Hearing Loss in Adults: Differential Diagnosis and Treatment.

More than 30 million U.S. adults have hearing loss. This condition is underrecognized, and hearing aids and other hearing enhancement technologies are underused. Hearing loss is categorized as conductive, sensorineural, or mixed. Age-related sensorineural hearing loss (i.e., presbycusis) is the most common type in adults. Several approaches can be used to screen for hearing loss, but the benefits of screening are uncertain. Patients may present with self-recognized hearing loss, or family members may observe behaviors (e.g., difficulty understanding conversations, increasing television volume) that suggest hearing loss. Patients with suspected hearing loss should undergo in-office hearing tests such as the whispered voice test or audiometry. Patients should then undergo examination for cerumen impaction, exostoses, and other abnormalities of the external canal and tympanic membrane, in addition to a neurologic examination. Sudden sensorineural hearing loss (loss of 30 dB or more within 72 hours) requires prompt otolaryngology referral. Laboratory evaluation is not indicated unless systemic illness is suspected. Computed tomography or magnetic resonance imaging is indicated in patients with asymmetrical hearing loss or sudden sensorineural hearing loss, and when ossicular chain damage is suspected. Treating cerumen impaction with irrigation or curettage is potentially curative. Other aspects of treatment include auditory rehabilitation, education, and eliminating or reducing use of ototoxic medications. Patients with sensorineural hearing loss should be referred to an audiologist for consideration of hearing aids. Patients with conductive hearing loss or sensorineural loss that does not improve with hearing aids should be referred to an otolaryngologist. Cochlear implants can be helpful for those with refractory or severe hearing loss.

Operation airway: the first sustainable, multidisciplinary, pediatric airway surgical mission.

OBJECTIVE: This study aimed to describe the development and implementation of the first sustainable, multidisciplinary, pediatric airway surgical mission in an underserved country. METHODS: This prospective, qualitative study was conducted for the first 4 Operation Airway missions in Quito, Ecuador. The major goals of the missions were to assist children with aerodigestive abnormalities, create a sustainable program where the local team could independently provide for their own patient population, develop an educational curriculum and training program for the local team, and cultivate a collaborative approach to provide successful multidisciplinary care. RESULTS: Twenty patients ages 4 months to 21 years were included. Twenty-three bronchoscopies, 5 salivary procedures, 2 tracheostomies, 1 T-tube placement, 1 tracheocutaneous fistula closure, 2 open granuloma excisions, and 6 laryngotracheal reconstructions (LTRs) were performed. All LTR patients were decannulated. A new type of LTR (1.5 stage) was developed to meet special mission circumstances. Two videofluoroscopic swallow studies and 40 bedside swallow evaluations were performed. One local pediatric otolaryngologist, 1 pediatric surgeon, 3 anesthesiologists, 7 intensivists, 16 nurses, and 2 speech-language pathologists have received training. More than 25 hours of lectures were given, and a website was created collaboratively for educational and informational dissemination (http://www.masseyeandear.org/specialties/pediatrics/pediatric-ent/airway/OperationAirway/). CONCLUSION: We demonstrated the successful creation of the first mission stemming from a teaching institution with the goal of developing a sustainable, autonomous surgical airway program.

A Randomized Controlled Trial of Dexamethasone as a Prophylactic Treatment for Subglottic Stenosis in a Rabbit Model.

