An Aerodigestive Approach to Laryngeal Clefts and Dysphagia Using Injection Laryngoplasty in Young Children.

PURPOSE OF REVIEW: Our objective is to summarize the presentation, diagnosis, and management of mild laryngeal clefts in children. We focus on deep interarytenoid notches (DIN), a subclassification of type 1 laryngeal clefts (LC1), and review the literature and our multidisciplinary experience utilizing injection laryngoplasty (IL). RECENT FINDINGS: DIN is a mild form of LC1 and is considered a normal anatomical variant. Recent cohort studies demonstrate IL to be a safe, low-risk, and efficacious treatment of LC1, but few studies focus on DIN. We present results from two aerodigestive clinic (ADC) pilot studies at our institution, in patients 1-3 years old, with DIN-related dysphagia and aspiration (DA). Feeding, respiratory-related symptom scores, and aspiration/penetration assessed on modified barium swallow (MBS) significantly improved following combined IL and feeding therapy using a thickener weaning protocol (TWP). Subgroup analysis reveals combined IL and TWP to be particularly effective in patients with severe baseline DA. Multidisciplinary aerodigestive evaluation and management with IL and feeding therapy focused on weaning levels of thickener is emerging as a novel and effective approach for treatment of DIN-related DA in young children. Further comparative, prospective trials investigating effects of IL and feeding therapy are required to validate results.

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric tracheotomy. STUDY DESIGN: Blinded, modified, Delphi consensus process. METHODS: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items. RESULTS: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus. CONCLUSIONS: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:2700-2707, 2020.

Deep interarytenoid notch in young children managed with systematic thickener wean and injection laryngoplasty.

OBJECTIVES: Deep interarytenoid notch (DIN) is a congenital variation of the larynx often associated with dysphagia and aspiration (DA) in young children. Feeding therapy with thickeners and surgical management with injection larygoplasty (IL) are used with various efficacies. Thickeners address the functional domain and IL addresses the anatomical domain of treatment. Our objective was to evaluate DIN patients managed with both interventions. METHODS: We conducted a retrospective pilot descriptive study of DIN patients with DA aged 1-3 years receiving thickeners and IL. Patients received a systematic weekly reduction of thickeners, referred to as the Thickener Weaning Protocol (TWP), based on clinical signs and symptoms of DA. The outcomes were assessed by the rate of thickener level reduction and DA-related sign/symptom frequency achieved at 6 months post-treatment. RESULTS: Thirteen patients with DIN associated DA were analyzed. The TWP was initiated within 2 months in 77% of patients, and within 4 months in 100% of patients. Thickener scores improved from an average of 5.76 (3/4 honey) to 2.15 (thin) (p = 0.001). DA-related signs/symptoms frequency improved from an average of 3.3 to 0.84 (p = 0.05). CONCLUSIONS: These findings suggest that treatment of DIN associated DA with a combination of thickeners and IL results in significant clinical improvements in young children.

Differential capture of serum proteins for expression profiling and biomarker discovery in pre- and posttreatment head and neck cancer samples.

INTRODUCTION: A long-term goal of our group is to develop proteomic-based approaches to the detection and use of protein biomarkers for improvement in diagnosis, prognosis, and tailoring of treatment for head and neck squamous cell cancer (HNSCC). We have previously demonstrated that protein expression profiling of serum can identify multiple protein biomarker events that can serve as molecular fingerprints for the assessment of HNSCC disease state and prognosis. METHODS: An automated Bruker Daltonics (Billerica, MA) ClinProt matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometer was used. Magnetic chemical affinity beads were used to differentially capture serum proteins prior to MALDI-TOF analysis. The resulting spectra were analyzed using postprocessing software and a pattern recognition genetic algorithm (ClinProt 2.0). An HNSCC cohort of 48 sera samples from 24 patients consisting of matched pretreatment and 6 to 12 month posttreatment samples was used for further analysis. Low-mass differentially expressed peptides were identified using MALDI-TOF/TOF. RESULTS: In the working mass range of 1,000 to 10,000 m/z, approximately 200 peaks were resolved for ionic bead capture approaches. For spectra generated from weak cation bead capture, a k-nearest neighbor genetic algorithm was able to correctly classify 94% normal from pretreatment HNSCC samples, 80% of pretreatment from posttreatment samples, and 87% of normal from posttreatment samples. These peptides were then analyzed by MALDI-TOF/TOF mass spectometry for sequence identification directly from serum processed with the same magnetic bead chemistry or alternatively after gel electrophoresis separation of the captured proteins. We were able to compare this with similar studies using surface-enhanced laser desorption ionization (SELDI)-TOF to show this method as a valid tool for this process with some improvement in the identification of our groups. CONCLUSIONS: This initial study using new high-resolution MALDI-TOF mass spectrometry coupled with bead fractionation is suitable for automated protein profiling and has the capability to simultaneously identify potential biomarker proteins for HNSCC. In addition, we were able to show improvement with the MALDI-TOF in identifying groups with HNSCC when compared with our prior data using SELDI-TOF. Using this MALDI-TOF technology as a discovery platform, we anticipate generating biomarker panels for use in more accurate prediction of prognosis and treatment efficacies for HNSCC.

