When Can Children Perform Valsalva and Toynbee Maneuvers? An Exploratory Study.

OBJECTIVES: Barochallenge-induced Eustachian tube dysfunction (ETD) is difficult to diagnose because the examination is often normal during clinical assessment. In adults, functional tympanometry testing, performed by asking the patient to Valsalva and Toynbee while measuring the pressure shift, can aid in the diagnosis of ETD. However, standardized values do not exist in children. We aim to determine the age at which children can perform these maneuvers and the normative values in this population. METHODS: Patients with a normal basic ear examination 4 years and older, presenting to the pediatric Otolaryngology clinic, were recruited. Otoscopy, baseline tympanometry, followed by Valsalva and Toynbee maneuvers were performed. Because there are no pediatric norms, we hypothesized that children would achieve the same minimum normal pressure shift as cited in the adult literature (+20 daPa or higher for Valsalva and -20 daPa or lower for Toynbee). The data were analyzed using receiver operating characteristic curves and logistic regression. RESULTS: One hundred sixty-eight children (276 ears) were assessed. Participants as young as 4 years old were able to perform a Valsalva and Toynbee. Age cut-offs at which children achieved adult norms were 12.5 years ( p = 0.016) and 8.5 years ( p = 0.071) for Valsalva and Toynbee maneuvers, respectively. Mean pressure shift ranged from +29 to -36 daPa, and males were 2.5 times more likely to achieve Toynbee compared with females ( p = 0.006). CONCLUSIONS: Functional tympanometry testing may be used to help diagnose barochallenge-induced ETD in older children.

Home sleep apnea tests: Conflicts of interest and funding.

OBJECTIVE: Pediatric otolaryngologists rely on HSAT literature to guide their diagnostic methods related to obstructive sleep apnea (OSA). Our objectives were to review the rates of presence of funding and/or potential conflict of interest (COI), as well as its relationship to the overall quality of HSAT publications in the literature over the last two decades. DATA SOURCES: Medline, Web of Science and Embase databases. REVIEW METHODS: A review was performed reviewing publications from January 2000 to December 2021. Oxford Level of Evidence (OLE) was used as a quality metric. COI and funding were recorded verbatim as self-declared in the text of the manuscript. RESULTS: Literature search yielded 4257 articles with 400 articles included in final analysis. The odds of higher quality studies (LOE 1 or 2) were higher in the last five years from 2016 to 2021 (OR, 3.6; 95% CI 1.4 to 6.9). Nearly half of all articles (43.0%) lacked a statement regarding funding or COI. There was a positive correlation between level of evidence and industry funding. The largest source of funding was from industry, comprising 39.6% of all studies that had a funding statement. Of these industry-funded studies, 37.5% reported no COI or lacked a COI statement. CONCLUSION: Despite a growing interest in HSATs for OSA evaluation, there is heterogeneity in reporting of COI and high prevalence of industry funding and COI. Re-evaluation and consensus amongst journals on guidelines for reporting disclosures are needed.

Pediatric Patient With Persistent Postoperative Fevers After Esophageal Foreign Body Removal.

A healthy teenager presented to the emergency department with high-grade fever, neck pain, and a foreign body sensation in the throat after eating chicken 3 days prior. What is your diagnosis?

Benign paroxysmal vertigo of childhood.

Benign paroxysmal vertigo of childhood (or recurrent vertigo of childhood) is the most common cause of vertigo in young children. It is considered a pediatric migraine variant or precursor disorder, and children with the condition have an increased likelihood of developing migraine later in life than the general population. Episodes are typically associated with room-spinning vertigo in conjunction with other migrainous symptoms (e.g. pallor, nausea, etc.), but it is rarely associated with headaches. Episodes typically only last for a few minutes and occur with a frequency of days to weeks without interictal symptoms or exam/test abnormalities. Treatment is rarely necessary, but migraine therapy may be beneficial in cases where episodes are particularly severe, frequent, and/or prolonged. An appreciation of the typical presentation and characteristics of this common condition is essential to any provider responsible for the care of children with migraine disorders and/or dizziness. This chapter will review the current literature on this condition, including its proposed pathophysiology, clinical presentation, and management. This chapter also includes a brief introduction to pediatric vestibular disorders, including relevant anatomy, physiology, embryology/development, history-taking, physical examination, testing, and a review of other common causes of pediatric dizziness/vertigo.

Long-term efficacy of balloon dilation of the pediatric Eustachian tube: A six-year matched cohort study.

