Hearing loss in pediatric temporal bone fractures: Evaluating two radiographic classification systems as prognosticators.

INTRODUCTION: Temporal bone fractures (TBF) are traditionally classified by their angle of fracture relative to the petrous ridge, and more recently by whether or not they violate the otic-capsule. This study compared rates of hearing loss (HL) and signs of otologic dysfunction among fracture types of both classification systems, within the pediatric population. METHODS: Pediatric patients were retrospectively characterized from a previously identified cohort of TBF patients, diagnosed from 2000 to 2014. CT scans were reviewed and TBFs were classified first as longitudinal (L), transverse (T) or mixed (M), and then as otic-capsule sparing (OCS) or otic-capsule violating (OCV). Medical records were reviewed, and rates of HL and presenting signs were compared among L, T and M fractures, and OCS and OCV fractures. RESULTS: Forty-three patients with 47 TBFs met the inclusion criteria. Eighteen, 4 and 25 TBFs were classified as L, T and M fractures, respectively. Thirty-three and 9 were classified as OCS, and OCV, respectively. Among 24 cases of HL: 20, 3, and 1 were conductive HL (CHL), sensorineural HL (SNHL) and mixed HL, respectively. Two cases of SNHL were found among OCV fractures, with none in OCS fractures (estimated difference 0.22; 95% confidence interval 0.01-0.60). Similar rates of CHL were found across L, T and M fractures (range 36-50%), and across OCV and OCS fractures (range 42-44%). Hemotympanum was the most common presenting sign, found in 68% of TBFs and 80% of CHL cases. There were no significant differences in the incidence of signs or symptoms between fracture types. CONCLUSIONS: In our cohort, both the traditional and otic-capsule radiographic classification systems failed to predict the incidence of CHL and other otologic signs in the pediatric population. Though OCV fractures conferred an increased risk for developing SNHL, we found a lower incidence than anticipated given violation to the bony labyrinth.

Securing an OTL-HNS residency: how competitive is it? Comparing medical student perceptions to actual Canadian statistics.

BACKGROUND: The residency match is an important event in an aspiring physician's career. Otolaryngology - Head and Neck Surgery (OTL-HNS) is a surgical specialty that has enjoyed high numbers of applicants to its residency programs. However, recent trends in Canada show a decline in first-choice applicants to several surgical fields. Factors thought to influence a medical student's choice include role models, career opportunities and work-life balance. The notion of perceived competitiveness is a factor that has not yet been explored. This study sought to compare competitiveness of OTL-HNS, as perceived by Canadian medical students to residency match statistics published yearly by CaRMS (Canadian Residency Matching Service), with the hope of informing future decisions of surgical residency programs. METHODS: An electronic survey was created and distributed to all medical students enrolled in the 17 Canadian medical schools. After gathering demographic information, students were asked to rank what they perceived to be the five most competitive disciplines offered by CaRMS. They were also asked to rank surgical specialties from most to least competitive. Publically available data from CaRMS was then collected and analyzed to determine actual competitiveness of admissions to Canadian OTL-HNS residency programs. RESULTS: 1194 students, from first to fourth year of medical school, completed the survey. CaRMS statistics over the period from 2008 to 2014 demonstrated that the five most competitive specialties were Plastic Surgery, Dermatology, Ophthalmology, Emergency Medicine and OTL-HNS. Among surgical disciplines, OTL-HNS was third most competitive, where on average 72% of students match to their first-choice discipline. When students were questioned, 35% ranked OTL-HNS amongst the top five most competitive. On the other hand 72%, 74% and 80% recognized Opthalmology, Dermatology and Plastic Surgery as being among the five most competitive, respectively. We found that fourth-year medical students were significantly more knowledgeable about the competitiveness of both OTL-HNS and Plastic Surgery compared to first-year students (p < 0.01). CONCLUSION: Overall, Canadian medical students may underestimate the competitiveness of OTL-HNS. Furthermore, competitiveness would appear to be a concept that resonates with medical students during the match process.

Sleep and breathing on the first night after adenotonsillectomy for obstructive sleep apnea.