OBJECTIVE: Iatrogenic injury is a common cause of subglottic stenosis (SGS). We investigated the role of pre-injury dexamethasone as a preventive treatment for iatrogenic subglottic stenosis. METHODS: 16 New Zealand White rabbits were used in an IACUC approved study. Subjects were divided into two groups: intramuscular dexamethasone (DEX) at a dose of 2 mg/kg 15 minutes prior to an endoscopic injury to create SGS, and the same injury creation with a preoperative intramuscular saline (SAL) injection. Three independent, blinded raters evaluated endoscopic images to obtain cross sectional area (CSA) airway measurements. Rabbit airways were measured just prior to injury and at one week post-injury. All subjects were provided as-needed postoperative steroids and buprenorphine for symptoms of respiratory distress. Data analysis was performed using Student t-test. Intraclass correlation coefficients were used to assess inter-rater agreement. RESULTS: All subjects survived to the one-week post-injury airway evaluation. There was no difference in airway size between groups prior to injury (P = .28). Subjects in the DEX group demonstrated an average stenosis of 20.3% (95% CI 10.2-30.5) at one week compared to 60.6% (95% CI 40.3-80.9) in the SAL group (P = .01). Subjects in the control group required significantly more doses of postoperative dexamethasone (P = .02). Inter-rater agreement for between raters was excellent (ICC = .88). CONCLUSION: This is the first study to examine the role of pre-injury glucocorticoids in preventing iatrogenic subglottic stenosis. In our model, a single dose of intramuscular dexamethasone given prior to a subglottic injury resulted in a statistically significant reduction in airway stenosis. This research suggests that administering systemic dexamethasone should be considered prior to any procedure that may injure the subglottis, including traumatic intubation, to prevent iatrogenic subglottic stenosis.

Randomized Controlled Trial of Balloon Dilation in Treatment of Subglottic Stenosis With a Rabbit Model.

OBJECTIVES: Identify the effects of balloon dilation duration and topical ciprofloxacin-dexamethasone application in treatment of subglottic stenosis. STUDY DESIGN: Randomized controlled trial. SETTING: Animal research facility. SUBJECTS AND METHODS: Forty-four rabbits underwent subglottic injury in an Institutional Animal Care and Use Committee-approved study. One week after injury, the subglottis of each rabbit was measured and treated with endoscopic balloon dilation for 2 rounds of short duration (SBD; 3 seconds), long duration (LBD; 30 seconds), or LBD with topical ciprofloxacin-dexamethasone application (LBD+C). The subglottis of each rabbit was remeasured at the study endpoint: 1 month postdilation or following development of life-threatening respiratory distress. RESULTS: Of 44 rabbits, 35 (80%) survived to endoscopic balloon dilation, with 21 rabbits developing a grade III Cotton-Myer stenosis. Prior to dilation, there was no difference in stenosis rates among groups (all subjects, P = .99; grade III stenosis only, P = .52). Among grade III subjects, improvement in stenosis after dilation was -1% (SD, 21%) for SBD, 27% (SD, 38%) for LBD, and 58% (SD, 29%) for LBD+C (P = .01). Early euthanasia/death rates among grade III subjects were 85% for SBD, 63% for LBD, and 17% for LBD+C (P = .03). Time to early euthanasia/death was 5.0 days for the SBD group and 8.4 days for the LBD group (P = .04). CONCLUSION: SBD was inferior to LBD or LBD+C in multiple metrics. LBD+C offered significant improvements in stenosis size and mortality over the SBD group and had the lowest rate of early mortality. Further research is needed to identify optimal balloon dilation treatment duration.

A Supraglottic Mass in a Pediatric Patient: An Unusual Presentation of Lymphoma.

OBJECTIVE: To present a case of laryngeal lymphoma in a pediatric patient and perform a literature review of this rare entity. PATIENT: A 13-year-old male presented with a rapidly enlarging right neck mass. Work-up of the neck mass included a computed tomography scan of the neck with contrast and revealed a 2.5 cm right level II neck mass and an asymmetric lobulated soft tissue mass in the right pyriform sinus. INTERVENTION: The patient underwent excisional biopsy of the right supraglottic mass. Once his diagnosis was confirmed, he was treated with a standard lymphoma protocol. RESULTS: Intraoperative frozen analysis revealed a small blue cell tumor. Final pathology demonstrated diffuse large B-cell lymphoma of the germinal center B-cell subtype (GC-DLBCL). The patient underwent treatment with primary chemotherapy 12 days after his original procedure with cyclophosphamide, doxorubicin, vincristine, and prednisone. CONCLUSION: Laryngeal lymphoma remains extremely rare in the pediatric population. With appropriate treatment, the 5-year disease-free survival remains excellent for germinal center diffuse large B-cell lymphoma.

