Screening for colorectal cancer by full colonoscopy in first-degree relatives of colorectal cancer patients: a multicentric study by the Italian League for the Fight against Cancer.

Background: Colorectal cancer currently presents the third-highest incidence of cancers worldwide, making secondary prevention through screening programs for colorectal cancer, usually by Fecal Occult Blood Testing, an essential preventive medicine intervention. First-degree relatives of colorectal cancer patients are a particularly at-risk group, with indications to consider direct screening by full colonoscopy. Colonoscopy is considered the gold standard for diagnosing colorectal cancer, as it has high sensitivity and specificity, and is both a diagnostic and therapeutic tool. However, it requires significant organizational and financial resources, and has a small but relatively higher risk of complications as opposed to fecal occult blood testing. The present study aimed to assess the appropriateness of a screening program without age restrictions of CRC by full colonoscopy in asymptomatic, first-degree adult relatives of patients with colorectal cancer, aiming both to actively increase screening coverage and to determine the detection rate of precancerous lesions and colorectal cancer in this population. Study Design: Uncontrolled interventional study - colorectal cancer screening by full colonoscopy for at-risk population. Methods: The Italian League for the Fight against Cancer started a colorectal cancer screening program by full colonoscopy for first-degree relatives of colorectal cancer patients in 1998 in the province of Latina, Lazio Region, Italy. The program was expanded to the provinces of Rieti, Lazio Region, and Sassari, Sardinia Region, in 2014 and 2016 respectively, and was concluded in 2018. Subjects were actively and voluntarily recruited by the study's working group. Subjects that had already been subjected to a full colonoscopy in the preceding 5 years were excluded from this study. Identified neoplastic lesions were treated either directly or referred to the Day Hospital setting, and histologically diagnosed following World Health Organization guidelines. Results: In total, 2,288 subjects (age range 15-88, mean 52.3 yrs, M/F = 946/1,204) were screened by colonoscopy, of which 103 (4.5%) were incomplete and 2,173 (95.0%) complete, with data on colonoscopy performance missing for 12 participants. Out of 468 positive outcomes on colonoscopy, diagnosis for 422 (204M/173F), 19.4% of total subjects, was adenomatous polyps and 46 (20M/20F), 2.1% of total subjects, was colorectal cancer. Female sex was a protective factor against a positive test outcome, with a 35% reduction compared to male sex, with OR=0.64 95%CI (0.52-0.80). On the other hand, being over 50 years of age was found to be a risk factor, making a positive outcome more than twice as likely, with OR=2.3 95%CI (1.8-2.9). Subjects over 50 also had significantly more instances of multiple adenomas being found, however the size distribution of found adenomas was not significantly different between subjects under and over 50, despite size being a predictor of risk of neoplastic progression. Conclusions: Given the high detection rate of precancerous lesions and colorectal cancer in the studied population, it is our opinion that guidelines should continue to recommend earlier and more frequent screening in first-degree relatives of patients with colorectal cancer, and, barring the introduction of more cost-effective and/or lower risk procedures with a similar efficacy profile, maintain the use of colonoscopy as the main screening option.

An interactive augmented reality software for facial reconstructive surgeries.

BACKGROUND AND OBJECTIVE: Surgical trainees need a lot of training and practice before being able to operate independently. The current approach of surgical education mainly involves didactic teaching and psychomotor training through physical models or real tissue. Due to the unavailability of physical resources and lack of objective ways of evaluation, there is a demand for developing alternative training methods for surgeons. In this paper, we present an application that provides additional training opportunities to surgical trainees in the field of facial reconstructive surgeries. METHODS: We built a mobile augmented reality application that helps the user to visualize important concepts and experiment with different surgical plans for facial reconstructive surgeries. The application can overlay relaxed skin tension lines on a live video input or a patient's photo, which serve as bases for aligning a skin flap. A surgical trainee can interactively compare different skin flap design choices with estimated final scars on a photo of a patient. Data collection capability is also added to the application, and we performed a Monte Carlo experiment with simulated users (five classes of 100 users each) as an example of objectively measuring user performance. RESULTS: The application can overlay relaxed skin tension lines on a patient's face in real time on a modern mobile device. Accurate overlays were achieved in over 91% as well as 84% and 88% out of 263 generated face images, depending on the method. Visual comparisons of the three overlay methods are presented on sample faces from different population groups. From the Monte Carlo experiment, we see that user actions in each class follow a normal distribution with a distinct set of parameters. CONCLUSIONS: This application can serve as a basis for teaching surgical trainees the fundamentals of different facial reconstructive procedures, especially concepts related to relaxed skin tension lines and skin flaps. It can objectively evaluate the performance of surgical trainees in a course. This setup focuses on illustrating the relationship between the orientation of skin flaps and relaxed skin tension lines, which is a prerequisite of minimizing scarring in patients in addition to good surgical techniques.

