Operative management of choanal atresia: a 15-year experience.

OBJECTIVE: To analyze factors affecting 15-year surgical outcomes of choanal atresia repair. DESIGN: Case series. SETTING: Tertiary care pediatric hospital. PATIENTS: Between April 17, 1996, and March 23, 2010, a total of 42 patients aged 3 days to 15 years underwent endoscopic or transpalatal choanal atresia repair by our pediatric otolaryngology faculty. MAIN OUTCOME MEASURES: Reoperation and restenosis rates, with consideration of effects of mitomycin C therapy, stenting, and postoperative dilation. RESULTS: Three of 42 patients were excluded because of inadequate follow-up data; the follow-up time for the remaining 39 patients averaged 6.3 years (range, 1-14.9 years). Excluding 6 patients whose initial repair was performed by other physicians, 31 of 33 patients in whom we performed initial repair had a total of 43 endoscopic surgical procedures (19 patients had unilateral procedures, and 12 patients had bilateral procedures), and the other 2 underwent bilateral transpalatal repair. Of the total 43 sides we operated on endoscopically, 9 sides (21%) required revision surgery, including excision of scar tissue or additional drilling of persistent bony stenosis. No significant difference was observed in the rate of restenosis among cases treated endoscopically with mitomycin C (22 of 43 operative sides, P = .13), with stenting (36 of 43 operative sides, P = .99), or with subsequent dilation (P = .45). When we used stents, they were usually (in 28 of 36 patients) left in place for 15 days or longer. CONCLUSION: Our revision rate after initial endoscopic repair of choanal atresia was low and was unaffected by adjuvant mitomycin C therapy or stenting.

MRSA and non-MRSA otorrhea in children: a comparative study of clinical course.

OBJECTIVE: To test the perception that post-tympanostomy tube otorrhea caused by methicillin-resistant Staphylococcus aureus (MRSA) is a more virulent disease than otorrhea caused by other pathogens by analyzing the clinical differences and disease courses in children diagnosed with otorrhea caused by MRSA bacteria vs non-MRSA bacteria. DESIGN: Retrospective review. SETTING: Tertiary children's hospital. PATIENTS: We retrospectively examined the medical records of children who presented to a tertiary children's hospital from January 1, 2003, to December 31, 2008, with otorrhea that occurred after tympanostomy tube insertion. MAIN OUTCOME MEASURES: Otorrhea culture records were used to group the 1079 patients into those whose otitis media was due to MRSA (n = 170) and those with non-MRSA otitis media (n = 909). From the non-MRSA group, we randomly selected an age-matched group of 170 and examined the differences between the MRSA and age-matched non-MRSA groups in organisms isolated by culture, demographic factors (including type of medical insurance), medical history, treatments, surgical procedures performed, audiometric data, and other admissions for infection-related illnesses. RESULTS: The overall incidence of MRSA in this series was about 16% (170 of 1079 patients). Of the 170 eligible children in each age-matched group, 135 with MRSA otorrhea and 141 with non-MRSA otorrhea had data in every category selected for statistical analysis. The groups did not differ significantly in type of insurance; history of tympanostomy tube placement, cholesteatoma, or prematurity; number or type (minor/major) of surgical procedures performed; or risk of subsequent infection-related diagnoses. More patients in the MRSA group received intravenous antibiotic therapy (11% vs 3.6%; P < .001). CONCLUSION: In this study, a diagnosis of otorrhea due to MRSA did not carry an increased risk for surgical procedures or infection-associated sequelae compared with a diagnosis of non-MRSA otorrhea.

Fixation methods in pediatric cochlear implants: retrospective review of an evolution of 3 techniques.

OBJECTIVE: To review 3 techniques of cochlear implant (CI) fixation used by a single surgeon for the fixation of 320 consecutive CIs in a pediatric population and associated complications. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral children's hospital. SUBJECTS AND METHODS: Patients receiving CIs between July 1995 and July 2009 were reviewed. Clinical information obtained included age at implant, implant type, duration of follow-up, method of implant fixation (intraosseous suture ligature, prolene mesh with titanium screws, and a small periosteal pocket with periosteal sutures), and postoperative complications of fixation (migration or extrusion). RESULTS: Three hundred twenty consecutive CIs were reviewed: 64 of which were bilateral (42 staged, 22 concurrent). The median age at implantation was 3.6 years (range, 8 months to 20 years). Manufacturers included Cochlear (223) and Advanced Bionics Corporation (97). Median follow-up was 26 months (range, 1 month to 12.7 years). The intraosseous suture ligation method of fixation was used for 182 CIs. Ninety-eight CIs were fixed using a small piece of polypropylene mesh and titanium screws. Forty implants were secured by using a tight periosteal pocket and placing the suture through the periosteum and soft tissue to collar the receiver in a modified well. No complications of device migration or extrusion were noted, nor were there any intracranial complications. Device failure occurred in 13 (4%) patients requiring explantation and reimplantation, but these were unrelated to surgical technique or fixation. CONCLUSIONS: This study illustrates that with an evolution toward less invasive and less complex methods of fixation, there has not been an associated increase in fixation-related complications.

The management of myringotomy tubes in pediatric cochlear implant recipients.

