER visits were patient age (OR = 1.101, 95 % CI = 1.050-1.154, p < .001) and resident involvement (OR = 0.585, 95 % CI = 0.429-,797, p < .001). Only age was associated with overall postoperative bleeding incidence (OR = 1.131, 95 % CI = 1.068-1.197, p < .001), as well as secondary bleeding (OR = 1.128, 95 % CI = 1.063-1.197, p < .001). There were no significant predictors of primary bleeding. CONCLUSION: Resident involvement in pediatric tonsillectomy is associated with decreased postoperative ER utilization and does not appear to increase common postoperative complications including bleeding and dehydration.

Tracheotomy in children older than two years: Analysis of discharge trends from 2015 to 2020.

OBJECTIVE: In light of increasingly complex patients being discharged with tracheostomies, we aimed to evaluate discharge trends over time in pediatric tracheotomy patients. We hypothesized that there would be delays in discharge from increased focus on preparing families for at-home care of critically ill pediatric patients. MATERIALS AND METHODS: We conducted a cross-sectional analysis of pediatric patients who underwent tracheotomy (Current Procedural Terminology code 31600) between 2015 and 2020 using the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIP-P). Univariate and multivariate regression analyses were performed to assess patient demographics, comorbidities, perioperative factors, postoperative complications, and discharge information. Data were analyzed using Stata 15. RESULTS: A total of 1552 patients were identified. There were 868 (56 %) males and 684 (44 %) females with a mean age of 7.3 ± 5.7 years. At least one comorbidity was seen in 1282 (83 %) patients, with 907 (58 %) having impaired cognitive status or developmental delay. Thirty-six (2.3 %) patients experienced mortality within 30 days, while 710 (46 %) were still in the hospital at 30 days. The odds of remaining in the hospital after 30 days were positively correlated with the year (p=.001). Other factors associated with an increased likelihood of remaining in the hospital after 30 days included younger patient age (p <.001), any complication (p <.001), and a higher American Society of Anesthesiologists classification (p <.001). CONCLUSION: As years have progressed, fewer children were discharged from the hospital after 30 days following tracheotomy. Further research may identify socioeconomic factors contributing to the increasing length of hospital stays associated with a need for tracheotomy.

Giant cutaneous squamous cell carcinoma of the scalp arising in the setting of folliculitis decalvans.

Squamous cell carcinoma (SCC) is uncommon in African Americans (AAs), with an incidence of approximately 0.003%. However, it is the most common skin cancer in that patient population. In AAs, SCC typically arises in sun-protected areas and mainly affects patients older than 50 years. We report a case of giant SCC in an AA man in his 40s with long-standing folliculitis decalvans on the scalp. Three previous skin biopsies were inconclusive. A wide excision was performed and the defect was reconstructed with an anterolateral thigh free flap. Histological analysis of the resected specimen revealed a well-moderately differentiated keratinising SCC with clear cell changes, severe mixed inflammation, folliculitis and dermal scar. He was discharged 2 weeks later and has been followed up closely. Four months later, the patient presents with metastatic SCC to an occipital lymph node.

Acute Herpetic Nasopharyngitis in an Adult Patient: A Case Report and Literature Review.

OBJECTIVE: To report a case of herpes virus-associated nasopharyngitis in an adult patient. METHODS: The patient's medical record was reviewed for demographic and clinical data. For literature review, all case reports or other publications published in English literature were identified using Pubmed with the MeSH terms "herpes," "nasopharyngitis," and "upper respiratory infection." RESULTS: A 40-year-old male presented for nasal congestion and a suspected nasal mass. Computed tomography of the sinuses revealed edematous changes in the nasopharynx which exerted a downward mass effect at the right aspect of the soft palate. Flexible fiberoptic laryngoscopy (FFL) revealed a lesion arising from the posterior aspect of the soft palate with extension into the posterior nasal cavity as well as copious mucopurulent secretions consistent with a superimposed acute sinusitis. Rigid nasal endoscopy demonstrated a friable and ulcerated lesion arising from the aforementioned anatomical location. Biopsy of this lesion and subsequent immunohistochemical analysis revealed a diagnosis of herpetic nasopharyngitis. CONCLUSIONS: Herpetic infection should be in the differential diagnosis of patients presenting with atypical symptoms of nasopharyngitis. Early accurate diagnosis and appropriate specific management can limit the duration of disease course and prevent further complications.

Recurrent Intramuscular Hemangioma (Infiltrating Angiolipoma) of the Lower Lip: A Case Report and Review of the Literature.