The role of CMV inflammatory genes in hearing loss.

HYPOTHESIS: The purpose of this study is to test the hypothesis that virally encoded immunomodulatory genes play a role in cytomegalovirus (CMV)-related hearing loss. OBJECTIVE: Cytomegalovirus is the leading cause of infectious-related congenital sensorineural hearing loss worldwide. Unfortunately, little is known about the pathophysiology of CMV-related injury to the developing ear. METHODS: Viral mutagenesis techniques were developed that allow the deletion of a specific viral immunomodulatory gene, macrophage inflammatory protein (MIP) 1alpha homolog. We assessed the extent to which this gene product contributed to auditory pathologic findings in the guinea pig (GP) model. Eighteen weanling GPs (250-350 g) were used under an Institutional Animal Control and Use Committee-approved protocol. We analyzed preinoculation hearing using auditory brainstem response recordings. Intracochlear inoculations were performed on one group of six GPs with sterile viral media, 6 GPs with wild-type (WT) CMV virus, and 6 GPs with mutant "knockout" (KO) virus (with deleted MIP-1alpha homolog). Auditory brainstem responses were then obtained on postinoculation Days 7, 14, 21, and 28. RESULTS: There was a significant difference in hearing between the KO group and the WT group, with significantly better hearing in the KO group. A comparison of the KO group to the sham group revealed no significant hearing differences between the groups. The WT group had significant threshold shifts by dose at all frequencies meeting our criteria of hearing loss (>30 dB). There were no statistical differences in the sham or KO group. CONCLUSION: Virally encoded immunomodulatory genes such as MIP-1alpha seem to play a significant role in CMV-related hearing loss. This study is the first demonstration of the role of specific viral immune modulation genes in the in vivo pathogenesis of CMV-induced hearing loss in a relevant animal model.

Macrophage inflammatory proteins in cytomegalovirus-related inner ear injury.

OBJECTIVE: Inner ear inflammation triggered by CMV infection may play a role in CMV-related auditory pathogenesis. The purpose of the study was to determine if a virally encoded macrophage inflammatory protein played a role in CMV-related hearing loss. DESIGN: Mutagenesis was performed with deletion of a guinea pig CMV macrophage inflammatory protein. Intracochlear inoculations were performed on three groups of animals (n = 18). Group 1 received sterile viral media, Group 2 received wild-type CMV virus, and Group 3 received "knockout" (KO) virus with a deleted immunomodulation gene. Baseline and postinoculation ABRs were obtained. ELISA and PCR were performed and temporal bones examined. SUBJECTS: Eighteen guinea pigs. RESULTS: The KO group had significantly better hearing than the WT group. There were no significant differences between the KO and sham groups. The WT group had significant hearing loss at all frequencies. Inflammation and fibrosis were noted in the WT temporal bones only. CONCLUSIONS: Virally encoded macrophage inflammatory proteins appear to play a significant role in CMV-related hearing loss.

Salivary gland surgery for chronic pulmonary aspiration in children.

