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.

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.

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.

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 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.

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.

History of pediatric laryngotracheal reconstruction.

In the early twentieth century, John Winslow wrote that there was no more difficulty in laryngology than treating chronic stenosis of the larynx and trachea. Winslow described cases as "excessively rebellious to treatment" and treatment requiring "patience, persistence, self-sacrifice and skill on the part of the surgeon" and "discomfort or even suffering by the patient." Three decades later, Chevalier Jackson wrote that curing patients required perseverance over a period of time rarely as short as 3 months and as long as 7 years. Significant strides in surgical technique have been made; this article chronicles the development of laryngotracheal reconstruction in children.

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.

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.

Histopathologic Finding of Both Gastric and Respiratory Epithelia in a Lingual Foregut Cyst.

Foregut cysts are uncommon, mucosa-lined congenital lesions that may occur anywhere along the gastrointestinal or respiratory tract and typically present within the first year of life. Although infrequent, these cysts may generate feeding or respiratory difficulties depending on the size and location of the lesion. Foregut cysts of the oral cavity are rarely seen and of those cases localized to the tongue are even more uncommon. We describe a 4-month-old girl with a foregut cyst involving the floor of mouth and anterior tongue. Subsequent histologic analysis demonstrated a cyst lined with both gastric and respiratory epithelia. This case represents an extremely rare finding of both gastric and respiratory epithelia lined within a single cystic structure in the tongue. Although a very rare finding, a foregut cyst should be on the differential diagnosis of any lesion involving the floor of mouth or tongue in an infant or child.

On the origin of tonsillectomy and the dissection method.

OBJECTIVES: To identify the person or persons responsible for the conception and description of the operation that we know of today as tonsillectomy and to determine whether this was accomplished by an American otolaryngologist(s) before the description by George Waugh of London in 1909. STUDY DESIGN: A review of the English language medical literature from 1879 to 1910. METHODS: Three hundred seventy-five articles relating to tonsil surgery or instrumentation for tonsil surgery were identified. It was possible to obtain and review only 67 articles. In addition, 20 textbooks relating to the tonsils and tonsil surgery (published between 1880 and 1966) were identified and reviewed. RESULTS: An attempt to remove the entire tonsil intact was described by Edwin Pynchon in 1890 with the use of galvanocautery. He recommended that only one tonsil be removed at one time with approximately 2 weeks between operations. In 1903, Charles Robertson advocated the removal of both tonsils at one operation using scissors but did not mention the capsule. J. Gordon Wilson published a description of the tonsillar capsule in 1906 but did not comment on tonsil surgery or the importance of any particular structure as a surgical landmark. In that same year, William Lincoln Ballenger of Chicago, Illinois, clearly recommended the complete removal of the tonsil with its capsule intact but commented that he usually used an écraseur-tonsillotome to finally remove the tonsil. Also in 1906, Ovidus Arthur Griffin of Ann Arbor, Michigan, described the use of a knife and a specially designed pair of scissors to remove the tonsils in their entirety in one operation without the use of a guillotine or an automatic instrument. CONCLUSION: The operation that we know of today as tonsillectomy, the removal of the entire tonsil with the capsule intact, and the term tonsillectomy itself were conceived, described, and published by American otolaryngologists before the description by George Waugh of London in 1909.

Use of the Palmaz stent in the treatment of severe tracheomalacia.

To present our experience with the use of the Palmaz stent in treating cases of severe, life-threatening tracheomalacia, and to report our experience with the use of tracheal stents in patients who have concomitant tracheotomies, we performed a retrospective study in a tertiary-care children's hospital. Nine patients with multiple congenital anomalies including severe tracheomalacia required placement of a Palmaz stent to prolong life. The congenital anomalies included congenital heart disease, congenital lung disease, meningomyelocele, laryngotracheoesophageal cleft, and tracheoesophageal fistula. Three of the patients had concomitant tracheotomies. Each patient had placement of one or more Palmaz stents in the trachea and/or bronchus. Four patients died, and 5 patients are still alive. Three of the 4 patients who died had concomitant tracheotomies and died of complications associated with significant tracheal hemorrhage. The fourth died of pulmonary complications following repeated episodes of pneumonia. None of the 5 patients who are still alive had a concomitant tracheotomy. The Palmaz stent is a useful tool for treating life-threatening tracheomalacia as a final resort in this difficult patient population; however, the use of these stents may lead to subsequent hemorrhage and death, especially in patients with tracheotomies, so their use must be carefully considered.