PURPOSE: Balloon dilation of the Eustachian tube (BDET) has not been evaluated extensively in children outside of retrospective case series. The purpose of this study is to report the long-term safety and efficacy of this procedure in children with matched controls. MATERIALS AND METHODS: This is a two-center retrospective matched cohort study. Children having undergone tympanostomy tube (TT) placement and adenoidectomy with recurrence of symptoms underwent BDET at an academic affiliated multi-specialty practice. Comparison was made with children receiving TT at a tertiary medical center, matching for number of prior TT, prior adenoidectomy, age, and sex. Outcome measures were risk of failure and the need for additional surgery. Kaplan-Meier survival plots were used to compare risk of failure. RESULTS: Thirty-three Eustachian tubes were dilated in 20 patients, aged 14 months-14 years. All patients had previously undergone TT insertion and adenoidectomy. Patients undergoing BDET had normal post-operative tympanograms in 80 % of cases. Mean follow up was 6.7 years with 2 patients failing in the BDET group and 8 in the TT insertion group. Dilated patients had a significantly lower risk of failure than those who underwent TT insertion (adjusted HR: 0.18; 95 % CI: 0.04, 0.81; p = 0.03). The probability of being failure free at six years was 88 % (95 % CI: 71, 95 %) in the BDET cohort and 53 % (95 % CI: 33, 70 %) in the TT insertion cohort. There were no complications. CONCLUSIONS: BDET appears to be safe and possibly superior to TT placement in children with refractory Eustachian tube dysfunction. LEVEL OF EVIDENCE: 2b.

Assessing the Value of a Pre-operative CT Sinus Anatomy Review Tool.

Performing endoscopic sinus surgery requires an intricate understanding of the anatomy of the paranasal sinuses, orbits and skull base. Avoidance of adverse events requires careful review of pre-operative computed tomography (CT) images to recognize potential areas of safety concern. Using a preoperative checklist may aid surgeons in identifying these features. The objective of this study is to determine the educational value of a pre-operative CT sinus review tool and to determine if its use improves identification of important anatomical features. Otolaryngologists from varying practice levels reviewed 2 preoperative sinus CTs, with and without the tool. A 6-item Likert scale questionnaire assessed the operator experience with the tool. The number of high-risk features identified, determination of overall safety risk and difficulty, and time needed for review were compared between the two groups. A total of 18 participants reviewed 36 CT scans. The use of the CT review tool improved identification of important anatomical feature from 47% to 74% on average. All participants agreed that the tool was useful in capturing important anatomical variations in an organized manner and enabled overall assessment of surgical risk and difficulty. The checklist required significantly more time to complete. A preoperative CT sinus tool is perceived to be a useful tool by surgeons who perform endoscopic sinus surgery. The tool requires more time, but increases the number and consistency of high-risk features identified.

Velcro Ties in Early Postoperative Pediatric Tracheostomy Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature to determine the difference in complications between standard twill and Velcro ties following pediatric tracheostomy. DATA SOURCES: MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Web of Science, and CINAHL Plus were searched up to August 2020. REVIEW METHODS: Two authors independently screened articles for eligibility. Retrospective and prospective studies were included as long as there was a direct comparison between twill and Velcro ties. Quantitative and qualitative analysis was performed. The main outcomes were skin-related complications and accidental decannulation. RESULTS: Three studies were included in the final analysis: 1 randomized prospective trial and 2 retrospective studies. There were 238 patients total (137 twill, 101 Velcro). Combined analysis showed skin-related complications in 23% of the Velcro group and 44% of the twill group. Meta-analysis for skin-related complications showed no significant difference when comparing Velcro with standard twill ties (risk ratio, 0.53 [95% CI, 0.24-1.17]; P = .12, n = 238 participants from 3 studies, I2 = 66%). Accidental decannulation rates were overall low and comparable between groups (1.0% of twill, 1.4% of Velcro). CONCLUSION: Based on limited data, skin-related complications were not statistically different between Velcro and twill ties. Accidental decannulation is rare with Velcro and standard twill ties, and both are viable options following pediatric tracheostomy.

Balloon Dilation for Obstructive Eustachian Tube Dysfunction in Children.

