Women Surgeons Who Contributed to the Development of Pediatric Otolaryngology in the United States.

OBJECTIVE: Our goal was to identify the early pioneering women surgeons in the United States who devoted their career or the majority of their practice to the care of otolaryngologic disorders in children. We sought to share their stories, recognize their contributions to the surgical subspecialty now known as pediatric otolaryngology, and acknowledge their vision and leadership. DATA SOURCES: Primary sources include books, published articles in the medical literature, newspaper articles, memorials/obituaries in both the medical literature and lay press, web logs, the John Q Adams Center for the History of Otolaryngology to include the Women in Otolaryngology, a number of otolaryngology departments, and children's hospitals nationwide. Interviews were conducted with former colleagues and senior pediatric otolaryngologists. REVIEW METHODS: Following review of all available information, women surgeons were included in this study if there was documentation of a clinical practice involving the otolaryngologic care of children in the United States before 1985 with demonstration of the education of others in this discipline. RESULTS: Six women surgeons were identified: Drs. Alice G Bryant, Margaret F. Butler, Ellen James Patterson, Emily Lois Van Loon, LaVonne Bernadene Bergstrom, and Joyce A. Schild. CONCLUSION: Six pioneering women surgeons in the United States have been identified who devoted their practice to the care of otolaryngologic disorders in children and mentored or trained other health care providers. The stories of their lives, their contributions to the care of otolaryngologic disorders in children, and their work as mentors or educators have been described. Laryngoscope, 134:40-46, 2024.

Endoscopic pediatric endonasal retrieval of transorbital projectile: An illustrative multimedia report.

Air guns, particularly BB (ball-bearing or bullet ball) guns, have gained significant power and velocity over the last few decades. More than 145,000 pediatric patients suffered injuries attributed to air guns in the United States between 2001 and 2011, and approximately 22,000 pediatric emergency department visits are attributed to air gun-related injuries annually (Hyak et al., 2020 [1]). This study aims to describe an effective surgical technique in addressing maxillofacial injuries caused by BB gun projectiles in the pediatric population. We present a detailed surgical approach for endoscopic endonasal retrieval of a transorbital projectile in a 13-year-old male who sustained a maxillofacial BB gun injury, with the goal of restoring sinonasal function in a minimally invasive fashion.

Adolescent subdural empyema in setting of COVID-19 infection: illustrative case.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an ongoing viral pandemic that has affected modern medical practice and can complicate known pathology. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes symptoms that may mimic a viral pneumonia, with potential for serious sequelae, including acute respiratory distress syndrome, coagulopathy, multiorgan dysfunction, systemic vascular abnormalities, and secondary infection. OBSERVATIONS: The authors describe a case of a 15-year-old boy who presented with a right subdural empyema and sinusitis while having active COVID-19 infection. The patient initially presented with left-sided weakness, frontal sinusitis, and subdural empyema. Emergent surgery was performed for evacuation of empyema and sinus debridement. Samples of purulent material within the subdural space were tested for SARS-CoV-2 by reverse transcriptase polymerase chain reaction. The patient had a successful recovery and regained the use of his right side after combined treatment. To our knowledge, this is the first reported case of a bacterial subdural empyema associated with frontal sinusitis in a coinfected patient with COVID-19 without evidence of COVID-19 intracranial infection. LESSONS: A subdural empyema, which is a surgical emergency, was likely a superinfection caused by COVID-19. This, along with the coagulopathy caused by the virus, introduced unique challenges to the treatment of a known pathology.

Crayon in the Orbit and Sinuses in a Pediatric Patient.

Penetrating transorbital injury with skull base involvement is a rare occurrence from a crayon. We report a case of a 2-year-old male who sustained a penetrating crayon injury through the right orbit and lamina papyracea into the posterior ethmoid sinus complicated by cerebrospinal fluid leak. There have been no other reported cases of this type of injury by a crayon.

Exceptionally early tympanostomy tube placement in pediatric patients with cleft lip and palate.