Diverse Oncogenic Fusions and Distinct Gene Expression Patterns Define the Genomic Landscape of Pediatric Papillary Thyroid Carcinoma.

Pediatric papillary thyroid carcinoma (PPTC) is clinically distinct from adult-onset disease. Although there are higher rates of metastasis and recurrence in PPTC, prognosis remains highly favorable. Molecular characterization of PPTC has been lacking. Historically, only 40% to 50% of childhood papillary thyroid carcinoma (PTC) were known to be driven by genomic variants common to adult PTC; oncogenic drivers in the remainder were unknown. This contrasts with approximately 90% of adult PTC driven by a discrete number of variants. In this study, 52 PPTCs underwent candidate gene testing, followed in a subset by whole-exome and transcriptome sequencing. Within these samples, candidate gene testing identified variants in 31 (60%) tumors, while exome and transcriptome sequencing identified oncogenic variants in 19 of 21 (90%) remaining tumors. The latter were enriched for oncogenic fusions, with 11 nonrecurrent fusion transcripts, including two previously undescribed fusions, STRN-RET and TG-PBF. Most fusions were associated with 3' receptor tyrosine kinase (RTK) moieties: RET, MET, ALK, and NTRK3. For advanced (distally metastatic) tumors, a driver variant was described in 91%. Gene expression analysis defined three clusters that demonstrated distinct expression of genes involved in thyroid differentiation and MAPK signaling. Among RET-CCDC6-driven tumors, gene expression in pediatric tumors was distinguishable from that in adults. Collectively, these results show that the genomic landscape of pediatric PTC is different from adult PTC. Moreover, they identify genomic drivers in 98% of PPTCs, predominantly oncogenic fusion transcripts involving RTKs, with a pronounced impact on gene expression. Notably, most advanced tumors were driven by a variant for which targeted systemic therapy exists. SIGNIFICANCE: This study highlights important distinctions between the genomes and transcriptomes of pediatric and adult papillary thyroid carcinoma, with implications for understanding the biology, diagnosis, and treatment of advanced disease in children.

Effectiveness of discovery learning using a mobile otoscopy simulator on knowledge acquisition and retention in medical students: a randomized controlled trial.

BACKGROUND: Portable educational technologies, like simulators, afford students the opportunity to learn independently. A key question in education, is how to pair self-regulated learning (SRL) with direct instruction. A cloud-based portable otoscopy simulator was employed to compare two curricula involving SRL. Pre-clerkship medical students used a prototype smartphone application, a 3D ear attachment and an otoscope to complete either otoscopy curriculum. METHODS: Pre-clerkship medical students were recruited and randomized to two curriculum designs. The "Discovery then Instruction" group received the simulator one week before a traditional lecture, while the "Instruction then Discovery" group received it after the lecture. To assess participants' ability to identify otoscopic pathology, we used a 100-item test at baseline, post-intervention and 2-week retention time points. Secondary outcomes included self-reported comfort, time spent using the device, and a survey on learning preferences. RESULTS: Thirty-four students completed the study. Analysis of knowledge acquisition and retention showed improvement in scores of both groups and no significant effects of group (F1,31 = 0.53, p = 0.47). An analysis of participants' self-reported comfort showed a significant group x test interaction (F1,36 = 4.61, p = 0.04), where only the discovery then instruction group's comfort improved significantly. Overall device usage was low, as the discovery then instruction group spent 21.47 ± 26.28 min, while the instruction then discovery group spent 13.84 ± 18.71 min. The discovery first group's time spent with the simulator correlated moderately with their post-test score (r = 0.42, p = 0.07). After the intervention, most participants in both groups (63-68%) stated that they would prefer the instruction then discovery sequence. CONCLUSIONS: Both curricular sequences led to improved knowledge scores with no statistically significant knowledge differences. When given minimal guidance, students engaged in discovery learning minimally. There is value in SRL in simulation education, and we plan to further improve our curricular design by considering learner behaviours identified in this study.