Thyroglossal duct remnant surgery: a reliable, reproducible approach to the suprahyoid region.

BACKGROUND: Recurrence of thyroglossal duct remnants remains a clinical problem despite the success of the Sistrunk procedure. Inadequate excision of disease in the suprahyoid region significantly impacts disease recurrence. The primary aim of this study is to describe and present the author's experience with a simple, reliable, and reproducible approach to the suprahyoid area in a Sistrunk procedure. METHODS: A retrospective review of the surgical management of thyroglossal duct remnants by a single surgeon at the Children's Hospital Los Angeles over a 16-year period was performed. Demographic and clinical data including disease recurrence and other complications were collected. Recurrence rates before and after the consistent application of a modified Sistrunk procedure were compared. RESULTS: 94 patients (54% female and 46% male; mean age 5.2 years) met the inclusion criteria for this study. Overall recurrence rate following a Sistrunk procedure was 2.2%; 11.1% prior to 2004 and 0% after 2004, following consistent implementation of the surgical approach to the suprahyoid region as detailed in this study. Complications were minor and mean follow-up was 5.4 months. CONCLUSIONS: The author has described a simple, reproducible, and reliable approach to the suprahyoid area in a Sistrunk procedure that limits incomplete excision with minimal risk for complications. This approach to the suprahyoid region should be considered for routine use in the management of both primary and revision thyroglossal duct remnants.

Thyroglossal duct cyst and sinuses: a 20-year Los Angeles experience and lessons learned.

BACKGROUND: First described in 1920 and later modified in 1928, the Sistrunk procedure substantially reduced the incidence of recurrence of midline neck cysts compared with a local excision or cystectomy. The purpose of this study was to determine if the rate of recurrence was influenced by performing either a 'classic' or a 'modified' Sistrunk procedure, if the recurrence rate was influenced by the physician's training, how successful we have been in managing patients with a recurrence? Finally, is outpatient surgery safe for Sistrunk procedures? METHODS: We performed a retrospective review of all patients with a thyroglossal duct remnant (TGDR) who were seen at the Children's Hospital Los Angeles (CHLA) from 1990 to 2010. The following data were collected: patient age, gender, presence or absence of a pre-operative infection, imaging studies, type of procedure performed, the attending surgeon's training background, inpatient or outpatient status, and complications. RESULTS: A total of 128 patients (61% male, 39% female) met the inclusion criteria. The age ranged from 2 months to 14 years (mean of 5.1 years). A total of 137 procedures were performed; 114 (83.2%) for primary and 23 (16.8%) for secondary disease. Complications included post-operative infection (10.9%), recurrence of disease (6.6%), undesirable scar (5.8%), and fistula (2.9%). Surgeons with fellowship-training in pediatric otolaryngology had a recurrence rate of 4.0% and surgeons with fellowship-training in pediatric surgery or pediatric plastic surgery had a recurrence rate of 30.1%. Twenty patients had a 'classic' Sistrunk (14.6%) and 117 (85%) had a 'modified' procedure. Patients were admitted after surgery in 78 cases (56.9%) and 59 patients (43.1%) had an outpatient (OPD) procedure. CONCLUSIONS: There is no place for cystectomy in the treatment of TGDR. A 'modified' Sistrunk procedure is the procedure of choice in both primary and revision cases. Wide local excision of recurrences is required and a 'classic' Sistrunk should be considered. Specific training to gain an intimate knowledge of the anatomy in and around the larynx and experience with multiple cases reduces the incidence of recurrence. Outpatient surgery is safe and effective for selected patients who undergo a Sistrunk procedure.