OBJECTIVE: To report a case of a recurrent intramuscular hemangioma (IMH) of the lower lip of a 68-year-old female and review the published literature to provide an overview of the presentation, diagnostic strategy, pathological classification, and management of these lesions within the oral cavity. METHODS: A case report was conducted by reviewing the documentation at a single institution. A systematic literature review on OVID MEDLINE and PubMed was performed using the MESH terms "intramuscular hemangioma" and "oral cavity," "tongue," "cheek," "buccal," "gingiva," and "lip." RESULTS: A 62-year-old female presented to our institution with a 2 × 2 × 1 cm IMH of the lower lip involving the surrounding orbicularis oris muscle. She underwent a submucosal resection and did well postoperatively. Six and a half years later, she represented to our institution with a new lower lip lesion in the area of her previous resection. Preoperative magnetic resonance imaging showed a new 10 × 11 mm lesion with a well circumscribed central component surrounded by ill-defined tissue. Preoperative angiography showed that the lesion was supplied by vessels branching off the left facial artery, which were embolized. She underwent wide-local excision (WLE) with bilateral advancement flaps and at her 2-month postoperative visit has not had recurrence. CONCLUSION: Only 39 cases of IMH in the oral cavity have been reported, with only 3 others occurring in the lower lip. Here we add the first case of an IMH of the oral cavity that recurred after primary WLE. The patient was successfully retreated with WLE. At a 3-month follow-up visit, she noted some incompetence with oral secretions and occasional tingling along the incision site but no evidence of recurrence.

Pediatric Otolaryngology During COVID-19: Parental Concern About Elective Surgery.

OBJECTIVE: To identify the concerns of parents whose children may need elective surgery during the COVID-19 pandemic. METHODS: In December 2020, parents of pediatric otolaryngology patients were recruited for a survey about concerns related to elective surgery during the COVID-19 pandemic. A Likert scale quantified concern. The 1 was anchored "Not at all important" and 5 was "Most important." Demographics included gender, age, race, education level, number of children in household, and whether their child had surgery since March 2020. RESULTS: About 253 participants were included. Medians ranged from 1 for concerns about emotional and family support to 4 for concerns about their child being exposed to COVID-19 in the Emergency Room. Black parents were more concerned about the risks of COVID than White parents; they were more concerned about their child contracting COVID-19 during surgery compared to White parents, median was 4 versus 3 (P = .027). Black parents had a median score of 3 for concern about medical expenses compared to a median of 2 (P = .001). Parents of children who had surgery since March 2020 had less concern about their child being exposed to COVID-19 during hospitalization (P = .045) and less concern about critique from others (P = .024). CONCLUSION: Parents were most concerned about the risk of seeking Emergency Room care. Black parents were generally more concerned about having their child undergo elective surgery. Whether this is translated into fewer Black children undergoing important but elective surgery requires more study.

The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis.

OBJECTIVE: There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy. METHODS: We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk. RESULTS: Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373). CONCLUSIONS: Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.

Carcinosarcoma of the Nasal Septum: A Case Report and Review of the Literature.

We report a case of a 62-year-old man with epistaxis and right-sided nasal obstruction. Nasal endoscopy revealed an exophytic mass arising from the anterior septum that extended posteriorly to the osteo-meatal complex. Excision with endoscopic sinus surgery was performed. Carcinosarcoma was diagnosed based on histopathology and immunohistochemical studies. The patient declined surgery and opted for chemoradiation therapy for the residual tumor. Six weeks after completion of the treatment, clinical resolution of the right nasal mass was noted. Carcinosarcomas are rare and rapidly growing tumors that have a high recurrence rate and are associated with poor patient prognosis. This report emphasizes the need for patients with prolonged nasal obstruction and epistaxis to consult otolaryngologists and undergo nasal endoscopy for definitive diagnosis and appropriate treatment.

Not Your Typical Tonsil: Metastatic Merkel Cell Carcinoma or Primary Disease?

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine tumor that almost always presents as a cutaneous lesion in the sun-exposed areas on the bodies of elderly white males. Metastasis to lymph nodes in the presence or absence of a known primary site and occurrence of these tumors in non-sun-exposed sites have also been described; however, an incidence of recurrent disease arising in the palatine tonsil in the absence of any detectable primary lesion has never been reported in the literature. In this report, we discuss a case of a 72-year-old female who was found to have a single axillary lymph node, which was resected and proved to be positive forMCC of unknown primary (MCCUP). Since there was no evidence of additional disease, the patient elected not to pursue adjuvant therapies. Six and a half months later, she presented with a complaint of dysphagia and a right-sided exophytic tonsillar mass. Tonsillectomy revealed MCC with no detectable primary cutaneous lesion. She received adjuvant therapy with avelumab and demonstrated a complete response after one year of bi-weekly treatments. Seven months following cessation of adjuvant treatments, surveillance positron emission tomography (PET) revealed enlarged retroperitoneal, pretracheal, periaortic, and left axillary lymph nodes concerning for recurrence. She elected to forgo additional biopsies and restarted avelumab the following month. She continues to be followed up on a monthly basis.