Abby C. Meyer

Airway interventions in children with Pierre Robin Sequence.

Objective To describe the interventions required for successful airway management in children with Pierre Robin Sequence (PRS). Study Design Case series. Subjects and Methods The records of both a cleft and craniofacial clinic and a pediatric otolaryngology clinic were searched, and all children with PRS were identified. Data concerning feeding interventions, airway interventions, and comorbid conditions were extracted. Results Seventy-four cases of PRS were identified. Thirty eight of the 74 children required airway intervention other than prone positioning. Fourteen of these 38 were managed nonsurgically with nasopharyngeal airway and/or short-term endotracheal intubation, whereas the remaining 24 required surgical intervention. Eighteen of the 24 underwent distraction osteogenesis of the mandible, one underwent tracheostomy, and five underwent tracheostomy followed by eventual distraction. Conclusion In our series, over 50 percent of children with PRS required an airway intervention. These were both nonsurgical and surgical. As otolaryngologists, we must be prepared for the challenges children with PRS may present and the interventions that may be necessary to successfully manage these difficult airways.

Quality of Life in Youth With Severe to Profound Sensorineural Hearing Loss

IMPORTANCE Adolescence is a life stage with rapid and major developmental changes, yet little is known about how these changes influence the quality of life of young people who are deaf or hard of hearing (DHH). OBJECTIVE To determine differences in the 3 domains of a hearing-specific quality-of-life instrument between youth who had severe to profound sensorineural hearing loss based on whether they used no technology, hearing aids, or cochlear implants. DESIGN AND SETTING A multi-institutional prospective cohort study. PARTICIPANTS A convenience sample of 11- to 18-year-old youths with severe to profound sensorineural hearing loss recruited between January 1 and December 31, 2008. MAIN OUTCOME MEASURES Youth Quality of Life-Research Instrument and Youth Quality of Life Instrument-Deaf and Hard of Hearing (YQoL-DHH) scores. The YQoL-DHH was composed of 3 domains: participation, self-acceptance/advocacy, and stigma-related quality of life. RESULTS A total of 157 individuals participated. Overall mean (SD) age was 14.1 (2.3) years, and the female-male ratio was 82:75. Forty-nine individuals (31.2%) were not using any technology, 45 (28.7%) were using hearing aids, and 63 (40.1%) were using cochlear implants. Mean age of unilateral or first cochlear implant was 62.9 months. Thirty-eight individuals (24.2%) attended schools with DHH programs, 55 (35.0%) attended schools without DHH programs, and 58 (36.9%) attended schools for the deaf. Statistically significant differences were noted in YQoL-DHH participation and perceived stigma scores between the groups when stratified by technology used and school setting. CONCLUSIONS These data suggest that the domains of quality of life as measured by our instrument differ significantly among youth based on technology used and school setting. Youth using no technology or cochlear implants tended to score higher than those using hearing aids in mainstream schools with or without DHH programs and in schools for the deaf. The YQoL-DHH instrument is able to detect differences in quality of life within a group of youth with severe to profound hearing loss.

Symptom duration and CT findings in pediatric deep neck infection

Objective: To investigate whether children with less than 48 hours of localized symptoms of deep neck infection are less likely to have an abscess on CT scan. Study Design: Case series. Subjects and Methods: The charts of children seen in a tertiary childrens hospital for deep neck infections between 2000 and 2007 were reviewed. Results: Of 179 children identified, 167 (93.3%) underwent a CT scan of the neck of which 102 (61.1%) were positive for abscess. There was no significant difference in the rate of abscess on CT between children with less than 48 hours of localizing symptoms and 48 or more hours of symptoms at 58.1 percent and 58.3 percent, respectively (P = 0.98). Furthermore, there was no significant difference in age, gender, C-reactive protein levels, disease location, or length of stay between children with and without abscess on CT. White blood cell counts were significantly higher in the abscess group (P = 0.01); however, the median white blood cell count in both groups was above normal. Conclusion: Because duration of symptoms does not predict finding of abscess on CT, it is appropriate to obtain a CT scan upon presentation in all children with symptoms concerning for neck abscess.