OBJECTIVE: At our institution, cleft lip repair is performed at or before 8 weeks of age, and tympanostomy tubes (TT) have been inserted concurrently in some of these patients. Our objective was to determine the feasibility and present the preliminary results of TT placement at this early age. METHODS: A retrospective review was conducted of 22 patients born with cleft lip and/or palate who had TT placement in the first 8 weeks of life. Data collected included complications and audiologic function post TT placement. RESULTS: Subjects had a mean age of 3.9 weeks at the time of TT placement and cleft lip repair. Thirteen patients (59%) reported otorrhea during the follow-up period. Eighteen of 21 (86%) patients who underwent auditory evaluation had normal audiological function following TT placement. One patient had sensorineural hearing loss and 2 patients had mild conductive hearing loss due to bilateral extruded TT and OME at 15.9 and 39.2 months after surgery. CONCLUSION: Exceptionally early TT is feasible. Placing TT at or before 8 weeks of age did not result in any major complications but demonstrated a high incidence of otorrhea. A randomized, prospective study with a larger sample size is necessary to determine the benefits of TT placement at this age.

The Relevance of and Surgical Approach to the Suprahyoid Region in Thyroglossal Duct Surgery.

OBJECTIVES: Persistent or recurrent disease following excision of a thyroglossal duct cyst/sinus (TGDC) is often found in the suprahyoid region. Cadaver dissections were performed to identify and name important surgical landmarks in the suprahyoid area; a histopathologic analysis of surgical specimens was completed to determine the incidence and extent of microscopic disease; and clinical outcomes were compared to determine the efficacy of a specific anatomic dissection. STUDY DESIGN: Retrospective case series. METHODS: Standardized dissections of four adult cadavers were performed. Consecutive surgical specimens were examined for evidence of microscopic TDGC disease in the suprahyoid region, measuring the greatest width and length of disease. A retrospective review of all consecutive TGDC procedures was completed. RESULTS: The important surgical landmarks in the suprahyoid area were identified in all cadavers. Microscopic disease in the suprahyoid area was found in 79% (37 of 47) of surgical specimens. The mean greatest length and width of microscopic disease was 12.4 mm and 1.4 mm, respectively. Following identification of these landmarks, the incidence of recurrent or persistent disease decreased (P = .02) from 5% (8 of 159) to 0% (0 of 112). CONCLUSION: The majority of pediatric patients with a TGDC will have microscopic disease in the suprahyoid area. The surgical landmark of the fascial plane between the geniohyoid and genioglossus muscles demarcates the anterior and lateral borders of resection in the suprahyoid area. This approach can be used as a reliable and easily reproducible technique in TGDC surgery to increase confidence of achieving complete removal of disease in the suprahyoid area, avoiding persistent or recurrent disease and a revision procedure. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:553-558, 2021.

Prospective Evaluation of a Smartphone Otoscope for Home Tympanostomy Tube Surveillance: A Pilot Study.

OBJECTIVES: Recent technological advances have led to the capability of performing high resolution imaging of the tympanic membrane. Smartphone technologies and applications have provided the opportunity to capture digital images and easily share them. The smartphone otoscope device was developed as a simple system that can convert a smartphone into a digital otoscope. This device has the prospective ability to improve physician-patient communication and assist with the diagnosis and management of ear disease. Our objective was to evaluate the feasibility and physician/parental satisfaction using the Cellscope® smartphone attachment for at home tympanostomy tube monitoring. METHODS: Children between 6 months and 15 years of age at an urban tertiary children's hospital that were scheduled for bilateral tympanostomy tube insertion or underwent bilateral tympanostomy tube surgery were prospectively enrolled in the study. Comparisons were made between parental home-recorded videos and findings during in-office otoscopy. Two independent otolaryngologists reviewed the videos and concordance between inter-rater agreements was calculated. Acceptability and use questionnaires were administered to physicians and parents. RESULTS: There was good intra-rater agreement between traditional otoscopy and video-otoscopy for tube extruding, tube blocked and tube extruded with at least 80% agreement (P < .05) and excellent inter-rater agreement between physicians for nearly all tube variables (P < .0001) There was a high degree of satisfaction with this mode of surveillance. Parents and physicians agreed that the CellScope® smartphone was easy to use, helpful with the occurrence of acute events, and appeared to improve quality of care. CONCLUSIONS: The CellScope® smartphone is feasible for use in tympanostomy tube surveillance. Use of the device may allow otolaryngologists to easily follow a child's tympanostomy tube remotely over time and offer greater parental satisfaction.