A Simple Endoscopic Technique for Measuring the Cross-Sectional Area of the Upper Airway in a Rabbit Model.

OBJECTIVE: Validate an accurate and reproducible method of measuring the cross-sectional area (CSA) of the upper airway. SUBJECTS AND METHODS: This is a prospective animal study done at a tertiary care medical treatment facility. Control images were obtained using endotracheal tubes of varying sizes. In vivo images were obtained from various timepoints of a concurrent study on subglottic stenosis. Using a 0° rod telescope, an instrument was placed at the level of interest, and a photo was obtained. Three independent and blinded raters then measured the CSA of the narrowest portion of the airway using open source image analysis software. RESULTS: Each blinded rater measured the CSA of 79 photos. The t testing to assess for accuracy showed no difference between measured and known CSAs of the control images ( P = .86), with an average error of 1.5% (SD = 5.5%). All intraclass correlation (ICC) values for intrarater agreement showed excellent agreement (ICC > .75). Interrater reliability among all raters in control (ICC = .975; 95% CI, .817-.995) and in vivo (ICC = .846;, 95% CI, .780-.896) images showed excellent agreement. CONCLUSIONS: We validate a simple, accurate, and reproducible method of measuring the CSA of the airway that can be used in a clinical or research setting.

Reproducing severe acute subglottic stenosis in a rabbit model.

OBJECTIVES: The objectives of this study were to develop an animal model with consistent, severe subglottic stenosis (SGS), and to develop the timeline needed for intervention to limit rabbit mortality. METHODS: Subglottic stenosis was created endoscopically using either a nylon or polypropylene brush in sixteen New Zealand White rabbits. The subglottic cross-sectional area was measured endoscopically using a right-angled probe and an open source image analysis software The cross-sectional areas of the stenotic and native airways were compared to calculate the subglottic stenosis percentage and Myer-Cotton grade classification. RESULTS: The average diameter of the native subglottis was 4.7 mm (SD 0.4). The mean subglottic stenosis percentage was 73% (SD 32) for all rabbits. The three rabbits injured with the nylon brush had 30, 52, and 76% stenosis. Nine of the 12 surviving rabbits (75%) injured with the polypropylene brush had a >86% subglottic stenosis. Four rabbits in the polypropylene brush cohort died from procedural complications. CONCLUSION: This study demonstrates a reliable model using a polypropylene brush to create severe acute subglottic stenosis. Cartilage exposure after creating the injury was associated with more severe stenosis. Mortality rate may have been reduced if endoscopic balloon dilation was performed electively seven days after injury, rather than emergently nine days after injury. LEVEL OF EVIDENCE: 4.

Novel management of an isolated comminuted cricoid cartilage fracture.

Laryngeal trauma is a rare occurrence that can result in significant morbidity and mortality. Isolated cricoid cartilage fractures are exceedingly rare, and their treatment is highly variable. We describe a case of an isolated comminuted, uncalcified cricoid cartilage fracture in a 34-year-old man that responded well to novel management with suture and 2-octylcyanoacrylate tissue adhesive fixation intraoperatively and topical ciprofloxacin/dexamethasone applied to the airway postoperatively. We discuss the novel application of cyanoacrylate glue in laryngeal trauma and the potential benefits of topical ciprofloxacin/dexamethasone application to the airway.

Dystrophic calcification: A rare pediatric parotid mass.

Dystrophic calcification, the ectopic deposition of calcium in previously damaged or inflamed tissues, is an uncommon finding in the head and neck. Only a few cases have been reported in the parotidomasseteric region, and all of them have been located within and adjacent to the masseter. We present a case of dystrophic calcification occurring entirely within the parotid gland in a 7-year-old girl without apparent inciting inflammation, infection, or trauma. Our patient's presentation highlights the diagnostic challenge associated with parotid masses in the pediatric population. To our knowledge, this is the first reported case of dystrophic calcification occurring entirely within the parotid gland in a child.