Unusual presentation of squamous cell carcinoma of the maxilla in an 8-year-old child.

Oral squamous cell carcinoma (OSCC) is extremely rare in patients younger than 20 years of age. We present here a case of OSCC of the maxillary alveolar ridge in an otherwise healthy 8-year-old patient. The clinicohistologic presentation was not typical for mucosal SCC, and the possibility of an intrabony origin from the odontogenic epithelium was considered. The patient was treated with surgical resection, and treatment decisions were made with consideration of the need for eradication of tumor as well as tissue preservation to allow normal growth and development. A review of the literature indicated a preponderance of gingival-alveolar ridge as the site of OSCC in children with no known genetic predisposition to cancer. More studies of this rare subset of OSCC will help understand the underlying biology and guide treatment decisions.

Pediatric tracheostomy.

Tracheotomy refers to a surgical incision made into a trachea. Tracheostomy, on the other hand, refers to a surgical procedure whereby the tracheal lumen is positioned in close proximity to the skin surface. Tracheostomy is an uncommon procedure in the pediatric population. When required tracheostomy is typically performed as an open surgical procedure under general anesthesia with the patient intubated. However, it may need to be performed under local anesthesia or over a rigid bronchoscope in the patient with a precarious airway. Over the past half century, the primary indication for pediatric tracheostomy has shifted from acute infectious airway compromise to the need for prolonged ventilatory support in neurologically compromised children. The surgical technique, choice of tracheostomy tube, and post-operative care requires a nuanced approach in infants and young children. This article will review these topics in a comprehensive fashion.

Objective Evaluation of Otoscopy Skills Among Family and Community Medicine, Pediatric, and Otolaryngology Residents.

INTRODUCTION: The objective of this study is to evaluate and compare the perceived need for otolaryngology training and otoscopy diagnostic skills in primary care (Family and Community Medicine, Pediatric Medicine), and Otolaryngology Head and Neck Surgery (OTO-HNS) postgraduate trainees. Participant otoscopy skills were evaluated using the OtoSim simulator. METHODS: Family and Community Medicine, Pediatric, and OTO-HNS residents were recruited. Each resident participated in 3 separate otoscopy training and assessment sessions. The ability to correctly identify middle ear pathology was objectively evaluated using OtoSim™. Pretest, posttest, and 3-month retention test results were compared among residents in a paired comparison paradigm. Survey data assessing exposure to OTO-HNS during undergraduate and postgraduate training were also collected. RESULTS: A total of 57 residents participated in the study. All residents reported limited exposure to OTO-HNS during undergraduate medical training. Primary care trainees performed poorly on pretest assessments (30% ± 7.8%; 95% CI). Significant improvement in diagnostic accuracy was demonstrated following a single 1-hour teaching session (30%-62%; p < 0.001). Primary care residents demonstrated a significant decrease in diagnostic accuracy at a 3-month follow-up assessment (62%-52%, p < 0.001). Self-perceived comfort with otology was poorly correlated to pretest performance among primary care trainees (r = 0.26) and showed a stronger positive correlation among OTO-HNS trainees (r = 0.56). CONCLUSIONS: A single teaching session with an otoscopy simulator significantly improved diagnostic accuracy in primary care and OTO-HNS trainees. Improved performance is susceptible to deterioration at 3 months if acquired skills are not frequently used. Self-perceived comfort with otology may not be an accurate predictor of otoscopic diagnostic skill.

Olfactory testing in children using objective tools: comparison of Sniffin' Sticks and University of Pennsylvania Smell Identification Test (UPSIT).

BACKGROUND: Detection of olfactory dysfunction is important for fire and food safety. Clinical tests of olfaction have been developed for adults but their use in children has been limited because they were felt to be unreliable in children under six years of age. We therefore administered two olfactory tests to children and compared results across tests. METHODS: Two olfactory tests (Sniffin' Sticks and University of Pennsylvania Smell Identification Test (UPSIT)) were administered to 78 healthy children ages 3 to 12 years. Children were randomized to one of two groups: Group 1 performed the UPSIT first and Sniffin' Sticks second, and Group 2 performed Sniffin' Sticks first and UPSIT second. RESULTS: All children were able to complete both olfactory tests. Performance on both tests was similar for children 5 and 6 years of age. There was an age-dependent increase in score on both tests (p < .01). Children performed better on the Sniffin' Sticks than the UPSIT (65.3% versus 59.7%, p < .01). There was no difference in performance due to order of test presentation. CONCLUSIONS: The Sniffin' Sticks and UPSIT olfactory tests can both be completed by children as young as 5 years of age. Performance on both tests increased with increasing age. Better performance on the Sniffin' Sticks than the UPSIT may be due to a decreased number of test items, better ability to maintain attention, or decreased olfactory fatigue. The ability to reuse Sniffin' Sticks on multiple children may make it more practical for clinical use.