INTRODUCTION: Chronic aspiration in the neurologically impaired child has a considerable morbidity and occasional morbidity. Hospitalization, physician visits and health costs associated with the sequelae of aspiration are considerable. AIM: To assess the efficacy of salivary gland surgery to treat chronic aspiration in children. SETTING: Tertiary pediatric center. STUDY DESIGN: A 6 year retrospective chart review of all patients undergoing salivary gland surgery to treat chronic aspiration. OUTCOME PARAMETERS: (1) Rate of lower respiratory tract infection (LRTI); (2) baseline oxygen saturation pre- and post-surgery. RESULTS: Sixty-two patients aged 7-279 months (mean 68 months) underwent four duct ligation or bilateral submandibular gland excision with unilateral or bilateral parotid duct ligation. The mean rate was 1.2/year pre-operatively and 0.7/year post-operatively (p=0.6). There was, however, a significant improvement in the baseline post-operative oxygen saturation (mean 94.3%) when compared to the pre-operative baseline oxygen saturation (mean 92.8%, p=0.003). Analysis of the cerebral palsy subgroup was performed (n=13). In this group there was no difference between mean pre- and post-operative LRTI rate (p=0.5) nor change in baseline oxygen saturation (p=0.83). Children under 3 years of age showed a reduction in the LRTI rate (mean of 2.1 versus 0.7 episodes per year, p=0.04) and an improvement in the post-operative baseline oxygen saturation (p=0.001) following surgery. CONCLUSIONS: Unlike a previous publication from this institution, when evaluating the population sample as a whole, there was no significant improvement in the rate of LRTI following salivary gland surgery, however, there was an improvement in baseline oxygen saturation, possibly reflecting an improvement in lung function. There was an improvement in neither outcome parameter in children with cerebral palsy and improvements in both outcome measures in children under the age of 3.

The clinical relevance of the submucosal cricoid cleft.

PURPOSE: Although fairly uncommon and sometimes difficult to diagnose, laryngeal clefts have been well-defined in the literature. The submucosal cleft variant has been described anatomically, but not clinically. We describe a series of patients with a submucosal cricoid cleft variant and its clinical relevance. METHODS: This is a case series of patients presenting with submucosal cricoid. A submucosal cricoid cleft is defined as a dehiscent posterior cricoid plate with an intact mucosal bridge. RESULTS: Eight patients presented during a 4 year period from October 2002 to September 2006. Patient ages ranged from 6 days to 15 years, with a mean age of 40 months. Four patients (50%) had a submucosal cricoid cleft only while four children presented with a laryngotracheal cleft in addition to the submucosal cricoid cleft. Six patients were diagnosed with subglottic stenosis and had tracheotomies. Four patients (50%) failed laryngotracheal reconstruction (LTR) prior to submucosal cricoid cleft diagnosis. Two patients had their submucosal cricoid cleft diagnosed during initial airway reconstruction surgery. Two patients were diagnosed after feeding difficulties. The submucosal cricoid cleft was felt to be an important factor contributing to the failure of previous laryngotracheal reconstruction. Almost all of the patients (7/8) had co-morbidities. Two patients needed revision airway surgery, both successful. Four of the six patients with a tracheostomy have been decannulated. CONCLUSION: Because of the subtle nature of its clinical presentation, submucosal cricoid cleft can be a challenging diagnostic entity, and the results of surgical reconstruction may be compromised if the cleft is undiagnosed.

Pediatric cholesteatoma: a retrospective review.

OBJECTIVES: The optimal treatment for pediatric cholesteatoma is controversial. Management decisions including intact canal wall versus open cavity techniques, second look procedures and staging ossicular reconstruction continue to be debated. In an attempt to clarify this issue we conducted an 11-year retrospective analysis of our experience with cholesteatoma presenting in our pediatric population. STUDY DESIGN: Retrospective review of children undergoing surgical intervention for cholesteatoma at a tertiary care pediatric hospital between 1 July 1992 and 1 July 2003 by the senior author. METHODS: Comparison of recurrence rates in intact canal wall (ICW) versus canal wall down (CWD) procedures; with analysis of second-look procedures, ossicular chain reconstruction (OCR) and hearing results in the management of pediatric cholesteatoma. RESULTS: Two hundred and sixty-two children with 278 cases of cholesteatoma underwent surgical resection. Of these children, 221 were managed via an ICW approach while the remaining 57 underwent a CWD procedure. The overall recurrence rate in this series was 16%, with 17% in the ICW group and 12% in the CWD group. OCR was performed in 97% of the ICW cases at time of second-look procedure, with 75% undergoing reconstruction with partial ossicular reconstruction prosthesis. The average air-bone gap improvement in these patients was 10.8 dB, with an average hearing improvement of total ossicular reconstruction of 5.8 dB. The average hearing improvement in the CWD group, all managed with cartilage interposition grafts, was 3.7 dB. CONCLUSIONS: Management of pediatric cholesteatoma requires a highly individualized approach that takes into account anatomic, clinical and social factors to determine the most successful surgical treatment paradigm.

