Abstract Cholesteatoma is a unique pathologic condition of the temporal bone characterized by migration of keratinized squamous epithelium positioned into the middle ear and mastoid cavity. The exact ...pathogenic molecular mechanisms behind the formation and propagation of cholesteatoma remain unclear. This review will aim to define the classification of cholesteatomas, review the most accepted pathogenesis theories, describe the inherent molecular mechanisms dictating the hyperproliferative nature of cholesteatoma keratinocytes, and explore innate biological differences between pediatric and adult cholesteatoma.
Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, ...frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the term
(middle ear inflammation). This guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The guideline is intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals.
The purpose of this clinical practice guideline update is to reassess and update recommendations in the prior guideline from 2013 and to provide clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. In planning the content of the updated guideline, the guideline update group (GUG) affirmed and included all the original key action statements (KASs), based on external review and GUG assessment of the original recommendations. The guideline update was supplemented with new research evidence and expanded profiles that addressed quality improvement and implementation issues. The group also discussed and prioritized the need for new recommendations based on gaps in the initial guideline or new evidence that would warrant and support KASs. The GUG further sought to bring greater coherence to the guideline recommendations by displaying relationships in a new flowchart to facilitate clinical decision making. Last, knowledge gaps were identified to guide future research.
In developing this update, the methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action" were followed explicitly. The GUG was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.
The GUG made
for the following KASs: (14) clinicians should prescribe topical antibiotic ear drops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea; (16) the surgeon or designee should examine the ears of a child within 3 months of tympanostomy tube insertion AND should educate families regarding the need for routine, periodic follow-up to examine the ears until the tubes extrude.The GUG made
for the following KASs: (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration, from the date of onset (if known) or from the date of diagnosis (if onset is unknown); (2) clinicians should obtain a hearing evaluation if OME persists for 3 months or longer OR prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties; (5) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who do not receive tympanostomy tubes, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (6) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (7) clinicians should offer bilateral tympanostomy tube insertion in children with recurrent acute otitis media who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (8) clinicians should determine if a child with recurrent acute otitis media or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (10) the clinician should not place long-term tubes as initial surgery for children who meet criteria for tube insertion unless there is a specific reason based on an anticipated need for prolonged middle ear ventilation beyond that of a short-term tube; (12) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (13) clinicians should not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement; (15) clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands, avoidance of swimming or water sports) for children with tympanostomy tubes.The GUG offered the following KASs as
: (4) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable, all or in part, to OME that include, but are not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life; (9) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for 3 months or longer; (11) clinicians may perform adenoidectomy as an adjunct to tympanostomy tube insertion for children with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) OR in children aged 4 years or older to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion.
Minimally invasive endoscopic techniques are an appealing alternative to open surgical management of pediatric subglottic stenosis (SGS), but more information is needed to understand the comparative ...risks, benefits, and limitations of such interventions.
To compare the effectiveness of endoscopic balloon dilation (EBD) and laryngotracheoplasty (LTP) in pediatric patients with SGS and to identify patient and disease factors that are associated with successful EBD.
A retrospective medical record review of children undergoing EBD and LTP for SGS in a tertiary care children's hospital from 2006 through 2012.
Success was defined as decannulation or tracheotomy avoidance. Additional outcomes were total number of procedures and number of unplanned procedures. Univariate χ2 analyses and multivariate regression analyses were performed to identify patient and disease factors statistically associated with success within treatment groups.
Overall, 86 of 90 patients (96%) successfully avoided tracheotomy or were decannulated. Fourteen patients were successfully treated with EBD, but for 13 patients, EBD failed, and they underwent LTP. A total of 76 patients underwent LTP. In univariate analyses, patients for whom EBD was successful were more likely to have mild (grade 1 or 2; n = 10) than severe (grade 3 or 4; n = 4) SGS compared with patients for whom EBD failed (grade 1 or 2, n = 0 vs grade 3 or 4, n = 13) (P < .001). Three patients who underwent initial EBD had worsening stenosis. Patients initially treated with EBD were more likely to require unplanned surgical intervention during their treatment (6 of 27; 22%) than patients initially treated with LTP (3 of 63; 5%) (P = .01). Patients initially treated with EBD had a lower number of airway interventions and/or evaluations under anesthesia (mean, 6.7) during their course of treatment than patients initially treated with LTP (mean, 9.2) (P = .003). In multivariate analyses, only severe SGS was significantly associated with failure of initial EBD (13 of 13 100% with type 3 or 4 vs 4 of 14 with type 1 or 2 29%) (P = .002).
