Pacific Northwest survey: posttympanostomy tube water precautions.

OBJECTIVES: To determine what recommendations are given to patients or parents of patients with tympanostomy tubes regarding water exposure and to elucidate any recommendation differences between primary care and specialty care physicians. DESIGN: Clinical survey. SETTING: General community in the Pacific Northwest, including Washington, Oregon, and Idaho. PARTICIPANTS: Physician surveys (N = 1116) were mailed to otolaryngologists, pediatricians, and family practitioners in the Pacific Northwest. Questions included what, if any, water precautions are given to patients or parents of patients who underwent tympanostomy tube insertion. Data were tabulated and compared among the 3 physician groups. MAIN OUTCOME MEASURES: Recommendations regarding water exposure. RESULTS: A response rate of 23.5% (n = 263) was obtained. Most respondents were self-described otolaryngologists (n = 150) followed by family practitioners (n = 77) and pediatricians (n = 36). chi(2) Analysis of the responses from each specialty group showed an overall significant difference about swimming precautions (P < .001). Further analysis of these data shows that many otolaryngologists (47% [n = 71]) and most primary care physicians (73% [n = 83]) recommend the use of barrier devices for swimming. Another 47% of otolaryngologist respondents allow swimming without any water precautions. With regard to depth of dive, there was no statistical significance found between the physician groups. CONCLUSIONS: Recommendations for swimming precautions are not universal among the physician groups that routinely see patients with tympanostomy tubes. Most primary care physicians and many otolaryngologists continue to prescribe water precautions to patients or parents of patients with tympanostomy tubes, despite published articles that have shown no reduction in the incidence of otorrhea from the use of barrier devices or from the avoidance of swimming.

Efficacy of treating children with anterior commissure and true vocal fold respiratory papilloma with the 585-nm pulsed-dye laser.

OBJECTIVE: To report preliminary results regarding the safety and efficacy of the 585-nm pulsed-dye laser (PDL) for the treatment of juvenile-onset recurrent respiratory papillomatosis (JORRP) in the pediatric population. DESIGN: Prospective longitudinal cohort study. SETTING: Two pediatric otolaryngology referral centers. PATIENTS: Twenty-three pediatric patients ranging in age from 6 months to 17 years. INTERVENTIONS: The 585-nm PDL was used for at least 1 treatment on each of these patients to treat JORRP of the true vocal folds or anterior commissure. MAIN OUTCOME MEASURES: Complications from the use of the 585-nm PDL in the treatment of JORRP. RESULTS: There was no evidence of anterior commissure webbing or true vocal fold scarring in this group of 23 patients followed up for 3 months to 1 year. CONCLUSIONS: The 585-nm PDL seems to be a safe instrument for treatment of JORRP. There is the potential that improved voice outcomes may be apparent when compared with traditional therapies because the vocal fold epithelium seems to be unharmed when treated with this method. Furthermore, the lack of epithelial damage incurred by the 585-nm PDL should enable more aggressive surgical excision of anterior commissure disease. Further prospective longitudinal studies examining voice outcomes are needed.

A useful algorithm for managing the difficult pediatric airway.

Management of the pediatric airway can be extremely challenging. A useful algorithm is presented that can be used when faced with even the most difficult of airways. A new adjuvant airway tool is also presented, as well as a list of equipment for the operating room. We will attempt to emphasize key points while presenting a patient that we have recently treated.

The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: a systematic review.

STUDY OBJECTIVE: Acute cardiogenic pulmonary edema is a common cause of respiratory distress in emergency department (ED) patients. Noninvasive ventilation by noninvasive positive pressure ventilation or continuous positive airway pressure has been studied as a treatment strategy. We critically evaluate the evidence for the use of noninvasive ventilation on rates of hospital mortality and endotracheal intubation. METHODS: We searched the databases of MEDLINE, EMBASE, and the Cochrane Library from 1980 to 2005. Additional sources included key journals, bibliographies of selected articles, and expert contact. We included studies that incorporated a randomized design; patients older than 18 years and with acute cardiogenic pulmonary edema; diagnosis and treatment initiated in the ED; noninvasive ventilation in addition to standard medical therapy compared to standard medical therapy alone, or noninvasive positive pressure ventilation compared to continuous positive airway pressure (both in addition to standard medical therapy); and data on hospital mortality or intubation. A random-effects model was used to obtain the summary risk ratios (RRs) and 95% confidence intervals (CIs) for hospital mortality and intubation. RESULTS: A pooled analysis of 494 patients suggested that noninvasive ventilation in addition to standard medical therapy significantly reduced hospital mortality compared to standard medical therapy alone (RR 0.61; [95% CI 0.41, 0.91]). Similarly, a meta-analysis of 436 patients suggested that noninvasive ventilation was associated with a significant decrease in intubation rates (RR 0.43; [95% CI 0.21, 0.87]). CONCLUSION: Our results suggest that noninvasive ventilation with standard medical therapy is advantageous over standard medical therapy alone in ED patients with acute cardiogenic pulmonary edema. Future studies, powered appropriately for mortality and intubation rates, are necessary to confirm these findings.