Evaluation of an otoscopy simulator to teach otoscopy and normative anatomy to first year medical students.

OBJECTIVE/HYPOTHESIS: Our study evaluates the effectiveness of the OtoSim as an educational tool for teaching otoscopy and normal middle ear anatomy to first-year medical students. STUDY DESIGN: Cross-sectional survey design. METHODS: A large group otoscopy simulator teaching session was held in January 2014 for 29 first-year medical students at the University of Toronto. Following the training session, survey questions were administered to assess the student experience. RESULTS: A total of 29 students completed the survey. All respondents rated the overall quality of the event as very good or excellent. Ninety-three percent of respondents indicated that the simulator increased their confidence in otoscopy. Students also commented that they were able to learn normal middle ear anatomy without causing discomfort to patients. CONCLUSIONS: The use of otoscopy simulation is a novel addition to traditional learning methods for undergraduate medical students. Students can effectively learn normal external and middle ear anatomy and improve their confidence in performing otoscopy examination. LEVEL OF EVIDENCE: NA.

Ultrasound to differentiate thyroglossal duct cysts and dermoid cysts in children.

OBJECTIVES/HYPOTHESIS: To determine if ultrasound could differentiate between thyroglossal duct cysts (TGDC) and midline dermoid cysts (DC). STUDY DESIGN: Cohort study. METHODS: A search of pathology reports yielded 91 patients with TGDC or midline DC. Ultrasound images were presented to a radiologist blinded to pathology who evaluated the following: 1) depth of lesion from skin, 2) maximum diameter, 3) dimensions, 4) midline location, 5) distance from base of tongue, 6) tract, 7) wall regularity, 8) wall thickness, 9) margin definition, 10) heterogeneity, 11) internal septae, 12) solid components, 13) intralesional Doppler flow, and 14) posterior enhancement. The predictive power of these variables was evaluated in a multiple logistic regression model. RESULTS: There were 53 TGDC and 38 DC. TGDC were significantly more likely than DC to have the following features: 1) smaller distance from base of tongue, 2) tract, 3) irregular wall, 4) ill-defined margin, 5) internal septae, 6) solid components, and 7) intralesional Doppler flow. Three clinically reliable ultrasound variables were independently able to discriminate between TGDC and DC. A predictive model was fashioned whereby each variable was scored as 0 or 1, with a total score calculated (septae + irregular wall + solid components = TGDC [or SIST] score). We propose a scoring system whereby 0 = suggestive of DC; 1 = suggestive of TGDC; and ≥2 = highly suggestive of TGDC. CONCLUSIONS: It may be possible to differentiate between TGDC and midline DC preoperatively using ultrasound.

Otoscopy simulation training in a classroom setting: a novel approach to teaching otoscopy to medical students.

OBJECTIVES/HYPOTHESIS: To determine the effectiveness of using of an otoscopy stimulator to teach medical students the primary principles of otoscopy in large group training sessions and improve their confidence in making otologic diagnoses. STUDY DESIGN: Cross-sectional survey design. METHODS: In March 2013, the Department of Otolaryngology-Head and Neck Surgery held a large-scale otoscopy simulator teaching session at the MaRS Innovation Center for 92 first and second year University of Toronto medical students. Following the training session, students were provided with an optional electronic, nine-question survey related to their experience with learning otoscopy using the simulators alone, and in comparison to traditional methods of teaching. RESULTS: Thirty-four medical students completed the survey. Ninety-one percent of the respondents indicated that the overall quality of the event was either very good or excellent. A total of 71% of respondents either agreed, or strongly agreed, that the otoscopy simulator training session improved their confidence in diagnosing pathologies of the ear. The majority (70%) of students indicated that the training session had stimulated their interest in otolaryngology-head and neck surgery as a medical specialty. CONCLUSIONS: Organizing large-group otoscopy simulator training sessions is one method whereby students can become familiar with a wide variety of pathologies of the ear and improve both their diagnostic accuracy and their confidence in making otologic diagnoses. LEVEL OF EVIDENCE: NA

Angiogenesis in costal cartilage graft laryngotracheoplasty: a corrosion casting study in piglets.