OBJECTIVE: Determine the safety and efficacy of balloon dilation of the Eustachian tube (ET) in pediatric patients. STUDY DESIGN: Retrospective matched cohort study. SETTING: Tertiary medical center. PATIENTS: Pediatric patients (<18 yr) with persistent (>1.5 yr) chronic Eustachian tube dysfunction (ETD) with previous tympanostomy tube (TT) insertion versus matched controls. INTERVENTIONS: Balloon dilation of the cartilaginous ET (BDET) was performed using concomitant myringotomy with/without tube placement and adjunctive procedures if indicated versus controls (TT). MAIN OUTCOME MEASURES: Otitis media with effusion (OME)/retraction with need for additional tube, tympanogram, audiogram, otomicroscopy, ET mucosal inflammation/opening score, and Valsalva maneuver. RESULTS: Forty six ETs (26 patients), ages 7 to 17 years (mean 12.5) underwent BDET. Mean follow-up was 2.3 years (standard deviation [SD], 1.1; range, 6 mo-5 yr). Significant improvements were observed for all measures. Tympanic membranes were healthy in 9% preoperatively, 38% at 6 months, 55% at 12 months, and 93% at 36 months postoperatively. Tympanograms improved to type A in 50% at 6 months, 59% at 12 months, and 85% at 36 months. Mean scores of mucosal inflammation declined from 3.2 (±0.6) preoperatively to 2.5 (±0.7) at 6 months and 1.7 (±0.6) at 36 months postoperatively. BDET had lower risk of failure versus TT insertion (adjusted hazard ratio [HR] 0.26; 95% confidence interval [CI]: 0.10, 0.70; p = 0.007). Probability of being failure free at 2 years was 87% (95% CI: 70, 94%) after BDET and 56% (95% CI: 40, 70%) after TT insertions. CONCLUSIONS: BDET is a safe and possibly effective procedure in selected pediatric patients with chronic ETD.

A Lodged Barramundi Fish-Bone Stabbing the Piriform Fossa in a Child.

Unintentional ingestion of a fish bone is common in children, especially among families with high consumption of seafood. Complications in children are extremely rare. We describe a 3-year-old healthy boy who had a large bone of Barramundi fish lodged in his upper esophagus causing significant distress. Soft tissue neck radiograph revealed a mildly thickened epiglottis and bulbous and hypertrophied adenoid soft tissue. A 21-mm foreign body was noticed. A flexible fiberoptic laryngoscopy revealed a large fish bone emerging from the left piriform fossa and arcing over the left arytenoid to hover over the posterior glottis. The bone was removed during anesthesia induction before a rigid esophagoscopy. The fish-bone entry point was seen stabbing through the edge of the piriform fossa and running down alongside the esophagus, without causing a through and through perforation. Fish bone ingestion can cause significant complications including perforation of the esophagus. Early suspicion of ingestion, radiological investigation, and swift management are important to ensure reduced complication rate in children.

Laryngeal penetration on videofluoroscopic swallowing study is associated with increased pneumonia in children.

OBJECTIVES: To determine whether children with laryngeal penetration on videofluoroscopic swallowing study are at higher risk for pneumonia than those with normal findings. METHODS: We reviewed the charts of 235 pediatric patients presenting to our Swallowing and Dysphagia clinic for videofluoroscopic swallowing study over a 3-year period. Patients with unsuccessful swallowing studies, incomplete charts, extra-laryngeal etiologies for recurrent pneumonia, or who were lost to follow up were excluded. Out of the 165 patients remaining, 58 had normal findings, 59 had laryngeal penetration, and 48 had tracheobronchial aspiration. The number of cases of pneumonia, aspiration events, and demographic data were recorded for all patients. RESULTS: Children with laryngeal penetration on videofluoroscopic swallowing study had significantly (P=0.032) more pneumonia than patients with neither penetration nor aspiration (median 2 vs. 0; mean 2.22 vs. 1.60). Furthermore, analysis revealed that glottic abnormalities (e.g. laryngeal cleft) represented a significant independent risk factor (P=0.004) for pneumonia and aspiration, while being diagnosed with a syndrome did not (P=0.343). CONCLUSION: To our knowledge, this is the first study to demonstrate that laryngeal penetration on videofluoroscopic swallowing study is associated with significantly more cases of pneumonia in children. While this remains a retrospective study demonstrating a weak association, the results suggest a need for future prospective studies to evaluate this important clinical question in children.

Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient.

BACKGROUND: Tubo-ovarian abscess (TOA) arises in most cases from pelvic infection. Appropriate treatment includes use of antimicrobials and, especially in patients with increased BMI, drainage of the contents. CASE: A 44-year-old morbidly obese woman (BMI 72) had a persistent TOA despite receiving antibiotic treatment for four months. She had no history of diabetes, and denied being sexually active. Imaging demonstrated a pelvic abscess of 14.9 × 8.9 × 11.1 cm. Successful percutaneous drainage was performed yielding purulent material which grew Candida albicans. The patient recovered after drainage of the abscess and the addition of fluconazole to her antimicrobials. She had no apparent risk factor for acquiring such an opportunistic infection, other than her morbid obesity. CONCLUSION: Because morbid obesity may confer a relative immunodeficiency, morbidly obese patients may develop unusual infections such as opportunistic fungal abscesses.