Management of choanal atresia in CHARGE association patients: a retrospective review.

RATIONALE: To examine the management and outcomes of choanal atresia in children with CHARGE association compared with non-CHARGE children. METHODS: This is a retrospective chart review at a tertiary care children's hospital examining the management and outcomes of choanal atresia repair in children with CHARGE from 1990-2005. At least two CHARGE features were used to define these children. Children with CHARGE association were compared with non-CHARGE children regarding type of atresia, method of repair, post-operative management, re-stenosis rate and revision surgery. RESULTS: Fifty-seven children (36 female, 21 male) with complete records were identified with 24% diagnosed with CHARGE association. The median age of primary repair was 0.75 months for CHARGE and 15 months for non-CHARGE children (p=0.047). Unilateral atresia was diagnosed in 36% of CHARGE children and 81% of non-CHARGE children. Bilateral atresia was diagnosed in 64% of CHARGE and 19% of non-CHARGE children (p=0.006). The median duration of stent placement was slightly longer in the CHARGE group with no difference in the median number of post-operative dilations. Of those with CHARGE, 36% required revision surgery compared to 44% of the non-CHARGE subjects (p=0.58). Of those undergoing primary transnasal repairs, 40% of the CHARGE and 37% of the non-CHARGE patients failed. 50% of CHARGE patients with primary transnasal repair for bilateral atresia failed. Only 25% of transpalatal CHARGE repairs failed, while 75% of transpalatal repairs failed in the non-CHARGE group. The median follow-up was 24.6 months for CHARGE and 24.9 months for non-CHARGE patients. CONCLUSIONS: Children with CHARGE and unilateral choanal atresia can be managed successfully with a transnasal approach. However, our data, as well as prior published reports, suggests that CHARGE patients with bilateral atresia should have primary transpalatal repairs due to the high failure rate with the transnasal approach in this population.

Human Papillomavirus Vaccination Counseling in Pediatric Training: Are We Discussing Otolaryngology-Related Manifestations?

OBJECTIVE: Demonstrate the need for increased education regarding otolaryngology-related manifestations of human papillomavirus (HPV). Highlight a need to incorporate otolaryngology-related manifestations of HPV in vaccine counseling. STUDY DESIGN: Survey. SETTING: Tertiary care academic children's hospital. SUBJECTS: Pediatric residents, fellows, and staff. METHODS: An online survey was made available regarding HPV education and vaccination. RESULTS: Participants (N = 348) initiated the survey representing 28.4%, 25.6%, and 19.0% postgraduate year 1, 2, and 3 residents, respectively, as well as 17.5% chief residents/fellows and 9.5% attendings. Participants rated their prior education as none or fair regarding recurrent respiratory papillomatosis (63.8%) and oropharyngeal squamous cell carcinoma (68.3%). In contrast, 60.6% and 70.9% rated their education on genital warts and cervical cancer correspondingly as good or excellent. When asked what was routinely discussed during HPV vaccine counseling, 63.3% reported "never" discussing recurrent respiratory papillomatosis and 52.9% "never" discussing oropharyngeal squamous cell carcinoma. A range from 92.7% to 95.5% responded that there was a need for increased education regarding HPV and its role in recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma. CONCLUSIONS: Increased education about HPV and its otolaryngology-related manifestations should be undertaken to increase provider, patient, and parent awareness of recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma. We propose that discussing the risks of otolaryngology-related disease be routinely included in HPV vaccination counseling.

"Window shade" tympanoplasty for anterior marginal perforations.