OBJECTIVES/HYPOTHESIS: To investigate the timing and degree of angiogenesis following anterior costal cartilage graft laryngotracheoplasty in an animal model. STUDY DESIGN: Randomized controlled animal model. METHODS: Twelve pigs were included in this study. Three control pigs were perfused with intravascular methyl methacrylate, and overlying tissue was corroded with potassium hydroxide and hydrochloric acid, leaving only a cast of vessels. Nine pigs underwent anterior costal cartilage graft laryngotracheoplasty and were survived for various lengths of time (3 for 48 hours, 3 for 10 days, 3 for 3 weeks) prior to corrosion casting. Transition zones between trachea and cartilage graft as well as the graft itself were analyzed for signs of angiogenesis (budding, sprouting, intussusception) and hypoxic or degenerative vessel features (extravasation, corrugation, circular constriction) using scanning electron microscopy. RESULTS: Angiogenesis peaked above control levels 48 hours after laryngotracheoplasty (P < .0001) and decreased 10 days and 3 weeks following surgery (P < .001, P < .0001, respectively) while remaining elevated above control levels (P < .0001, P < .005, respectively). There was no difference in hypoxic or degenerative features across surgical and control groups. Sprouting angiogenesis dominated over intussusception preoperatively (P < .0001) and 3 weeks following surgery (P < .05). However, there was no difference in type of angiogenesis 48 hours and 10 days following surgery. CONCLUSION: Angiogenesis peaked by 48 hours following costal cartilage graft laryngotracheoplasty and persisted for at least 3 weeks (although decreased) after surgery in this animal model. Hypoxic or degenerative processes did not appear to play a role in tracheal revascularization during the first 3 postoperative weeks.

Assessment of aspiration risk from dynamic modulation of endotracheal tube cuff pressure.

OBJECTIVES/HYPOTHESIS: To assess the risk of aspiration using a novel valve circuit that dynamically modulates endotracheal tube cuff pressure during the ventilatory cycle using bench and live animal models. STUDY DESIGN: Animal model. METHODS: The bench model consisted of a cuffed endotracheal tube inserted into an artificial trachea. Leakage of liquid around the cuff was measured after 4 hours of constant or dynamic modulation of cuff pressure at variable peak end expiratory pressures. In the porcine model, eight animals were ventilated with the modulating valve circuit and compared to eight controls ventilated with a constant cuff pressure (25 cm of water). Aspiration was monitored quantitatively using a pH probe (measured as voltage) and visually using fluoroscopy. RESULTS: There was no difference in the amount of fluid leakage around the endotracheal tube cuff in the constant or dynamically modulated pressure-cuff groups in the bench or animal models. CONCLUSION: Dynamically modulating endotracheal tube-cuff pressures to minimize tracheal mucosal damage does not increase the tendency to leak around the cuff compared to endotracheal tube cuffs inflated to a constant pressure. LEVEL OF EVIDENCE: N/A.

Quantitative assessment of pulmonary aspiration: A novel porcine model.

OBJECTIVES: Pulmonary aspiration is a common cause of ventilator-associated pneumonia in the intensive care setting. Current bench and animal models of aspiration are based on the qualitative assessments. The purpose of the present study was to develop a porcine model for the real-time quantitative assessment of aspiration. METHODS: Five sus scrofa piglets were anaesthetized and underwent placement of a pH probe through the endotracheal tube so that the distal tip of the probe resided at the carina. The pH probe was sutured to the posterior tracheal wall via an open approach and the position of the probe tip was verified by flexible endoscopy. 10 mL of acidic solution (pH = 2.7) was delivered through a catheter attached to the outside of the endotracheal tube so that the solution remained between the endotracheal tube and trachea proximal to the inflated endotracheal tube cuff. The pH probe was connected to a pH metre, a multifunctional data acquisition device with an analogue output signal measuring the voltage generated, and a computer for analysis. Leakage of fluid past the endotracheal tube cuff (aspiration) was therefore continuously assessed quantitatively by detecting voltage changes over a period of time. RESULTS: The mean voltage of the tracheal mucosa at the beginning of the experiment (maximum voltage) was 916.6 mV ± 24.5 mV (range 891.0-945.7 mV). There was a slight drop in voltage at the end of the 2 h period to 840.8 ± 22.6 mV (range = 812.3-867.3 mV). After deflation of the endotracheal tube cuff, the mean voltage dropped to 497.3 mV ± 24.8 mV (range 435.7-567.1 mV) with a mean drop in voltage of 419.3 mV ± 32.6 mV (range 368.9-455.3 mV). CONCLUSIONS: This porcine model allows for the continuous quantitative assessment of aspiration over time. Such a model may be of value for the evaluation of techniques for reducing aspiration.