Prevalence of Diagnosed Sleep Disorders and Related Diagnostic and Surgical Procedures in Children with Autism Spectrum Disorders.

OBJECTIVE: Sleep disorders are common and important comorbid conditions in children with autism spectrum disorder (ASD) and can contribute to cognitive and behavioral problems. Sleep-disordered breathing (SDB) is a diagnosable and treatable cause of behavioral problems in children. We aimed to quantify the relative risk for children with ASD versus controls of being diagnosed with sleep disorders including SDB and undergoing related diagnostic and surgical procedures. METHOD: This retrospective case-cohort study included 48,762 children with ASD aged 2 to 18 years enrolled in the military health system (MHS) from 2000 to 2013. Children with ASD were matched 1:5 by birthdate, sex, and enrollment time to children without an ASD diagnosis. The MHS database was queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for sleep disorders or ICD-9-CM and Current Procedural Terminology codes for diagnostic and surgical procedures. Relative risks (RR) and 95% confidence intervals (CI) were determined with binary Poisson regression conditional on the match and adjusting for confounders. RESULTS: Children with ASD were at higher risk of receiving any sleep disorder diagnosis (RR: 1.97 [95% CI, 1.91-2.02]) including SDB (RR: 1.96 [95% CI, 1.88-2.05]). Children with ASD also were at increased risk of undergoing polysomnography (RR: 3.74 [95% CI, 3.56-3.93]) and sleep disorder-related surgery (RR: 1.50 [95% CI, 1.46-1.54]). CONCLUSION: Children with ASD are more likely to be given a sleep disorder diagnosis including SDB and are more likely to undergo related diagnostic and surgical procedures compared with controls without ASD.

Systemwide change of sedation wean protocol following pediatric laryngotracheal reconstruction.

IMPORTANCE: Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol. OBJECTIVE: To standardize and decrease length of sedation wean in pediatric patients undergoing LTR. DESIGN, SETTING, AND PARTICIPANTS: Using Institute for Healthcare Improvement (IHI) methodology, we implemented systemwide change at a tertiary care center with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n = 16, prewean group) and after (n = 13, postwean group) wean document implementation. INTERVENTIONS: Implementation of a standardized sedation protocol. MAIN OUTCOMES AND MEASURES: Presence of sedation wean document in the electronic medical record, length of sedation wean, and need for continued wean after discharge. RESULTS: The sedation wean document was used in 92.3% patients in the postwean group. With the new process, the mean (SD) length of sedation wean was reduced from 16.19 (11.56) days in the prewean group to 8.92 (3.37) days in the postwean group (P = .045). Fewer patients in the postwean group required continued wean after discharge (81.3% vs 33.3%; P = .02). CONCLUSIONS AND RELEVANCE: We implemented a systemwide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.

Establishment of a normative cepstral pediatric acoustic database.