Adenotonsillectomy (T&A) has established effectiveness for the treatment of obstructive sleep apnea (OSA). However, more than 20% of children with OSA have respiratory compromise requiring medical intervention in the postoperative period. The reasons for this complication are not well-defined. We aimed to compare the nature and severity of sleep-disordered breathing in children with mild and severe OSA on the first night following adenotonsillectomy. Ten children were classified into groups of mild and severe OSA, based on preoperative testing. On the first night after T&A, they underwent polysomnography, including electroencephalograph, submental electromyography, bilateral electro-oculograms, monitoring of respiratory movements, heart rate, ECG, and oxygen saturation. Sleep-disordered breathing was assessed by the apnea-hypopnea index, the SaO(2) nadir, and the desaturation index, including dips in saturation below 90% (DI(90)). Sleep quality was assessed by sleep efficiency, time spent in each sleep state, and respiratory arousal index. Obstructive events occurred postoperatively in all children, but were more frequent in those with severe OSA preoperatively: the median (interquartile range) mixed/obstructive apnea/hypopnea indicies were 6.9 (2.2-9.8) events/hr and 21.5 (15.1-112.1) events/hr for the mild OSA group and the severe OSA group, respectively (P = 0.009). Obstructive events were the major cause of desaturation during sleep postoperatively. Sleep quality was severely disrupted in both groups, with reductions in both slow-wave sleep and rapid eye movement sleep. In conclusion, despite removal of obstructing lymphoid tissue, upper airway obstruction occurred on the first postoperative night in children with OSA. This study is the first to demonstrate the mechanism of respiratory compromise after adenotonsillectomy, a common postoperative complication in children with severe OSA.

Hyalinizing trabecular adenoma versus papillary thyroid carcinoma in a child.

Hyalinizing trabecular adenoma (HTA) of the thyroid gland is a rare, benign neoplasm predominantly diagnosed in middle-aged women. There is mounting evidence in the medical literature, however, to suggest that HTA may represent an encapsulated variant of papillary thyroid carcinoma (PTC). This report describes an unusual case of PTC in a child initially diagnosed as HTA. Establishing an accurate diagnosis has important management implications for the pediatric patient.

Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea.

OBJECTIVE: We tested the hypothesis that a 6-week course of a nasal glucocorticoid spray would decrease the severity of obstructive sleep apnea in children with adenotonsillar hypertrophy. STUDY DESIGN: We conducted a randomized, triple-blind, placebocontrolled, parallel-group trial of nasal fluticasone propionate versus placebo in 25 children aged 1 to 10 years with obstructive sleep apnea proven on polysomnography. The primary outcome was the change from baseline in the frequency of mixed and obstructive apneas and hypopneas. RESULTS: Thirteen children received fluticasone, and 12 received placebo. The mixed/obstructive apnea/hypopnea index decreased from 10.7 +/- 2.6 (SE) to 5.8 +/- 2.2 in the fluticasone group but increased from 10.9 +/- 2.3 to 13.1 +/- 3.6 in the placebo group, P =.04. The mixed/obstructive apnea/hypopnea index decreased in 12 of 13 subjects treated with fluticasone versus 6 of 12 treated with placebo, P =.03. The frequencies of hemoglobin desaturation and respiratory movement/arousals also decreased more in the fluticasone group. Changes from baseline in tonsillar size, adenoidal size, and symptom score were not significantly different between groups. CONCLUSION: Nasal fluticasone decreased the frequency of mixed and obstructive apneas and hypopneas, suggesting that topical corticosteroids may be helpful in ameliorating pediatric obstructive sleep apnea.

Acute airway obstruction from a laryngeal lymphangioma in a child.

Lymphangiomas present commonly in the head and neck region with over 90% of lesions diagnosed before 2 years of age. These lesions have rarely been reported as a cause of acute upper airway obstruction and to date, there are very few reports in the literature documenting the presence of lymphangiomas in the larynx. We present the case of a previously asymptomatic 13-year-old girl with Joubert's syndrome, who presented with acute airway obstruction while undergoing extubation for a routine dental procedure. Near-complete obstruction of her supraglottis from a lymphangioma necessitated tracheotomy to secure the airway. The diagnostic work-up and management of this patient and her post-operative course are discussed. This case illustrates the insidious presentation of a laryngeal lymphangioma and emphasizes the management options for such patients.

Functional endoscopic sinus surgery in the paediatric population: outcome of a conservative approach to postoperative care.