Multidisciplinary perinatal management of the compromised airway on placental support: lessons learned.

OBJECTIVE: The aims of this study were to review fetal and maternal outcomes after management of the compromised perinatal airway via operation on placental support or ex utero intrapartum treatment and to discuss implications for future management of these complex and rare cases. METHODS: We have presented a retrospective case series of 12 neonates requiring airway management on placental support at a single tertiary care, academic center. RESULTS: One mother experienced significant blood loss. Operative recovery times were unremarkable. Eight neonates required airway management due to mass obstruction, two for removal of an endotracheal balloon for fetoscopic treatment of congenital diaphragmatic hernia, one for laryngeal atresia, and one for severe retrognathia. One of our series is an unusual case of management on placental support after vaginal delivery. Another child would have ideally been managed on placental support, but an extremely short umbilical cord prevented this. Even though the airway was secured in all 12 cases, five neonates died in the perinatal period. CONCLUSIONS: These procedures have a risk for substantial maternal blood loss. Despite excellent rates of success securing the neonatal airway, children who require management on placental support still have high mortality. A formalized multidisciplinary approach at our institution has enhanced preparedness for these cases.

A simple mechanical device reduces subglottic injury in ventilated animals.

OBJECTIVES/HYPOTHESIS: To test whether a simple inexpensive device that dynamically minimizes endotracheal cuff pressure throughout the respiratory cycle reduces endotracheal cuff pressure-related subglottic injury. STUDY DESIGN: Hypoxic animal model with one control and one experimental group. METHODS: Twelve S. scrofa domesticus piglets (14-16 kg) were intubated with standard endotracheal tubes and maintained in a hypoxic state to accelerate airway injury. Animals in the control group (n = 6) were ventilated with a constant pressure of 20 cm H2O in the endotracheal tube cuff. Animals in the experimental group (n = 6) were ventilated using a custom-designed circuit that altered the pressure in the endotracheal tube cuff in synchrony with the ventilatory cycle. Larynges were harvested at the end of the experiment and examined histologically to determine the degree of airway injury induced by the endotracheal cuff. RESULTS: Animals in the experimental group suffered significantly less airway damage than those in the control group. The differences were seen primarily in the subglottis (aggregate damage score 6.5 vs. 12, P <0.05), where the experimental endotracheal tube cuff exerted the least pressure. There was no difference in damage to the glottic or supraglottic structures. CONCLUSIONS: A simple, reliable, and inexpensive means of modulating endotracheal tube cuff pressure with the ventilatory cycle led to a substantial decrease in airway injury in our animal model. Such reduction in cuff pressure may prove important for humans, particularly those in intensive care units who tend to have underlying conditions predisposing them to tracheal damage from the endotracheal tube cuff.

Corrosion casting of the subglottis following endotracheal tube intubation injury: a pilot study in Yorkshire piglets.