Validation of the Pediatric Voice-Related Quality-of-Life survey.

OBJECTIVE: To validate the Pediatric Voice-Related Quality-of-Life (PVRQOL) survey, which was designed to assess voice changes over time in the pediatric population. DESIGN: Prospective longitudinal study. SETTING: Outpatient pediatric otolaryngology office practice. PARTICIPANTS: One hundred twenty parents of children aged 2 through 18 years having a variety of otolaryngological diagnoses including disorders that affect the voice. INTERVENTIONS: The previously validated Pediatric Voice Outcomes Survey and the PVRQOL were jointly administered to the parents of the study participants. Test-retest reliability was accomplished by having 70 caregivers repeat the instrument 2 weeks after the initial visit. The Cronbach alpha value was calculated to determine reliability. Instrument validity was determined by examining convergent and discriminant validity. MAIN OUTCOME MEASURE: Correlation of PVRQOL scores with Pediatric Voice Outcomes Survey scores. RESULTS: Reliability of the PVRQOL was established by evaluating the Cronbach alpha value (.96; P<.001) and by test-retest reliability (weighted kappa value, 0.8). Validity of the PVQROL was tested by evaluating its ability to show significant change in voice-related quality-of-life after adenoidectomy (discriminant validity) (P<.001). The PVQROL also proved valid when the overall score was correlated with the previously validated Pediatric Voice Outcomes Survey (r = 0.7; P<.001). CONCLUSION: The PVRQOL is a more comprehensive survey than the previously validated Pediatric Voice Outcomes Survey and is another valid instrument to examine the health-related quality-of-life issues in pediatric voice disorders.

Pediatric partial cricotracheal resection: a new technique for the posterior cricoid anastomosis.

OBJECTIVE: Partial cricotracheal resection has become a more popular procedure in the pediatric population as a treatment for severe subglottic stenosis. We describe a new technique for the posterior cricoid anastomosis. STUDY DESIGN AND SETTING: This is a case series of 4 pediatric patients with a Myer-Cotton grade III or IV subglottic stensosis. SETTING: Tertiary care hospital with a pediatric intensive care unit. RESULTS: All 4 patients were decannulated and there were no observed complications to include posterior mucosal dehiscence and/or recurrent laryngeal nerve injury. CONCLUSIONS: Placing sutures through the cricoid cartilage is technically less difficult than previously described techniques for treating subglottic stenosis near the undersurface of the true vocal folds and affords a more stable posterior mucosal suture line. SIGNIFICANCE: This technique provides a surgical means to treat high subglottic stenosis that closely approximates the true vocal folds by enabling a stable posterior mucosa to mucosa apposition. EBM RATING: Grade C-4.

Development of the human true vocal fold: depth of cell layers and quantifying cell types within the lamina propria.

OBJECTIVES: We sought to further describe the development of the 3-layered human vocal fold in children and to quantify macrophage and myofibroblast concentrations in each layer. METHODS: We used an optical analysis software package to examine 8 longitudinally sectioned human vocal folds that had been fixed in formalin (ages 2 days to 14 years). RESULTS: The 2-day-old vocal fold contained only a monolayer of cells. This became a bilayer by 5 months, and a trilayer began to become evident by 7 years. The percent of total depth represented by the superficial layer of the lamina propria (SLP) gradually decreased with age. The SLP made up 22% of the total lamina propria by age 7 years; this percentage approximates that in the adult vocal fold. Macrophages and myofibroblasts were predominately found in the SLP, and began to be apparent by 11 months of age. CONCLUSIONS: These results help describe the development of human voice and may have implications as to when phonosurgical therapy can be considered for children.

Charcot-Marie-Tooth Disease type 1 and pediatric true vocal fold paralysis.