Functional endoscopic sinus surgery (FESS) has become a widely used and effective tool in treating chronic sinusitis refractory to medical therapy. Reported success rates, defined mainly on the basis of improvement of preoperative symptoms, have been encouraging and ranged between 71 and 93%. However, in most of these studies, a second-look endoscopy under general anaesthesia was performed 2 to 3 weeks following the initial surgery in order to débride and clean the operative site. In this study, we present the outcome of FESS in our centre, where a second-look endoscopy was never performed. A retrospective study on all of the patients operated on between May 1987 and May 1997 was undertaken. All 35 patients had symptoms of sinusitis and had received initial medical therapy for at least 2 months. Only those who did not improve were considered candidates for surgery. Prior to the operation, all patients had computed tomography scan of the sinuses to document the extent of their disease. Eleven patients (31%) had asthma, 3 patients had cystic fibrosis, 1 had leukemia, 1 had immotile cilia, and 1 had Kartagener's syndrome. The period of follow-up ranged between 3 months and 5 years. Success was determined by resolution or improvement of the preoperative symptoms as assessed during their latest follow-up visit. Our data show an overall success rate of 74%. More than half of the patients (56%) who had recurrence of symptoms had an underlying systemic condition (cystic fibrosis, leukemia, or ciliary dyskinesia); however, these patients showed an initial improvement during the first few months following FESS. Also, five patients (14%) required revision FESS within 1 to 3 years following their initial surgery; four of those patients (80%) had an underlying systemic condition. Based on these results, we conclude that second-look endoscopy is of no benefit following routine FESS since our success rates are comparable to those reported in the literature.

Ultrasound and a new videobronchoscopic technique to measure the subglottic diameter.

OBJECTIVE: The aim of this study was to evaluate ultrasound (US) and a new videobronchoscopic (VB) technique in the measurement of the subglottic lumen diameter. DESIGN: This blind prospective animal study of 62 recently sacrificed rabbits was conducted at the Montreal Children's Hospital. METHODS: Three different diameter measurements of the subglottis were assessed using B-mode US on each intact animal. The same diameter measurements, as well as a fourth, were estimated with a VB measuring technique. Finally, the subglottic area was surgically exposed allowing for direct caliper measurements of all four corresponding diameters. All three US measurements on each of the 62 rabbits and all four VB measurements on each of the 60 rabbits were compared with the gold standard corresponding caliper measurements. RESULTS: Statistical analysis revealed strikingly convergent values in subglottic lumen diameter measurements using US and calipers. The mean difference between these methods for all 186 observations was 0.11 mm. With 95% confidence, the maximum discordance was less than 0.30 mm on the smallest evaluated lumen. Convergent values were also demonstrated in subglottic lumen diameter measurements using VB and calipers. The mean difference between these methods for all 240 observations was 0.16 mm. With 95% confidence, the maximum discordance was less than 0.37 mm on the smallest evaluated lumen. Pearson's correlation coefficient supported a strong and positive relationship between US and caliper measurements as well as VB and caliper measurements. Simple linear regression model indicated that the subglottic lumen diameter could be predicted by both US and our VB technique. CONCLUSION: This work represents the first attempt to validate B-mode US and a VB technique as measuring tools for the subglottic lumen diameter. Our results have clearly shown that both methods are precise measuring modalities for this purpose. With further studies, these two objective methods of measuring the subglottic diameter could be adopted universally. The precise knowledge of this diameter could help physicians recognize and describe the severity of a narrowed lumen. Reporting results in such a standardized fashion, by either US or VB, could facilitate communication among clinicians and institutions.

Sino-orbital foreign body in a child.

Foreign bodies of the sinuses are uncommon. Few reports exist in the English literature. Among these, the frontal and maxillary sinuses are most often involved. Ethmoid and sphenoid foreign bodies are rare and tend to present with chronic symptoms due to delayed diagnosis. We present a case of an acute presentation of a foreign body involving the orbit and ethmoid sinus in a 12-year-old male.

Surgical treatment of cholesteatoma in children.

We retrospectively reviewed patients surgically treated for cholesteatoma to determine the impact of surgical procedures on preoperative hearing status and whether there was preservation, improvement, or deterioration. We reviewed 173 patients treated over a 15-year period. One hundred eighteen (68%) patients had acquired cholesteatoma and 55 (32%) patients had congenital cholesteatoma. One hundred (58%) patients had extensive disease on presentation that required canal wall-down mastoidectomy. Patients with attic cholesteatoma underwent canal wall-up mastoidectomy, and those with cholesteatoma localized to the middle-ear space were adequately treated with tympanotomy. Hearing was preserved in 101 cases (59%), improved in 30 (17%), became worse in 23 (13%), and could not be accurately assessed in 19 (11%) due to lack of documentation. A second surgical procedure for recidivistic (recurrent or residual) disease was required in 53 (30%). Ipsilateral facial paralysis was noted in 3 (1.7%) patients immediately after recovery from anaesthesia, and 1 (0.5%) patient had a sensorineural hearing loss. This study confirmed the aggressiveness of cholesteatoma in children and demonstrated the need for careful preoperative evaluation, meticulous surgical technique, and prudent postoperative follow-up.