The Generalizability of the Clinical Assessment Score-15 for Pediatric Sleep-Disordered Breathing.

OBJECTIVE: The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion. METHODS: Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15. RESULTS: Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P < .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1. CONCLUSION: This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing. LEVEL OF EVIDENCE: 2B Laryngoscope, 130:2256-2262, 2020.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

To drain or not to drain following a Sistrunk procedure: A dual institutional experience.

INTRODUCTION: A Sistrunk procedure is the standard operative management of patients with thyroglossal duct cysts. Drain placement is commonly employed with the goal of reducing postoperative complications. This study investigates the association between drain use and relevant postoperative complications following pediatric Sistrunk procedures. METHODS: Retrospective cohort study evaluating 295 pediatric patients treated between 2007 and 2016 at two tertiary care children's hospitals. RESULTS: The mean age of the study population was 5.6 years (SD 4.0). A drain was utilized in 234 cases (79.3%). The mean procedural duration was 108 min (SD 48), and significantly longer in patients receiving a drain. Early postoperative complications included seroma (5.8%), secondary infection (3.4%), wound breakdown (2.0%) and hematoma (0.3%). The risk of such complications did not significantly differ between patients without drain placement (9.8%) versus those who underwent surgical drain placement (12.0%) after accounting for age and history of preoperative infection (adjusted RR = 0.86; 95% CI: 0.37, 1.98; p = 0.72). In the subgroup analysis, findings were consistent across institutions, age category, history of infection, and primary versus secondary procedure. CONCLUSION: This dual institutional study found drain placement during a Sistrunk procedure may not reduce rates of common postoperative complications, even in longer duration cases in which a drain is more frequently placed. This data suggests a Sistrunk procedure may be safely performed without drain placement in select cases.

The incidence of microscopic thyroglossal duct tissue superior to the hyoid bone.

OBJECTIVE: Despite the success of the Sistrunk procedure, persistence of a thyroglossal duct cyst (TGDC), sinus, or remnant following excision remains a clinical problem. This is most likely due to the presence of microscopic disease that was not excised at the time of surgery. The purpose of this study is to determine the incidence of microscopic disease superior to the hyoid bone in children who have had either a primary or revision procedure for a TGDC. METHODS: A prospective review of pathologic specimens was conducted of all consecutive patients undergoing TGDC excision by pediatric otolaryngologists at the Children's Hospital Los Angeles beginning March 2014 through July 2017 in both primary and revision procedures. RESULTS: Microscopic disease was present superior to the hyoid bone in 25 of the 34 (74%) specimens and in 100% (6) of the specimens from a revision procedure. CONCLUSION: The majority of persons who have a TGDC will have microscopic disease superior to the hyoid bone. In order to minimize the incidence of persistence following a primary procedure, tissue superior to the hyoid bone should be removed routinely even if no gross disease is noted at the time of surgery. When performing a revision procedure, special attention should be given to the suprahyoid area as a likely site of persistent disease. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:1215-1217, 2019.

Epistaxis health disparities in the United States pediatric population.

OBJECTIVE: Despite epistaxis occurring in up to 60% of the population, few studies have investigated health status disparities in the pediatric epistaxis population. The aim of this study was to evaluate sociodemographic risk factors associated with epistaxis visits for pediatric patients. METHODS: Data were extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department from 2001 to 2010. Outpatient visits of children less than 18 years who received a primary, secondary, or tertiary diagnosis of epistaxis (ICD-9CM code 784.7X) were included. Bivariate and stepwise multivariate regressions were conducted to develop a final model for epistaxis visits described by sociodemographics. RESULTS: Epistaxis visits accounted for 5 ±â€¯0.6 million visits in children less than 18 years. 51% and 33% of children presenting with epistaxis had private insurance and Medicaid, respectively (p = 0.001). 69% of epistaxis visits were evaluated at a pediatric clinic, 18% at an ENT/surgery clinic, and 13% at a general/family medicine clinic (p < 0.0001). After multivariate adjustment, epistaxis visits were associated with older age (p = 0.006). Black children were more likely to present with epistaxis (95% CI 1.3-4.1, p = 0.005) compared to white children. Allergic rhinitis, present in 11% of epistaxis visits, was a significant comorbidity associated with visits (95%CI 1.3-4.6, p = 0.008). Patients were also more likely to present to an ENT/surgery clinic (95% CI 4.5-16.5, p < 0.0001) compared to a general/family medicine clinic. CONCLUSIONS: Epistaxis visits by children are associated with age, race, and specialty. Targeted interventions to help reduce this common presentation should be developed.