Contexte : Les abcès ovario-tubaires (AOT) sont, dans la plupart des cas, attribuables à une infection pelvienne. Parmi les moyens de prise en charge adéquats, on trouve le recours à des agents antimicrobiens et, particulièrement chez les patientes qui présentent un IMC accru, le drainage des abcès en question. Cas : Une femme obèse morbide de 44 ans (IMC 72) présentait un AOT persistant malgré l'administration d'une antibiothérapie pendant quatre mois. Elle ne présentait pas d'antécédents de diabète et affirmait ne pas être sexuellement active. L'imagerie a révélé la présence d'un abcès pelvien de 14,9 cm sur 8,9 cm sur 11,1 cm. Un drainage percutané a été mené avec succès; la présence de Candida albicans a été identifiée dans le matériel purulent drainé. La patiente a récupéré à la suite du drainage de l'abcès et de l'ajout de fluconazole à ses agents antimicrobiens. À part son obésité morbide, elle ne présentait aucun facteur de risque apparent de contracter une telle infection opportuniste. Conclusion : Puisque l'obésité morbide pourrait conférer une immunodéficience relative, les patientes obèses morbides pourraient contracter des infections inhabituelles, telles que des abcès fongiques opportunistes.

The Canadian contribution to the otolaryngology literature: a five year bibliometric analysis.

OBJECTIVES: To assess the 2008-2012 Canadian contribution to the Otolaryngology literature. METHODS: All articles published from January 2008 - December 2012 in 5 Otolaryngology journals were reviewed. Nationality, number of authors, and study type were extracted. The output, number of authors, and study type of Canadian papers were compared to International papers using Mantel-Haenszel Common Odds Ratio Estimate, Pearson's Chi-Squared or Fishers exact tests. RESULTS: 4519 papers were analyzed. There was a statistically significant decrease in Canadian authored papers from 12.8% in 2008-9 to 10.2% in 2011-12 (Fishers exact, p = .01). Multi-authorship increased in Canadian papers (χ2, p = .01). The types of studies published by Canadian Otolaryngologists did not change over the study period. CONCLUSIONS: Canadian authored papers in a sample of Otolaryngology journals decreased from 2008 to 2012. The increase in multiauthorship, whilst indicating increasing collaboration, suggests reduced per capita publication productivity. These findings warrant further study.

A case of recurrent anaplastic meningioma of the skull base with radiologic response to hydroxyurea.

Anaplastic meningiomas are rare and aggressive tumors with a high propensity for local recurrence. Surgical resection and postoperative radiotherapy are the standard of care for primary disease and local recurrences. Refractory disease is managed with chemotherapy with limited success. A highly efficacious, well-tolerated chemotherapeutic agent has yet to be found for this disease entity. Hydroxyurea is currently receiving renewed attention because of its efficacy in inducing apoptosis of meningioma cells in vitro and its favorable side-effect profile. Thus far, in humans, this agent has only induced stable disease. We describe the first patient showing a near complete/partial clinical and radiological regression after 5 months of 25 mg/kg of hydroxyurea once daily, given within 1 month after stereotactic fractionated reirradiation of a previously irradiated and operated anaplastic meningioma of the skull base. Magnetic resonance imaging showed a significant and sustained response with tumor shrinkage and cavitation.

Incidence of platinum-induced ototoxicity in pediatric patients in Quebec.

BACKGROUND: The antineoplastic agents cisplatin and carboplatin are widely-used and highly-effective against a variety of pediatric cancers. Unfortunately, ototoxicity is a frequently encountered side effect of platinum-based chemotherapy. There is currently no treatment or prevention for platinum-induced ototoxicity and development of hearing loss may lead to devastating consequences on the quality of life of pediatric cancer survivors. The objective of this study is to determine the incidence of platinum-induced ototoxicity in a large series of pediatric patients and to evaluate the incidence of progression of ototoxicity after completion of treatment. PROCEDURES: A retrospective chart review of pediatric patients treated with cisplatin or carboplatin between 2000 and 2012 was conducted. The incidence of ototoxicity was determined based on the American-Speech-Language-Hearing Association (ASHA) criteria and severity was based on the Chang classification. RESULTS: Four hundred and sixty-six patients received platinum-based chemotherapy. Patients were excluded due to congenital hearing loss (n = 1) and insufficient data for calculating the platinum dose (n = 24) or for assessing ototoxicity (n = 135). Three hundred and six patients were included in the analysis. Post-chemotherapy ototoxicity was detected in 148 (48%) patients, and clinically-significant ototoxicity was present in 91 (30%). In addition, based on the ASHA criteria, 48% of patients (97/204) with long-term follow-up had further deterioration of their hearing after completion of treatment. CONCLUSIONS: Ototoxicity following chemotherapy with cisplatin or carboplatin is common and can frequently progress after the completion of treatment. Long-term follow-up is strongly recommended.