PURPOSE: Subglottic stenosis can result from endotracheal tube injury. The mechanism by which this occurs, however, is not well understood. The purpose of this study was to examine the role of angiogenesis, hypoxia and ischemia in subglottic mucosal injury following endotracheal intubation. METHODS: Six Yorkshire piglets were randomized to either a control group (N=3, ventilated through laryngeal mask airway for corrosion casting) or accelerated subglottic injury group through intubation and induced hypoxia as per a previously described model (N=3). The vasculature of all animals was injected with liquid methyl methacrylate. After polymerization, the surrounding tissue was corroded with potassium hydroxide. The subglottic region was evaluated using scanning electron microscopy looking for angiogenic and hypoxic or degenerative features and groups were compared using Mann-Whitney tests and Friedman's 2-way ANOVA. RESULTS: Animals in the accelerated subglottic injury group had less overall angiogenic features (P=.002) and more overall hypoxic/degenerative features (P=.000) compared with controls. Amongst angiogenic features, there was decreased budding (P=.000) and a trend toward decreased sprouting (P=.037) in the accelerated subglottic injury group with an increase in intussusception (P=.004), possibly representing early attempts at rapid revascularization. Amongst hypoxic/degenerative features, extravasation was the only feature that was significantly higher in the accelerated subglottic injury group (P=.000). CONCLUSIONS: Subglottic injury due to intubation and hypoxia may lead to decreased angiogenesis and increased blood vessel damage resulting in extravasation of fluid and a decreased propensity toward wound healing in this animal model.

Removal of impacted cerumen in children using an aural irrigation system.

OBJECTIVES: Impacted cerumen in the ear canal is a common problem that can cause discomfort or prevent assessment. Cerumen removal can have deleterious side effects if performed improperly. We created an aural irrigation system which is currently not available on the market to provide a continuous flow of water at a regulated pressure and temperature. The purposes of this study were to (1) evaluate the safety and efficacy of this aural irrigation system in children and (2) determine the success rate of cerumen disimpaction when used by an allied health professional. METHODS: The following were evaluated in a nurse-run clinic: (1) referral patterns; (2) extent of canal occlusion; (3) cerumen consistency; (4) peak water pressure used; (5) patient discomfort; (6) efficacy of removal. Each ear was recorded as a separate event. RESULTS: 302 procedures were performed on 244 children (mean age 7.6 ± 4.1 years (range 0.5-18.3 years)). Patients were most commonly referred by an Otolaryngologist (63%), parent (17%), hearing aid provider (10%) or audiologist (9%). The most common reasons for referral were difficulty seeing the tympanic membrane (42%), fitting a hearing aid (20%) or performing an audiogram (11%). Prior to irrigation, 98% of canals were partially or fully occluded. After irrigation (mean peak pressure=488.21 ± 18.61 mm Hg (range 390-590 mm Hg), 92% of canals were completely free of cerumen (99% clear enough for evaluation or treatment). There was mild or no discomfort in 99% of patients and there were no incidences of trauma. CONCLUSIONS: An aural irrigation system can be effective at clearing impacted cerumen from pediatric ear canals with minimal discomfort and no trauma and can be successfully employed in a completely nurse-run clinic.

Quality of life and voice outcomes after thyroid ala graft laryngotracheal reconstruction in young children.

OBJECTIVES: (1) To assess the long-term impact of thyroid ala cartilage laryngotracheal reconstruction (TAC-LTR) on health-related quality of life (QOL) in infants using 4 validated instruments: Health Utility Index version 3 (HUI3), Pediatric Voice-Related QOL (PVRQOL), Impact on Family Questionnaire, and a visual analog scale and (2) to perform acoustic and perceptual voice assessments to evaluate longterm voice quality outcomes. STUDY DESIGN: Prospective study. SETTING: Tertiary academic pediatric hospital. SUBJECTS: Eligible children who received TAC-LTR before the age of 24 months between 1995 and 2007. METHODS: Interviews with parents and children using 4 validated instruments, voice analyses, and endoscopic evaluation were performed. RESULTS: Twelve patients (7 male, 5 female, median age 10 years) were enrolled over a 6-month period. The mean age at LTR was 5 months (range, 1-20 months), and the mean study followup period was 9 years (range, 2-14 years). The average speech HUI3, PVRQOL, and Impact on Family scores were 0.83 (95% confidence interval = 0.74, 0.92), 0.93 (interquartile range [IQR] = 0.81, 1.00), and 0.65 (IQR = 0.54, 0.92), respectively. All acoustic scores were either normal or mildly abnormal for the variables jitter, shimmer, noise-to-harmonic ratio, peak amplitude variation, and fundamental frequency. The Consensus Auditory-Perceptual Evaluation of Voice overall severity score was in the normal to mildly abnormal range for 8 of 9 patients. CONCLUSION: This is the first study to explore and quantify longterm QOL and voice quality in children following LTR with thyroid ala graft at a very young age. Most patients had very good functional voice outcome as evidenced by the HUI3 and PVRQOL scores. This was corroborated by acoustic and perceptual voice assessments.