OBJECTIVES/HYPOTHESIS: Anterior marginal perforations of the tympanic membrane often present a reconstructive challenge to the otolaryngologist. Poor surgical outcomes are often due to inadequate exposure, a lack of residual tympanic membrane, impaired vascular supply, and delayed healing. This study reports on the success of the "window shade" technique, combining aspects of both the traditional underlay and overlay tympanoplasty techniques, for the management of anterior marginal tympanic membrane perforations. STUDY DESIGN: Retrospective review of patients undergoing window shade tympanoplasty from July 1, 1994, to July 1, 2003, at a tertiary care referral center. METHODS: Only patients found to have anterior tympanic membrane perforations and who underwent a window shade tympanoplasty were included in the study. Tympanoplasty success rate was studied by examining postoperative complications of recurrent perforation, tympanic membrane lateralization, or anterior blunting. RESULTS: The authors identified 164 patients who underwent window shade tympanoplasty during the study period. The overall success rate for tympanic membrane repair was 94.5%. There were no cases of tympanic membrane lateralization or significant blunting. The average healing time was 4 weeks. The surgical technique is described in detail. CONCLUSION: The window shade tympanoplasty is an excellent surgical option for repair of anterior marginal perforations of the tympanic membrane.

American Society of Pediatric Otolaryngology members' experience with recurrent respiratory papillomatosis and the use of adjuvant therapy.

OBJECTIVE: To evaluate how evolving treatment technologies have affected our management of recurrent respiratory papilloma (RRP) since the last comprehensive survey of pediatric otolaryngologists in 1998. DESIGN: Web-based survey of all American Society of Pediatric Otolaryngology members residing in the United States, Canada, Europe, and Australia. RESULTS: Evaluable survey results were tabulated from 74 practitioners in 62 separate practices managing 700 current children with RRP. A total of 150 (21%) of these patients presently receive adjuvant medical therapies with cidofovir and interferon, accounting for more than two thirds of the total. Sixty-one percent of patients treated with cidofovir have experienced a beneficial response. Distal spread of RRP has occurred in 94 (13%) of the 700 patients. Half of the practices surveyed have experienced a death from RRP, with 89% of deaths directly related to RRP. The laryngeal microdebrider (53%) has supplanted the carbon dioxide laser (42%) as the preferred means of surgically removing papilloma from the larynx in children. Spontaneous, apneic, and jet ventilation (88%) anesthesia techniques have replaced the use of laser-safe endotracheal tubes (10%) as the preferred anesthetic management. Routine human papillomavirus subtyping is practiced by 45% of respondents while 15% treat all their patients with antireflux medications. Half of respondents send lesions for histologic examination only if there is a change in growth pattern while one third send lesions with every surgery. CONCLUSIONS: Recurrent respiratory papilloma continues to be a frustrating disease to treat and is associated with significant morbidity and mortality. There has been an evolution in the past decade toward the increased use of antiviral adjuvant therapy and the use of microdebrider techniques for surgical management.

Nasal obstruction in newborns.

Nasal obstruction is a serious clinical scenario in the newborn infant with a large differential diagnosis. This article reviews the etiologies of nasal obstruction to aid the pediatrician in prompt evaluation, diagnosis, and treatment.

The significance of post-operative fever following airway reconstruction.

OBJECTIVE: Post-operative management of children undergoing airway reconstruction has been well-described. However, many of these patients develop post-operative fevers. We conducted a retrospective review in an attempt to define the significance of post-operative fever following pediatric airway reconstruction. METHOD: Retrospective analysis of 78 pediatric laryngotracheoplasties (LTPs) from May 1, 2006 - April 30, 2007 at a tertiary care pediatric hospital. Fever was defined as temperature >or=38.5. A fever was "significant" if accompanied by a positive sputum, blood or urine culture, or an elevated WBC. Chest radiograph (CXR) results and co-morbidities were examined. RESULTS: Forty-five percent of cases (35/78) had fever. Of those febrile, 46% (n=16) had significant fever. Overall, 20.5% had significant fevers. Fifty-two cases were single-stage LTP (SSLTP) with 31 febrile and 26 cases were double-stage LTP (DSLTP) with 4 febrile. SSLTP cases were at a significantly greater risk for post-operative fever compared with DSLTP, 59% vs 15% respectively (p=0.0002). 42% of febrile SSLTPs (n=13) had significant fevers compared to 50% (n=2) of febrile DSLTPs (Fisher's Exact p=1.0). 81.5% of cases with CXR findings had fevers, but only 50% of these fevers were significant. Subjects with post-operative atelectasis were more likely to have a fever compared to subjects with no post-operative atelactasis (93% vs. 33% respectively, p<0001). 30.8% of those with atelectasis had significant fever, compared to 52% of those without atelectasis (p=0.2) and 25 of SSLTPs vs. 3.9% of DSLTPs had atelactasis (p=0.027). No comorbidities were shown to be significant risk factors for post-operative fever. CONCLUSION: Based on our review, most children undergoing LTPs will have insignificant fevers. Those children undergoing SSTLP and/or having post-operative atelectasis are at higher risk for post-operative fever. Fevers in children with double-stage procedures or all reconstruction cases with CXR findings other than atelectasis should have a thorough fever work-up.