Prevalence of an intact hyoid bone at revision excision of a thyroglossal duct remnant.

OBJECTIVE: To determine the prevalence of an intact hyoid bone at the time of revision thyroglossal duct cyst (TGDC) surgery in a pediatric population. METHODS: The operative reports of 44 patients under 18 years of age who underwent a revision TGDC surgery from March 1997 to October 2015 at Children's Hospital Los Angeles were reviewed to determine finding of an intact hyoid bone at the time of the revision procedure. RESULTS: At the time of the revision surgery, 75% of the patients had an intact hyoid bone and 25% did not. CONCLUSION: Patients who experience a recurrence of a TGDC are more likely than not to have an intact hyoid bone at revision surgery. These data indicate that some surgeons are not following the recommendation from Schlange and Sistrunk that removal of the mid-portion of the hyoid bone should be a routine part of any primary procedure for excision of a known or suspected TGDC in order to decrease the risk of recurrence. Despite the prevalent knowledge that the central portion of the hyoid bone be removed during a TGDC procedure, special attention should be given to the area of the midportion of the hyoid bone as a likely site of persistent disease in revision cases even if a previous operative report documents resection of a portion of the hyoid bone and/or cartilage.

The incidence of revision adenoidectomy: A comparison of four surgical techniques over a 10-year period.

Approximately 130,000 adenoidectomies are performed each year in the United States. Few studies have examined adenoid regrowth and the incidence of revision surgery or have compared four different surgical instruments commonly used for adenoid surgery within the same institution. This study aimed to determine the incidence of revision adenoidectomy after the use of microdebrider, Coblation, suction cautery, and curette instruments over a 10-year period at a single major tertiary children's center in the United States. A retrospective chart review was performed for all patients who underwent primary and/or revision adenoidectomy at the Children's Hospital Los Angeles (CHLA) between August 2004 and August 2014. During the 10-year study period, a microdebrider was used in 212 cases, Coblation in 382, suction cautery in 1,926, and curette in 3,139 adenoidectomies. The percentages of revision adenoidectomy were 1.42% (3 patients) for microdebrider, 0.79% (3 patients) for Coblation, 0.36% (7 patients) for suction cautery, and 0.03% (1 patient) for curette. The cumulative incidence of revision adenoidectomy for initial surgeries performed at CHLA was 0.2% for the 10-year study period. Pearson chi-square analysis showed statistically significant differences between the surgical techniques (p < 0.0001). In conclusion, regrowth of adenoid tissue requiring revision surgery occurs very infrequently irrespective of the instrument used for the primary procedure, and the most common indication for revision adenoidectomy is to improve eustachian tube dysfunction rather than nasal obstruction due to adenoid hypertrophy.

Safety and efficacy of intratympanic ciprofloxacin otic suspension post-tubes in a real-world pediatric population.

PURPOSE: Otorrhea frequently follows tympanostomy tube (TT) placement. We evaluated otorrhea following single 6mg OTO-201 (OTIPRIO®, ciprofloxacin otic suspension 6%) intraoperative injection into each middle ear in a variety of effusion types and concurrent procedures in children undergoing TT placement. SECONDARY OBJECTIVE: Efficacy based on Medicaid status and safety. BASIC PROCEDURES: In this prospective, 8-week, multicenter, open-label study, 501 patients were enrolled: mean age 2.9years, male (56.9%), wet/wet ears (66.9%), wet/dry (16.8%), dry/dry (16.3%), and Medicaid-insured (32.9%). MAIN FINDINGS: In per-protocol population (n=410), otorrhea rate through Day 15 were 8.8% (CI:5.7%-12.8%), 6.6% (CI:2.2%-14.7%), 3.3% (CI:0.4%-11.3%) in wet/wet, wet/dry, and dry/dry ears, respectively. For Medicaid patients through Day 15, Week 4 and Week 8, otorrhea rates were 8.1% (CI:4.1%-14.1%), 17.0% (CI:11.1%-24.5%), and 17.8% (CI:11.7%-25.3%) compared with those non-Medicaid insured: 7.3% (CI:4.5%-11.0%), 14.5% (CI:10.6%-19.3%), and 21.8% (CI:17.1%-27.2%), respectively. Safety was similar to previous Phase 3 trials. PRINCIPAL CONCLUSIONS: OTO-201 demonstrated otorrhea rates consistent with Phase 3 trials in a broader, real-world, ENT practice-based pediatric population. Outcomes were similar in Medicaid- and non-Medicaid insured patients. OTO-201 was well-tolerated.