Analysis of archived newborn dried blood spots (DBS) identifies congenital cytomegalovirus as a major cause of unexplained pediatric sensorineural hearing loss

PURPOSE Congenital cytomegalovirus (cCMV) infection is the most common non-genetic cause of sensorineural hearing loss (SNHL). However, accurate diagnosis of cCMV as the etiology of SNHL is problematic beyond the neonatal period. This study therefore examined whether cCMV infection could be identified retrospectively in children presenting with unexplained SNHL to a multidisciplinary diagnostic outpatient otolaryngology clinic at an academic medical center in Minnesota. METHODS Over a 4-year period, 57 patients with an age range of 3months to 10years with unexplained SNHL were recruited to participate in this study. Informed consent was obtained to test the archived dried blood spots (DBS) of these patients for cCMV infection by real-time PCR, targeting a highly conserved region of the CMV UL83 gene. Results were normalized to recovery of an NRAS gene control. Chart review was conducted to identify subjects who underwent genetic testing and/or neurodiagnostic imaging to investigate possible genetic, syndromic, or anatomical causes of SNHL. RESULTS In total, 15 of the 57 children with unexplained SNHL tested positive for CMV DNA in their DBS (26%). A mean viral load of 8.3×104 (±4.1×104) [range, 1×103-6×105] copies/μg DNA was observed in subjects retrospectively diagnosed with cCMV. No statistically significant correlation was found between viral load and SNHL severity. CONCLUSIONS A retrospective DBS analysis demonstrated that 26% of patients presenting with unexplained SNHL in childhood had cCMV. DBS testing is useful in the retrospective diagnosis of cCMV, and may provide definitive diagnostic information about the etiology of SNHL.

Tympanostomy Tube Placement in Children Using a Single-Pass Tool with Moderate Sedation:

Insertion of tympanostomy tubes is a common elective pediatric surgical procedure and is typically performed under general anesthesia. The potential to reduce general anesthetic requirements for young children has led to increased interest in alternatives for tympanostomy tube placement. A tympanostomy tube system, developed to enable tympanostomy tube placement in a single pass on conscious patients under moderate sedation, was evaluated. A prospective study on 128 children and 253 tympanostomy tube placements conducted at 4 centers in the United States demonstrated an 88.3% success rate in performing the procedure under moderate sedation with adverse events within normal rates reported in the literature. The feasibility of completing tympanostomy tube placement under moderate sedation enables avoidance of general anesthesia and provides additional choices to physicians and parents.

Single-Stage Tympanosotomy Tube Insertion: Design Issues on a New Surgical Approach:

Objectives: Multiple efforts are under way to develop methodologies to allow tympanostomy tube (TT) placement in young children under conscious sedation where there can be significant head motion. This practice modification would provide an option for TT placement without the risk of general anesthesia and the potential for procedures being performed in an office. Methods: Investigators evaluated a tool designed to perform a quick, single pass tube delivery across the tympanic membrane with a downward force of motion in a moving child under conscious sedation. Training required bench evaluation and the use of general anesthesia before performing conscious sedation cases. Results: A total of 176 TTs were performed in 89 children at 3 institutions. Ninety-one TTs in 46 children used general anesthesia, and 85 TTs in 43 children used conscious sedation. Conscious sedation included nitrous oxide in 35 children and midazolam plus nitrous oxide in 8 patients. All cases used phenol as a topical anesthetic. Twelve children were converted to general anesthesia for over-insertions, design challenges, anatomy, or movement. The major complication encountered was delivery of the TT into the middle ear space. Multiple tubes were used, but a beveled medial flange tube with a lateral visualization tab to provide depth feedback proved most effective for attenuating patient movement without TT over-insertion (64 children). Conclusions: Early results show that TT placement in children may be done safely under conscious sedation. Additional clinical experience is required to optimize the tool and the training to prevent complications of TT placement with a single-pass device.