Severe injuries from coin cell battery ingestions: 2 case reports.

Although coin cell battery ingestion is usually not associated with adverse consequences, case reports have been published that describe serious morbidity and occasional mortality. This report describes 2 young children developing serious complications from unwitnessed Lithium coin cell ingestion. A 19-month-old developed an aortoesophageal fistula from the proximal descending aorta, whereas the other developed bilateral vocal cord paralysis. Massive bleeding from the aortoesophageal fistula occurred 10 days post battery removal, resulting in a fatal outcome despite maximal surgical efforts. The patient with bilateral vocal cord paralysis required tracheostomy for airway stridor but is recovering function. This report adds to the evidence that primary prevention efforts are needed to caution parents about the dangers associated with coin cell batteries, and secondary prevention can be improved by raising awareness among clinicians as to the various clinical presentations and therapeutic options for this condition.

Contemporary indications for ventilation tube placement.

PURPOSE OF REVIEW: To discuss the current indications for ventilation tube placement RECENT FINDINGS: In the past year, several studies have challenged the current guidelines for ventilation tube placement and antibiotic use for otitis media in children. Critics argue that some of these studies have poor scientific validity, yet these studies are being referenced, and sometimes misinterpreted, by the media. Fueled by these media reports, many concerned parents are now questioning otolaryngologists as to the efficacy and safety of ventilation tube placement. Whereas the indications for tube placement in children may be in a state of flux, the indications for tube placement in adults has (and is) fairly static. I will discuss the current published guidelines and the potential for changing trends in tube placement rates. I will also review the literature for the past year regarding postoperative management and adjuvant therapies. SUMMARY: Although there have been no radical changes in the indications for ventilation tube placement, recent studies have challenged the current clinical indicators and the ramifications of these studies may be more evident in the years to come.

Outcomes in children with perforated tympanic membranes after tympanostomy tube placement: results using a pilot treatment algorithm.

PURPOSE: The objective of this study was to examine the success of a pilot treatment algorithm for tympanic membrane perforations in children after tympanostomy tube placement. MATERIALS AND METHODS: A retrospective chart review of children with diagnosed tympanic membrane perforations after tympanostomy tube placement from 1998 to 2003 at a tertiary care children's hospital was performed. The patients had been treated according to an algorithm used by 2 pediatric otolaryngologists for management of tympanic membrane perforations: observation vs myringoplasty. Success rates were examined. RESULTS: Ninety-five children were identified, 27% of whom had nonhealing perforations after tube extrusion; 73% of the perforations were caused by a retained tube. The median duration of tube retention was 48 months, ranging from 13 to 120 months. After the treatment protocol, 76% of the patients underwent gelatin film or paper patch myringoplasty, 23% had adipose myringoplasty, and 1% were observed. Overall, 91% had healed perforations after the first intervention. Among those requiring a second intervention, the sizes of initial perforations were between 15% and 40%, with postrepair perforation sizes between 5% and 40%. In addition, 75% of those requiring a second intervention underwent tympanoplasty repair and 25% had fat patch myringoplasty. None required a third intervention. CONCLUSIONS: Our treatment algorithm for children with tympanic membrane perforations after tympanostomy tube placement appears to be successful and is an excellent model for other clinicians.