A case study of a child with Charcot-Marie-Tooth type 1 (CMT1) that presented with bilateral vocal fold paralysis. This is the first case of bilateral vocal fold paralysis in a child with CMT1 and it is the first case to be managed endoscopically. The surgical decision making process is discussed, and in particular the role of fiberoptic endoscopic evaluation of swallowing (FEES) in determining what surgical options should be entertained. In children with bilateral vocal fold paralysis who also have other neurologic abnormalities, the clinician should consider the possibility of CMT as the cause.

The utility of the fiberoptic endoscopic evaluation of swallowing (FEES) in diagnosing and treating children with Type I laryngeal clefts.

This case series of three young children with type I laryngeal clefts is presented to demonstrate the utility of fiberoptic endoscopic evaluation of swallowing (FEES) in managing these patients. FEES revealed laryngeal penetration in a posterior to anterior direction in two patients and penetration from lateral to medial in the third patient. The type of laryngeal penetration helped in making the diagnosis of a type I cleft in two children and helped establish a safe feeding regiment in the third child. Patients with type I laryngeal clefts are often misdiagnosed, most likely resulting from the complex presentation of signs/symptoms and the difficulty of detecting small clefts with currently available tests. The pattern of laryngeal aspiration seen with FEES can help in diagnosis and management in this patient population.

Trends in orbital complications of pediatric rhinosinusitis in the United States.

IMPORTANCE: Several studies have documented the prevalence and treatment of orbital complications secondary to pediatric rhinosinusitis, but to our knowledge, none have investigated the national health care burden of this disease since the introduction of the heptavalent pneumococcal vaccine (PCV-7). OBJECTIVE: To identify the current public health burden of orbital complications of pediatric rhinosinusitis, and to determine if the introduction of the PCV-7 has resulted in a change in national practice patterns. DESIGN, SETTING, AND PARTICIPANTS: Population-based study using the 2000 and 2009 Kids' Inpatient Databases to gather data on a sample of all pediatric discharges in the United States during the years 2000 and 2009. Children diagnosed as having orbital complications of sinusitis were identified by corresponding International Classification of Diseases, Ninth Revision (ICD-9) codes. Database analyses generated national estimates of summary statistics and comparison of trends over the 9-year period. INTERVENTIONS: Database analysis. MAIN OUTCOMES AND MEASURES: National health care trends according to year. End points assessed included prevalence, age, sex, length of hospital stay, and treatment of disease. RESULTS: The estimated prevalence of orbital complications of sinusitis requiring hospitalization in the United States has slightly decreased from 5338 (95% CI, 4956-5720) admissions in 2000 to 4511 (95% CI, 4165-4858) in 2009. However, the mean age has increased from 4.77 (95% CI, 4.56-4.97) years to 6.07 (95% CI, 5.87-6.26) years. The proportion of children undergoing surgical treatment increased from 0.108 (95% CI, 0.093-0.123) to 0.195 (95% CI, 0.176-0.213). Total charges increased from $4,140,000 (95% CI, $3,440,000-$4,830,000) to $10,000,000 (95% CI, $8,480,000-$11,600,000) with a mean charge per admission increasing from $8390 (95% CI, $7096-$9685) in 2000 to $22,656 (95% CI, $19,997-$25,314) in 2009. The mean length of stay remained stable at 3.67 (95% CI, 3.37-3.97) to 4.05 (95% CI, 3.81-4.29) hospital days. CONCLUSIONS AND RELEVANCE: The public health impact of orbital complications of pediatric rhinosinusitis continues to be substantial. Since the institution of the PCV-7 vaccine, national trends demonstrate a slightly decreased prevalence of hospital admissions. However, there is a shifting trend toward an older age at admission and a higher proportion of children undergoing surgical treatment.

Endoscopic management of anterior skull base encephaloceles.

Encephaloceles are relatively rare phenomena produced by the protrusion of brain and dura through an anterior skull base defect. Although they can occur as congenital defects, encephaloceles can also present after trauma. The diagnosis is usually made with nasal endoscopy and imaging studies. This report reviews our recent experience repairing 5 encephaloceles in 4 patients. The diagnostic approach and the technical aspects of surgical management are discussed. Although encephaloceles are a rarity, this diagnosis should be considered as part of the differential diagnosis in evaluating a patient with a unilateral polypoid nasal mass, particularly in the setting of recurrent meningitis or cerebrospinal fluid rhinorrhea.

Assessing the outcome of surgery to correct velopharyngeal insufficiency with the pediatric voice outcomes survey.