For severe SGS, EBD has limited application compared with LTP, and in some cases failed EBD is even detrimental, increasing the risk of unplanned urgent interventions compared with LTP.
Objectives/Hypothesis
To identify any potential barriers for decannulation in children undergoing double‐staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself.
Study ...Design
Case series with chart review.
Methods
We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand‐alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR.
Results
Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log‐rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log‐rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log‐rank), and race/ethnicity (P = .001 Log‐rank).
Conclusion
In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation.
Level of Evidence
4 Laryngoscope, 131:2141–2147, 2021
The personal statement is often an underutilized aspect of pediatric otolaryngology fellowship applications. In this pilot study, we use deep learning language models to cluster personal statements ...and elucidate their relationship to applicant rank position and postfellowship research output.
Retrospective cohort.
Single pediatric tertiary care center.
Data and personal statements from 115 applicants to our fellowship program were retrieved from San Francisco Match. BERT (Bidirectional Encoder Representations From Transformers) was used to generate document embeddings for clustering. Regression and machine learning models were used to assess the relationship of personal statements to number of postfellowship publications per year when controlling for publications, board scores, Alpha Omega Alpha status, gender, and residency.
Document embeddings of personal statements were found to cluster into 4 distinct groups by
-means clustering: 2 focused on "training/research" and 2 on "personal/patient anecdotes." Training clusters 1 and 2 were associated with an applicant-organization fit by a single pediatric otolaryngology fellowship program on univariate but not multivariate analysis. Models utilizing document embeddings alone were able to equally predict applicant-organization fit (receiver operating characteristic areas under the curve, 0.763 and 0.750 vs 0.419;
values >.05) as compared with models utilizing applicant characteristics and personal statement clusters alone. All predictive models were poor predictors of postfellowship publications per year.
We demonstrate ability for document embeddings to capture meaningful information in personal statements from pediatric otolaryngology fellowship applicants. A larger study can further differentiate personal statement clusters and assess the predictive potential of document embeddings.
The purpose of this study is to evaluate for discrepancies in diagnostic auditory brainstem responses (ABR) between Children's National Hospital (CNH), a pediatric medical center, and outside ...facilities (OSF) that referred patients to CNH for confirmatory evaluation. Such discrepancies impact early hearing detection and intervention (EHDI) timelines.
A retrospective chart review was conducted from an internal database of patients who underwent diagnostic ABR from 2017 to 2021. Only patients with ABR results from both CNH and OSF were analyzed. Demographic data, external and internal test results, and intervention data were obtained. Hearing loss (HL) severity was graded on a scale of 0 to 8, where 0 indicated normal hearing and 8 indicated profound. Each ear was analyzed separately.
Forty-nine patients met the inclusion criteria, and each ear was evaluated separately. Median HL severity was 1.0 0.0, 4.3 at CNH compared to 3.0 1.8, 6 at OSF (p = 0.004). Forty-seven ears (48.0%) showed lower severity at CNH. Twenty-seven patients (55%) received hearing amplification devices. The median age at time of hearing intervention was 220 days.
Our results showed statistical significance in the median severity of HL between CNH and OSF. A substantial proportion (70%) of children in our dataset who received amplification via cochlear implant or hearing aids were shown to have discrepancies in ABR findings from CNH and OSF. These findings have implications with regards to the appropriate usage of health care resources and maintaining EDHI timelines.
4 (Retrospective Cohort Study) Laryngoscope, 133:3571-3574, 2023.
Systematic Review of Slide Tracheoplasty Outcomes Zalzal, Habib G.; Behzadpour, Hengameh K.; Leonard, James ...
Annals of otology, rhinology & laryngology,
05/2023, Volume:
132, Issue:
5
Journal Article
Peer reviewed
Objective:
To identify factors predicting success in slide tracheoplasty surgery at a regional children’s hospital and compare with available published literature.
Measures:
Retrospective chart ...review comparing demographics (age, weight) and clinical (operative and hospital course, need for additional airway intervention) factors experienced with slide tracheoplasty. Findings were compared with a systematic review of published literature.