Laterally hypertrophic adenoids as a contributing factor in otitis media.

Adenoidectomy has been demonstrated in randomized controlled studies to be effective in the prevention of otitis media with effusion (OME). Despite an apparent lack of correlation between adenoid size and outcome, it has been suggested that the role of adenoid tissue in the pathophysiology of OME relates either to obstruction of the Eustachian tube (ET) with impairment of its function, or to adenoid tissue serving as a reservoir of infection. The aim of this study was to further delineate the relationship between adenoid hypertrophy and OME. This prospective survey was performed in an ambulatory care setting of a tertiary care pediatric hospital, where data was collected on 273 consecutive adenoidectomy patients. At the time of surgery, adenoid position in relation to the ET orifice was recorded as well as concurrent procedures performed (e.g. pressure equalization tubes; PET). Sixty percent of patients undergoing simultaneous PET insertion were found to have laterally hypertrophic adenoid tissue encroaching upon the ET orifice versus only 22% for those undergoing adenoidectomy alone. Thus, a strong correlation was found to exist between OME, requiring the placement of PET and lateral adenoids abutting the torus tubarius (chi2 = 39.12; P < 0.001). The clinical relevance of this finding is that it may allow the prediction of children with OME, who will benefit most from undergoing adenoidectomy. Patients with OME requiring PET insertion, who are found to have lateral adenoid hypertrophy encroaching upon the ET orifice, could be selected for adenoidectomy, thus allowing a more judicious application of this surgical procedure in the setting of OME.

Neonatal/infant rigid bronchoscopy.

OBJECTIVE: The neonatal intensive care unit (NICU) of the Montreal Children's Hospital (MCH) has averaged 358 admissions/ year over the past 10 years. Over the same period, 1.8% of these admissions have required rigid bronchoscopy in either the neonatal or infant time period: 175 rigid bronchoscopies were performed on 76 patients since 1977. METHOD: We retrospectively reviewed the findings at first bronchoscopy. Our cases were analyzed regarding indication for bronchoscopy, primary airway pathology, concomitant secondary airway pathology, management, outcome, and overall prognosis. RESULTS: Normal bronchoscopic findings were seen in 25% of cases. The remaining 75% revealed pathology in sites ranging from the oropharynx to the bronchus. The majority were subglottic (15), esophageal atresia/tracheoesophageal fistula (14), and glottic (11). There was concurrent airway pathology in 41% of the cases, ranging from 0% in the bronchial group to 75% in the oral/pharyngeal group. Thirty three percent of patients with a secondary airway pathology identified required further airway intervention, either therapeutic bronchoscopy at the same time or later airway surgery. There were no major complications from rigid bronchoscopy in our series. The mortality due to airway pathology was highest in the supraglottic/ glottic group (36%). CONCLUSION: Rigid bronchoscopy performed in the neonatal/infant period is safe. The primary and concomitant secondary diagnosis are high (75% and 41%, respectively), while both may require further airway intervention. Finally, it directs early management of these cases for better prognosis.

Do systemic corticosteroids effectively treat obstructive sleep apnea secondary to adenotonsillar hypertrophy?

To determine if pediatric obstructive sleep apnea syndrome (OSAS) caused by adenotonsillar hypertrophy (ATH) could be treated by a short course of systemic corticosteroids, we conducted an open-label pilot study in which standardized assessments of symptomatology, OSAS severity, and adenotonsillar size were performed before and after a 5-day course of oral prednisone, 1.1+/-0.1 (+/-SE) mg/kg per day. Outcome measures included symptom severity, adenotonsillar size, and polysomnographic measures of OSAS. Selection criteria included age from 1 to 12 years, ATH, symptomatology suggesting OSAS, an apnea/hypopnea index (AHI) > or = 3/hour, and intent to perform adenotonsillectomy. Only one of nine children showed enough improvement to avoid adenotonsillectomy. Symptomatology did not improve after corticosteroid treatment but did after removal of tonsils and adenoids. Polysomnographic indices of OSAS severity did not improve after corticosteroid treatment. After corticosteroids, tonsillar size decreased in only two patients, adenoidal size was only marginally reduced, and the size of the nasopharyngeal airway was not significantly increased. These results suggest that a short course of prednisone is ineffective in treating pediatric OSAS caused by ATH.

Ablative adenoidectomy: a new technique using simultaneous liquefaction/aspiration.