OBJECTIVE: To investigate the impact of myringotomy tubes (MTs) on outcomes for pediatric cochlear implant (CI) recipients. DESIGN: Retrospective case-control chart review. SETTING: Tertiary care pediatric hospital. PATIENTS: Sixty-two patients received an MT before CI (mean [SD] age at initial CI, 3.20 [2.45] years). Seventy-eight ears received CIs and MTs. INTERVENTION: The MTs were removed and allowed to extrude before CI (59% [n = 46]) or kept in place until CI (41% [n = 32]). MAIN OUTCOME MEASURES: Otorrhea, persistent tympanic membrane (TM) perforation, and need for additional procedures were recorded. Statistical analysis was performed with the Fisher exact test. RESULTS: Forty ears (51%) required more than 1 set of MTs. Ten ears (22%) in which the MTs were removed before CI required a separate MT after CI compared with 6 ears (19%) in which the MTs remained in place until CI (P = .78). The MTs that were present during CI were either removed with myringoplasty (31% [n = 10]) or retained after surgery (69% [n = 22]). All TMs in which the tubes were removed before or during CI healed. There were 3 persistent TM perforations that required surgical treatment. There were no cases of meningitis and no removals of CIs because of infection. CONCLUSIONS: Myringotomy tubes do not appear to adversely affect the final outcomes of pediatric CI recipients and can be managed similarly to MTs in other otitis media-prone children. They may be left in place in children who continue to experience recurrent acute otitis media or removed in children who no longer need them.

The multidisciplinary evaluation and management of cleft lip and palate.

Cleft lip with or without a cleft palate (CLP) and cleft palate alone (CPA) are common birth defects, with a combined birth prevalence of about 1 to 2/1,000. Affected children have a number of medical issues and potential complications, and therefore require a wide variety of healthcare specialists beyond plastic surgeons and dental specialists. For this reason, the best environment in which to deliver this care is a multidisciplinary cleft clinic (MCC) that features a team of healthcare providers, including audiology, pediatric otolaryngology, speech pathology, occupational/feeding therapy, and genetics. In this setting, the many medical issues that these children face are comprehensively addressed in the most convenient manner, as all the specialists can be seen in a single busy day. Furthermore, the referring primary care provider (PCP) will receive a concise letter that documents the team evaluation, including future management plans and recommendations for therapy. Unfortunately, few papers are available in the literature that review the workings of these clinics. In this paper we will provide such an overview, discussing the management issues for children with CLP/CPA, and how these are addressed by members of the MCC.

The use of genetic testing in the evaluation of hearing impairment in a child.

PURPOSE OF REVIEW: To review the role of genetic testing in the evaluation of hearing impairment in children. RECENT FINDINGS: The introduction of genetic testing has greatly enhanced the evaluation of deafness and hearing impairment in children. It can save time and money as well as providing patients, their families, and their physicians with important information; however, this testing is different from the medical testing that pediatricians typically order. SUMMARY: For patients and families to realize the benefits of genetic testing it must be done early in the evaluation process and must be accompanied by appropriate pretest and posttest counseling.

Hearing screening at well-child visits.

OBJECTIVES: To determine hearing screening failure rates in primary care settings and to examine the referral practices in response to an abnormal screening test. METHODS: We enrolled a convenience sample of children between 3 and 19 years of age who were undergoing hearing screening during a well-child visit. A failure was defined as missing any frequency (1000, 2000, or 4000 Hz) in either ear at 20-dB hearing level. The pediatrician made the decision of whether to refer the patient for further evaluation. RESULTS: Three academic and 5 private practices enrolled 1061 children. Sixty-seven children (7%) were unable to complete the screening. Of the 948 children who completed the screen, a total of 852 children (90%) passed the screening and 96 children (10%) failed. After multivariable logistic regression analysis, the only statistically significant factor predictive of a failed screen was developmental delay (P = .02). Of the 96 children who failed the hearing screening, 57 (59%) had no further evaluation, 12 (13%) were rechecked, and 27 (28%) were referred. Similar percentages were seen with children who could not be screened. CONCLUSIONS: Although 10% of the children failed hearing screening, pediatricians neither rechecked nor referred more than half of these children. Screening that does not result in action for those failing the screening wastes resources and fails to properly identify hearing impairment in children.

Multiple intraparenchymal parotid calculi: a case report and review of the literature.

We describe an unusual case of bilateral intraparenchymal parotid stones with unilateral parotitis in a 17-year-old boy. The patient went on to develop multiple parotid abscesses, which we treated with a superficial parotidectomy. To our knowledge, this is only the second report of intraparenchymal parotid stones in a pediatric patient.

Success and complications of four-duct ligation for sialorrhea.

OBJECTIVE: Sialorrhea can have a significant negative effect on quality of life, impeding social interactions and severely limiting employment opportunities. Many surgical options to control sialorrhea have been reported. One of the newest procedures is combined ligation of the submandibular and parotid ducts, reported only once in the literature in one series of five patients to date. We have compared results in our first 21 patients undergoing this procedure with results reported in the literature for other procedures to treat sialorrhea. MATERIALS AND METHODS: We retrospectively reviewed medical records of all 21 children we treated with four-duct ligation, a relatively simple intraoral procedure to control sialorrhea, between August 1999 and September 2000 and contacted primary caregivers by telephone to answer a questionnaire regarding objective and subjective results of surgery. Surgery was considered successful when caregivers rated patients as 'much better' or 'better' after surgery. RESULTS: Follow-up was completed in all 21 of the patients 1-14 months after surgery. The success rate of four-duct ligation ('much better' or 'better' after surgery) was 81%, and no patient's sialorrhea problem was worse after surgery. Major complications occurred in two (10%) of the patients (one ranula and one case of sialoadenitis), which were both successfully treated surgically. Minor complications occurred in four (19%) of the patients, tongue swelling that prolonged hospitalization, a ranula that resolved, and prolonged submandibular gland swelling that resolved (two cases). More than half of patients were discharged the day of or the day after surgery. CONCLUSIONS: Four-duct ligation should be considered when surgery is indicated to treat sialorrhea.