OBJECTIVE: To assess the functional outcome of surgery for velopharyngeal insufficiency (VPI) by administering the pediatric voice outcomes survey (PVOS) to the parents of the affected children. DESIGN: Prospective longitudinal study. SETTING: Tertiary referral pediatric otolaryngology office. SUBJECTS: Twelve children who underwent surgery to correct VPI during the 12-month-period between 1 January 2002 and 31 December 2002. METHODS: Parents of the 12 children were administered the PVOS prior to surgery and again 6 weeks post-operatively. The PVOS is a validated instrument designed to measure voice-related quality of life (V-RQOL). The score has been transformed to range from 0 (low V-RQOL) to 100 (high V-RQOL). RESULTS: The mean age of the children was 5 years (standard deviation [S.D.], 2.3 years). Seven children underwent sphincteroplasty and five had a superior based pharyngeal flap as a primary procedure. Three children required secondary procedures to correct their underlying VPI and one of those had a third procedure consisting of a posterior wall fat injection. The mean pre-operative PVOS score was 38.3 (S.D., 12) and the mean 6 weeks post-operative score was 72.3 (S.D., 22.7) (paired t-test; P < 0.001). CONCLUSION: The PVOS represents a valid clinical tool to measure the functional impact of surgery to correct pediatric velopharyngeal insufficiency.

Management of tracheal stenosis.

PURPOSE OF REVIEW: The treatment for pediatric tracheal stenosis has evolved over the past 50 years. Open airway reconstruction has traditionally been the treatment of choice for this condition. Numerous recent publications now support the use of endoscopic techniques to both augment and sometimes replace open procedures. RECENT FINDINGS: During the past 12 months, a significant interest in expanding the role of airway dilation with balloons to manage airway stenoses has emerged. Development of novel airway stents, to include bioabsorbable products, holds promise to decrease the morbidity of stenting procedures. Continued improvement in preoperative imaging, in the form of virtual bronchoscopy, may someday replace airway endoscopy for planning purposes. Additionally, perioperative management strategies and the use of novel adjuvants have been introduced with a goal of improving outcomes in both endoscopic and open techniques through better control of granulation. Ultimately, advances in tissue engineering may provide yet another reconstructive option in the future. SUMMARY: Endoscopic techniques have an increasing role in the management of pediatric subglottic and tracheal stenosis. However, open airway reconstructive procedures are still required in cases of mature scar, high-grade stenosis, and long-segment stenosis.

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.

Prospective comparison of handheld pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children.

OBJECTIVES: To compare pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children and to determine if a significant difference exists in sensitivity and specificity based on patient age and/or experience of the examiner. METHODS: A prospective study of 102 patients, or 201 ears, enrolled over a 1-year period in a tertiary medical center. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for staff and resident-performed pneumatic otoscopy, staff and resident-performed binocular microscopy, and tympanometry. Tympanometry data were stratified for age. A kappa correlation was used to compare each tool to myringotomy result (gold standard) and to compare staff versus resident. RESULTS: Binocular microscopy by staff pediatric otolaryngologist was the most sensitive, 88.0% (95% CI 81.4-94.7), and specific, 89% (95% CI 83.1-94.9). Resident binocular microscopy revealed a sensitivity of 81.5% (95% CI 73.6-89.5) and specificity 78.9% (95% CI 71.2-86.6). Staff was more sensitive and specific than resident at pneumatic otoscopy, sensitivity 67.9% (95% CI 57.6-78.3) and specificity 81.4% (95% CI 73.8-88.9) versus 57.7% (95% CI 46.7-68.7) and 78.4% (95% CI 70.4-86.4). Tympanometry had a much lower specificity for ages 5-12 months than for older children. CONCLUSIONS: Binocular microscopy by staff pediatric otolaryngologist revealed the best sensitivity and specificity. Pneumatic otoscopy even performed by an inexperienced examiner is more sensitive and specific than tympanometry. The tympanometer is less specific in children under 1 year of age.

Spasmodic dysphonia in an adolescent patient with an autoimmune neurologic disorder.

Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) has been primarily described in the neurology and psychiatry literature. The symptoms of this syndrome typically are a range of obsessive compulsive disorders and neuromuscular tics. The otolaryngologist occasionally becomes involved with these children when it is deemed that chronic tonsil infections are the source. We report here on a child diagnosed with PANDAS who presented with severe ventricular hyperfunction and adductor spasmodic dysphonia. She was treated with botulinum toxin, which resulted in a significant improvement in subjective voice as well as reduced jitter and shimmer on objective voice measurements.