OBJECTIVE: This study was performed to critically evaluate a new cautery technique for adenoidectomy that combines indirect visualization with complete hemostasis, ultimately permitting the surgeon to tailor the procedure to the patient's specific needs. DESIGN: This prospective study of 138 consecutive adenoidectomy patients of the senior author was carried out at the Montreal Children's Hospital over 17 months. Concurrent adenoidectomy patients of another senior otolaryngologist in our institution as well as cases of the senior author using the conventional cold curettage technique served as controls. METHOD: Data were collected preoperatively with respect to indication for surgery and radiologic findings. Operative findings including duration of surgery, concurrent procedures, position of adenoid hypertrophy, and blood loss were also recorded. Postoperative complications such as hemorrhage, infection, dehydration, as well as the incidence of velopharyngeal insufficiency and nasopharyngeal stenosis were also recorded up to 1 year from the date of surgery. The operative technique involves indirect visualization of the nasopharynx with a laryngeal mirror combined with cautery-liquefaction and suction ablation of the adenoid tissue. RESULTS: Our results demonstrate a significant reduction in blood loss as well as a reduction in operative time. There was a low incidence of postoperative infection, no patients required a return to the operating room for hemostasis, and there were no cases of recurrent adenoid hypertrophy. There was no detectable difference in the incidence of postoperative complications. CONCLUSION: We conclude that this technique is safe and time-efficient, with the advantages of excellent visualization and essentially no operative blood loss.

Adenoidectomy: indirect visualization of choanal adenoids.

A retrospective review of adenoidectomies was carried out at the Montreal Children's Hospital, Montreal, Quebec. From April 1, 1990, to November 14, 1992, the senior author (JJM) was involved in 330 adenoidectomies with or without concurrent tonsillectomy or pressure equalization tube (PET) insertion. In all cases, adenoid surgery was performed with proper soft palate retraction and indirect visual inspection using laryngeal mirrors. A subgroup of 31 patients (9.4%) was identified as having adenoid tissue extending from the nasopharynx into the choanae and posterior nasal cavity: "choanal adenoids." The characteristics of this subgroup are outlined in the hope that features may be useful in identifying potential choanal adenoids preoperatively. Furthermore, the use of indirect visualization, as opposed to the traditional "blind adenoidectomy," is proposed so that no significant residual adenoid tissue remains post-adenoidectomy.

Hospitalized croup (bacterial and viral): the role of rigid endoscopy.

This is a retrospective study of 500 cases of hospitalized patients with the diagnosis of croup (laryngotrachitis), admitted between January 1986 and August 1988, at the Montreal Children's Hospital. The patient's age, sex, clinical history, physical examination, number of admissions, season of admission, method of diagnosis, treatment and management were reviewed. Two per cent of these patients were diagnosed as bacterial croup. All of them required intubation and endoscopic evaluation in their management. Of all the viral croup patients, less than one-third were severe enough to require an intensive care setting for their management. In these patients, 6% required endotracheal intubation, and on endoscopy, a significant number of these patients had an endoscopic airway abnormality in addition to croup (subglottic edema). According to our findings, we suggest diagnostic micro-laryngoscopy and bronchoscopy be performed on certain groups of croup patients because of their higher yield of airway abnormality on endoscopy.

Extracranial primitive neuroectodermal tumor of the head and neck.

Malignant peripheral neuroectodermal tumors are rare neoplasms of the head and neck. We describe a case of a teenage girl presenting with this neoplasm in the head and neck. The clinical histological and ultrastructural features are reviewed and presented, along with guidelines for the management of this highly aggressive neoplasm.

Congenital cholesteatoma of the middle ear in children.

Congenital cholesteatoma, once considered to be a rarity, has shown an exponential increase in its incidence as evidenced by numerous clinical studies over the past decade. No explanation has been offered for this phenomenon. A review of the literature indicates that the definition of "congenital cholesteatoma" has strayed from the original one formulated by Derlacki and Clemis, which included a cholesteatoma medial to an intact tympanic membrane, without prior history of aural infections. Allowing patients with recurrent otitis media into studies may have contributed to a "false positive" rise in the incidence of this condition. This article reviews 19 cases of cholesteatomas behind intact tympanic membranes, treated at the Montreal Children's Hospital over a 10-year period. They represent 22% of the entire cholesteatoma population. There appears to be two groups of patients, each with a distinct clinical presentation that correlates well with the surgical outcome. Whether this implies different pathogenetic mechanisms remains unclear.