Results:
Of the 16 tracheal stenosis patients in our cohort, 13 (81.3%) presented with an additional congenital or cardiovascular anomaly. When adjusted for cardiovascular anomalies, congenital tracheal stenosis patients had a mean age of 5.2 months (range 6 days-17 months), mean weight of 5.04 kg, and average ICU and hospital length of stay of 31.5 and 36.0 days, respectively. Tracheostomy was required for 4 patients and no early deaths were recorded. Of the 391 children in the grouped cohort, mean age and weight was older at 7.67 months and larger at 5.70 kg. Length of stay in both ICU and overall hospital course was 31.6 and 43.5 days, respectively. Mortality etiology for 44 patients was reported: 17 (38.6%) cardiac-related and 28 (63.6%) late mortalities. Our overall calculated mortality risk of 1.26 (P < .05) was lower than reported ratios of 2.0+.
Conclusion:
Despite the numerous institutional studies involving tracheal stenosis, mortality and surgical challenges remain high. Future studies with the inclusion of specific perioperative data can prove to further evaluate correlations between presentation characteristics and mortality.
Abstract
Study Objectives
Several birth cohorts have defined the pivotal role of early lower respiratory tract infections (LRTI) in the inception of pediatric respiratory conditions. However, the ...association between early LRTI and the development of obstructive sleep apnea (OSA) in children has not been established.
Methods
To investigate whether early LRTIs increase the risk of pediatric OSA, we analyzed clinical data in children followed during the first 5 years in the Boston Birth Cohort (n = 3114). Kaplan–Meier survival estimates and Cox proportional hazards models adjusted by pertinent covariates were used to evaluate the risk of OSA by the age of 5 years between children with LRTI during the first 2 years of life in comparison to those without LRTI during this period.
Results
Early life LRTI increased the risk of pediatric OSA independently of other pertinent covariates and risk factors (hazard ratio, 1.53; 95% CI, 1.15 to 2.05). Importantly, the association between LRTI and pediatric OSA was limited to LRTIs occurring during the first 2 years of life. Complementarily to this finding, we observed that children who had severe respiratory syncytial virus bronchiolitis during infancy had two times higher odds of OSA at 5 years in comparison with children without this exposure (odds ratio, 2.09; 95% CI, 1.12 to 3.88).
Conclusions
Children with severe LRTIs in early life have significantly increased risk of developing OSA during the first 5 years of life. Our results offer a new paradigm for investigating novel mechanisms and interventions targeting the early pathogenesis of OSA in the pediatric population.
Surgical bleeding is an unlikely, but potentially devastating, event during the surgical management of pediatric and adult laryngotracheal disorders. Therefore, an intimate knowledge of the anatomy ...of the large vessels coursing in the vicinity of the airway is imperative. Anatomic variants in the position of the inominate artery or the superior thyroid artery can place individuals with these variations at particular risk in these cases. Delayed bleeding from an inominate artery fistula is a particularly devastating complication from open airway surgery. A high index of suspicion is necessary to allow for early identification and aggressive treatment of this potential complication.
Thyroglossal Duct Cyst (TDC) is the most common congenital neck mass in children and is surgically managed with a Sistrunk procedure. Some surgeons perform a modified Sistrunk (mSis), involving the ...dissection of the fistula beyond the hyoid bone without coring out the foramen cecum at the base of the tongue. We aim to evaluate surgical outcomes of children undergoing Sistrunk (Sis) or modified Sistrunk (mSis) procedures for TDC at an academic pediatric institution.
We conducted a retrospective chart review of the Children's National Medical Center database from 2004 to 2014. Basic demographic information, preoperative characteristics, postoperative complications, and recurrence were extracted for children diagnosed with TDC. We estimated descriptive statistics using Kruskal-Wallis tests and Pearson's chi-square for continuous and categorical values.
157 patients that underwent TDC excision were identified. Sistrunk (Sis) was performed in 52 cases (33%) and modified Sistrunk (mSis) performed in 105 (67%) cases. 84 (54%) were female and the mean age at surgery was 5.4 years (SD=4.5). Overall recurrence was detected in 8 cases (5.1%) and did not differ significantly by procedure type 2 (4%) in Sis and 6 (6%) in mSis, p = 0.616. Post-operative complications did not differ significantly between Sis and mSis procedure: swelling 6 (12%) and 18 (17%), p = 0.481; seroma 5 (10%) and 10 (10%), p = 1.00; surgical site infection 3 (6%) and 8 (8%), p = 0.752; or post-excision incision and drainage 3 (6%) and 9 (9%), p = 0.752 (respectively).
Our findings reveal no statistical difference in recurrence rates between Sis and mSis with no risk factors for recurrence identified. Furthermore, there was no difference in post-operative complications between the groups. Both surgical procedures were associated with few complications and low recurrence.
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