A Human Hemangioma Culture System for Pharmaceutical Testing

OBJECTIVE: First national study of prevalence of ear and hearing disorders conducted in Latin America which follows the World Health Organization Ear and Hearing Disorder Survey protocol. 1) Provide regional governments, institutions, and professionals with local and accurate information on the prevalence of ear and hearing pathologies in the Ecuadorian population. 2) Contribute to the global burden of disease by generating standardized data that can be compared among countries and regions. METHOD: Prospective, multi-stage cluster sample design study, conducted over a 9-month period (March to Dec 2009). Population tested: all members of households selected according to the sample strategy (cluster sample design, 28 clusters by population proportional to size in Ecuador). Testing was carried out in hospital facilities across the country including: audiometry/TEAOEs, and otological examination. Outcome measures: the diagnostic criteria for disabling hearing impairment established by the WHO. Data was entered in EARFORM software for basic statistical analysis and then compared to results obtained from contingency tables. RESULTS: 5762 subjects tested. The prevalence of hearing impairment (HI) in the adult population (15 yrs and older) was 6.4% with a CI of 5.6% to 7.2%. In the 4 to 14 yrs, 11 months age group was 1.7% with a CI of 1.1% to 2.3%. Out of the total population tested, 14.52% are in need of action or services. The prevalence of different ear pathologies and the total prevalence of HI including those under the age of 4 will be further discussed in the full paper. CONCLUSION: The prevalence of HI correlates with the prevalence found in other studies using the same protocol and it is under the 10% estimated by the WHO. The Ecuadorian population is in need of a substantial improvement in hearing services delivery.

S256 – Microbiology of Pediatric Head and Neck Abscesses:

Objectives To report the microbiology of pediatric head and neck abscesses. Methods The records of a tertiary pediatric hospital were searched and all children with infections of the head and neck region between 2000 and 2007 were identified. Cases of peritonsillar abscess were excluded. Data regarding presentation, physical exam findings, radiographic findings, and treatment were extracted. All children who were diagnosed with abscesses and treated surgically were further identified, and the results of intraoperative cultures were reviewed. Results A total of 179 children with infections of the head and neck were treated between the years of 2000 and 2007 of which 57% (102 children) were diagnosed with abscesses. 71% (72 children) with abscesses were treated surgically. Of 62 children with drainable abscesses, culture data was available for 54 children. A single organism was isolated in 24.1% of cultures, 2 organisms in 18.5% of cultures and 3 organisms in 16.7% of cultures. More than 3 organisms were identified in 38.9% of cultures. The most commonly isolated organisms included alpha-hemolytic streptococci (57.4%), group A streptococci (37.0%), anaerobes (29.6%), hemophilus (22.2%), neisseria (22.2%), and “respiratory flora” (20.4%). Other streptococcal species (14.8%), candida (14.8%), staphylococci (11.1%), stomatococci (11.1%) and other organisms (7.4%) were also identified. One culture showed no growth. No cases of methicillin-resistant staphylococcus aureus (MRSA) were encountered. Conclusions In our series, streptococci and anaerobic bacteria were the most commonly isolated organisms, and almost 40% of cultures identified greater than 3 different organisms. No cases of MRSA were encountered.

S253 – Management of Pediatric Skull Base Abscesses

Objectives To describe the presentation and management of pediatric deep neck space infections located at the skull base. Methods Design: Retrospective review. Setting: Tertiary childrens hospital. The study population comprised pediatric patients admitted to the hospital for management of deep neck space infections between 2000 and 2007. Main Outcome Measure: Resolution of abscess. Results Over the study period, 179 patients were admitted for management of deep neck space infections. Of these, 10 (6%) were localized to the skull base by CT scan. 7 of the 10 met radiographic criteria for an abscess; the remaining 3 were designated edema or phlegmon. Patients ranged in age from 2 to 8 years old. The most common presenting symptoms were sore throat (60%), stiff or sore neck (50%), neck or facial swelling (20%), and drooling (20%). Otitis media and Streptococcal pharyngitis were the most common co-morbidities found in 40% of patients. Initial treatment consisted of IV antibiotics in all cases. 70% resolved with medical management alone. 3 patients failed to resolve following 48 hrs of IV antibiotics and were taken to the operating room for abscess drainage, which was unsuccessful in all cases. Repeat CT after an additional 48 hours of medical therapy indicated persistent abscess in 2 of the 3 operative cases. Repeat drainage was successful in only 1 of these. Conclusions Skull base abscesses in children can be effectively managed in most cases by IV antibiotics alone. Surgical drainage is difficult and often unsuccessful and therefore poses unnecessary risk to the patient.