IMPORTANCE: Few studies have used objective measures to evaluate the development of the normal pediatric voice. Cepstral analysis of continuous speech samples is a reliable method for gathering acoustic data; however, it has not been used to examine the changes that occur with voice development. OBJECTIVE: To establish and characterize acoustic patterns of the normal pediatric voice using cepstral analysis of voice samples from a normal pediatric voice database. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 218 children aged 4 to 17 years, for whom English was the primary language spoken at home, conducted at a pediatric otolaryngology practice and pediatric practice in a tertiary hospital (April 2012-May 2014). INTERVENTIONS AND EXPOSURES: Sustained vowel utterances and continuous speech samples (4 Consensus Auditory-Perceptual Evaluation of Voice [CAPE-V] and 2 sentences from the rainbow passage) were recorded and analyzed from children with normal voices. MAIN OUTCOMES AND MEASURES: Normal values were collected for the acoustic measures studied (ie, fundamental frequency, cepstral peak fundamental frequency, cepstral peak prominence [CPP], low-to-high spectral ratio [L/H ratio], and cepstral-spectral index of dysphonia in recorded phrases) and compiled into a normative acoustic database. RESULTS: Significant changes in fundamental frequency were observed with a distinct shift in slope at ages 11 and 14 years in boys for sustained vowel (ages 4-11 years, -6.83 Hz/y [P < .001]; 11-14 years, -27.62 Hz/y [P < .001]; and 14-17 years, -5.68 Hz/y [P = .001]), all voiced (ages 4-11 years, -4.19 Hz/y [P = .002]; 11-14 years, -29.42 Hz/y [P < .001]; and 14-17 years, -4.63 Hz/y [P < .001]), glottal attack (ages 4-11 years, -4.51 Hz/y; 11-14 years, -27.23 Hz/y; and 14-17 years, -1.70 Hz/y [P < .001 for all]), and rainbow (ages <14 years, -20.68 Hz/y [P < .001]; and 14-17 years, -4.50 Hz/y [P = .001]) recordings. A decreasing linear trend in fundamental frequency among all recordings (vowel, all voiced, easy onset, glottal attack, plosives, and rainbow) was found in girls (-2.56 Hz/y [P < .001], -3.48 Hz/y [P < .001], -2.82 Hz/y [P < .001], -3.49 Hz/y [P < .001], -2.30 Hz/y [P < .001], and -2.98 Hz/y [P = .01], respectively). A linear increase in CPP was seen with age in boys, with significant changes seen in recordings for vowel (0.10 dB/y [P = .05]), all voiced (0.2 dB/y [P < .001]), easy onset (0.13 dB/y [P < .001]), glottal attack (0.12 dB/y [P < .001]), plosives (0.15 dB/y [P < .001]), and rainbow (0.17 dB/y [P = .006]). A significant linear increase in CPP for girls was only seen in all voiced (0.13 dB/y [P < .001]). L/H ratio showed a linear increase with age among all speech samples (vowel, all voiced, easy onset, glottal attack, plosives, and rainbow) in boys (1.14 dB/y [P < .001], 0.92 dB/y [P < .001], 1.19 dB/y [P < .001], 0.79 dB/y [P < .001], 0.69 dB/y [P < .001], and 0.54 dB/y [P = .002], respectively) and girls (0.96 dB/y, 0.60 dB/y, 0.75 dB/y, 0.37 dB/y, 0.44 dB/y, and 0.58 dB/y, respectively [P ≤ .001 for all]). CONCLUSIONS AND RELEVANCE: This represents the first pediatric voice database using frequency-based acoustic measures. Our goal was to characterize the changes that occur in both male and female voices as children age. These findings help illustrate how acoustic measurements change with development and may aid in our understanding of the developing voice, pathologic changes, and response to treatment.

Use of botulinum toxin in pediatric otolaryngology and laryngology.

The use of botulinum toxin in adult otolaryngology has been commonly used in conditions such as spasmodic dysphonia, cricopharyngeal spasm, palatal myoclonus, sialorrhea, and for cosmetic reasons. The current use of botulinum toxin in pediatric otolaryngology and laryngology has primarily been off label and in children older than 2 years of age. This review discusses the different applications of botulinum toxin in pediatric patients and its effectiveness in treating different pediatric conditions.

Evaluation of true vocal fold growth as a function of age.