Paranasal Rosai-Dorfman Disease with Osseous Destruction.

Rosai-Dorfman disease is a rare histiocytic proliferative disorder of unknown etiology typically characterized by cervical lymphadenopathy. Extranodal involvement often manifests in the head and neck region. We present a 10-year-old male who presented to our hospital with left epiphora from an aggressive paranasal mass invading the left orbit with osseous destruction. The mass was surgically biopsied and debulked with histopathological examination revealing Rosai-Dorfman disease. Although rarely found in the sinuses, Rosai-Dorfman disease should be considered when evaluating sinonasal masses.

Safety and Efficacy of Intratympanic Ciprofloxacin Otic Suspension in Children With Middle Ear Effusion Undergoing Tympanostomy Tube Placement: Two Randomized Clinical Trials.

IMPORTANCE: Otorrhea after tympanostomy tube placement (TTP) in children is common. Although not approved by the US Food and Drug Administration, antibiotic ear drops are routinely used intraoperatively and prescribed for multidose, multiday postoperative administration by caregivers. OBJECTIVE: To investigate the safety and efficacy of a single-dose intratympanic, intraoperative, thermosensitive, otic suspension of ciprofloxacin (OTO-201) in children requiring TTP. DESIGN, SETTING, AND PARTICIPANTS: Two identically designed, prospective, double-blind, sham-controlled, multicenter phase 3 randomized clinical trials included 532 patients aged 6 months to 17 years with middle ear effusions. Patients with confirmed bilateral effusions on the day of TTP were randomized to TTP alone or to TTP with OTO-201 injection. Children underwent a 28-day observation period. Data were collected from November 14, 2013, to June 3, 2014. Final follow-up was completed on June 16, 2014, and intent-to-treat data were analyzed from June 10 to August 27, 2014. MAIN OUTCOMES AND MEASURES: Efficacy was assessed as treatment failure, including the presence of otorrhea, use of otic or systemic antibiotics, loss to follow-up, or missed visits. Safety was assessed for serious adverse events and treatment-emergent adverse events using audiometry, otoscopy, and tympanometry. RESULTS: Among the 532 patients included in the trials, 175 were randomized to TTP only and 357 to OTO-201 treatment (304 boys [57.1%]; 228 girls [42.9%]; mean [SD] age, 2.4 [2.1]). At day 15, the cumulative proportion of treatment failures (primary end point) was 24.6% (44 of 179 patients) in trial 1 and 21.3% (38 of 178 patients) in trial 2 in the OTO-201 groups vs 44.8% (39 of 87 patients) in trial 1 and 45.5% (40 of 88 patients) in trial 2 in the TTP-alone groups. At day 15 otorrhea-only treatment failures in trial 1 included 21 of 179 (11.7%) in the OTO-201 group vs 22 of 87 (25.3%) in the TTP-only group; in trial 2, 17 of 178 (9.6%) in the OTO-201 group vs 29 of 88 (33.0%) in the TTP-only group. The odds of otorrhea-only failure were significantly reduced in the OTO-201 groups compared with the TTP-only groups in both trials (age-adjusted odds ratios, 0.38 [95% CI, 0.19-0.75] and 0.19 [95% CI, 0.09-0.38]; P < .001 for both trials, post hoc analysis). No drug-related serious adverse events were seen, and most adverse events were mild or moderate. No evidence of increased tube occlusion and no negative effect on results of audiometry, tympanometry, or otoscopy were noted with OTO-201 administration. CONCLUSIONS AND RELEVANCE: Two large phase 3 randomized clinical trials demonstrate the safety and efficacy of a single intraoperative administration of OTO-201 for middle ear effusion at the time of TTP. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: NCT01949142 and NCT01949155.