OBJECTIVE: To evaluate change in true vocal fold length as a function of age. STUDY DESIGN: Prospective study. SETTING: Tertiary aerodigestive center. SUBJECTS AND METHODS: In total, 205 patients (aged 1 month to 20 years), of whom 87 (42.4%) were female and 118 (57.6%) male, were included. Lengths of the total vocal fold (TVFL), membranous vocal fold (MVFL), and cartilaginous vocal fold (CVFL) were measured during direct laryngoscopy. Membranous-to-cartilaginous (M/C) ratios were calculated. RESULTS: For patients younger than 1 year, mean (SD) MVFL was 4.4 (1.3) mm for females and 4.9 (1.8) mm for males. At age 17 years, mean (SD) MVFL was 12.3 (2.1) mm for females and 14.0 (1.4) mm for males. Mean TVFL, MVFL, and CVFL increased an average of 0.7 mm, 0.5 mm, and 0.2 mm per year in linear fashion, respectively (linear regression, P < .0001). The M/C ratio did not significantly change with age (P = .33). Mean TVFL, MVFL, and CVFL showed no statistical difference between males and females (P = .27, .11, and .75, respectively). CONCLUSION: This is the largest longitudinal pediatric study specifically examining vocal fold length as a function of age. Each length of the true vocal fold appeared to linearly increase for both females and males. The M/C ratio remained relatively constant, unlike previously reported data, possibly due to in vivo vs cadaveric measurements. These findings suggest that critical periods of development in females and males are not explainable by changes in vocal fold length alone, and other factors such as vocal fold layers need further exploration.

Endoscopic CO2 laser laryngofissure in pediatric laryngotracheal reconstruction.

Anterior laryngofissure is often needed to provide excellent visualization of the posterior cricoid lamina during pediatric laryngotracheal reconstruction. Focus has shifted from survival and decannulation outcomes to postoperative voice outcomes as surgical techniques continue to improve. Surgeons must perform the laryngofissure extremely precisely to avoid damage to the true vocal folds and ensure proper reapproximation of the anterior commissure. Endoscopic CO2 laser laryngofissure represents a novel technique to divide the anterior commissure and facilitate its accurate reapproximation.

Use of adjuvant intralesional bevacizumab for aggressive respiratory papillomatosis in children.

IMPORTANCE: Juvenile recurrent respiratory papillomatosis (RRP) can be an aggressive disease process necessitating frequent trips to the operating room with multiple anesthetics for tumor debulking and airway preservation. Adjuvant therapy, such as that which is reported in this article, may help reduce the number of operative procedures affected children need each year and therefore may also affect their overall quality of life (QOL). OBJECTIVE: To describe our experience with intralesional bevacizumab (Avastin) treatment for children with severe RRP by comparing median number of surgical procedures per year, median duration of time between procedures, Derkay staging, and voice QOL before and after bevacizumab treatment. DESIGN: Prospective, consecutive case series. SETTING: Tertiary care aerodigestive center. PARTICIPANTS: Ten children, aged 18 months to 18 years, with severe RRP necessitating more than 4 operative interventions in 1 year whose parents (or legal guardians) consented to intralesional bevacizumab treatment. INTERVENTIONS: Intralesional bevacizumab administered at concentration of 2.5 mg/mL for 3 consecutive injections (with 532-nm pulsed KTP [potassium titanyl phosphate] laser when necessary) at intervals of 2 to 3 weeks. MAIN OUTCOME MEASURES: Time between surgical procedures, number of procedures per year, Derkay staging, total Pediatric Voice-Related Quality of Life (PVRQOL) score, Emotional PVRQOL score, and Physical PVRQOL score defined by comparing the year leading up to first of 3 bevacizumab injections with the year following the third bevacizumab injection. RESULTS: The median duration of time between surgical procedures increased by 5.9 weeks after bevacizumab (P = .002). The median number of procedures per year decreased by 4 (P = .002). Derkay staging decreased by 6 (P = .03). The median total PVRQOL score increased by 25.5 (P = .02), the median Emotional PVRQOL score increased by 11.3 (P = .047), and the median Physical PVRQOL score increased by 14.3 (P = .047). CONCLUSIONS AND RELEVANCE: Intralesional bevacizumab treatment may increase duration of time between surgical procedures and decrease number of procedures per year, while improving voice QOL.

Vascular compression of the airway: establishing a functional diagnostic algorithm.

IMPORTANCE: Pediatric imaging carries the risk of radiation exposure. Children frequently undergo computed tomography with angiography (CTA) for findings on bronchoscopy with limited knowledge regarding the necessity of such imaging. OBJECTIVE: To report our experience with all pediatric patients at our institution over an 8-year period with airway symptoms warranting bronchoscopy followed by CTA for potential vascular anomaly. Goals were to report the percentage of positive findings seen on CTA leading to surgery; discuss relative radiation exposure risk and sedation risk for additional radiologic studies; and propose a functional diagnostic algorithm. DESIGN, SETTING, AND PARTICIPANTS: Retrospective chart review of 42 children aged 2 months to 11 years with tracheomalacia who underwent CTA between 2004 and 2012 in our tertiary aerodigestive center. INTERVENTIONS: Bronchoscopy and CTA. MAIN OUTCOMES AND MEASURES: Presence of vascular anomaly and need for thoracic surgery. RESULTS: Of these 42 children, 21 (50%) had a vascular anomaly identified on CTA. Of these 21, 17 (81%) had innominate artery compression; 1 (5%) had double aortic arch; 1 (5%) had right aortic arch; 3 (14%) had bronchial compression by pulmonary artery; and 1 (5%) had dextrocardia with duplicated vena cava. Six (29%) of these 21 had clinical symptoms and CTA findings requiring thoracic surgery. The most common symptoms in children requiring thoracic surgery were cough, cyanosis, and stridor. CONCLUSIONS AND RELEVANCE: Deciding when to obtain imaging for bronchoscopic findings suggestive of vascular compression remains challenging. A diagnostic algorithm is proposed as a means to provide the best clinical care while weighing risks of additional radiation exposure vs sedation and exposure to general anesthesia.

Modified superior pharyngeal flap for the treatment of velopharyngeal insufficiency in children.

OBJECTIVE: To describe a modified rolled superior pharyngeal flap for treatment of velopharyngeal insufficiency (VPI) in children. METHODS: Prospective case series at a tertiary care multidisciplinary aerodigestive center. Four children, aged 5-12 years, with VPI refractory to speech therapy resulting after cleft palate (bilateral, submucous, or soft palate only) repair, failed traditional superior pharyngeal flap, fine motor incoordination, or adenoidectomy were studied. All 4 children underwent surgery with a modified superior pharyngeal flap, where aspects of the most commonly employed pharyngeal flap designs were combined to achieve the benefits of each technique and to allow for mucosal covering on either side of the flap, improved control of the lateral port size due to the horizontal-to-horizontal inset technique, and the ability to avoid a vertical or horizontal split in a previously repaired cleft palate. RESULTS: All 4 patients demonstrated resolution of their VPI as measured by subjective and/or objective criteria. Every patient required additional speech therapy postoperatively. CONCLUSIONS: Our modified superior pharyngeal flap technique may be a good option in patients with small velopharyngeal gaps undergoing revision velopharyngeal surgery. A larger, longitudinal study would better address the overall outcomes of this technique.

Endoscopic resection of juvenile nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibromas remain rare tumors representing approximately 0.05% of head and neck tumors. The typical presentation is a male teenager with recurrent epistaxis and nasal obstruction. These tumors were traditionally approached via external and/or intraoral incisions, but many are amenable to endoscopic removal. Preoperative embolization of major feeding vessels to these tumors by interventional radiology has resulted in significantly less blood loss and facilitated endoscopic resection. The following chapter discusses endoscopic resection of juvenile nasopharyngeal angiofibromas and outlines pertinent anatomy while covering important surgical techniques. Appropriate patient selection, anesthesia considerations, surgical preparation and techniques, and postoperative care are discussed. A case presentation is included with preoperative imaging and an accompanying video to demonstrate these surgical techniques.

Enchondroma of the skull base secondary to generalized enchondromatosis: a case report and review of the literature.

Generalized enchondromatosis, of which Ollier disease is the most common type, is a rare bone dysplasia characterized by multiple intraosseous tumors near growth-plate cartilage. These cartilaginous tumors have a propensity to transform into chondrosarcomas. Enchondromas of the skull base are exceedingly rare. We present the case of a patient with generalized enchondromatosis who developed a large enchondroma of the clivus, and we discuss the clinical presentation and potential treatments for this entity.