Anna K. Meyer

Propranolol in the Management of Airway Infantile Hemangiomas

OBJECTIVE To report our experience with propranolol in managing airway infantile hemangiomas. DESIGN Case series of 3 consecutive patients who had extensive, symptomatic airway infantile hemangiomas treated with propranolol. SETTING Tertiary academic medical center. PATIENTS Three infants with facial cutaneous hemangiomas who developed stridor that progressed to respiratory distress, which according to laryngoscopic examination results was confirmed to be caused by extensive subglottic hemangiomas. These patients underwent follow-up during their course of therapy, ranging from 3 weeks to 15 months. RESULTS Patient 1 failed to respond to systemic corticosteroids, laser ablation, and intravenous vincristine for her airway hemangioma and had to undergo tracheotomy. She was given propranolol after her tracheotomy and had a significant reduction in her subglottic airway obstruction. Patient 2 developed progressive stridor secondary to airway hemangioma at age 6 1/2 months following tapering of systemic corticosteroids prescribed for her periorbital hemangioma. Systemic corticosteroids were restarted with the addition of propranolol. The stridor improved within 24 hours, and she was able to be weaned off corticosteroids. Patient 3 was also treated with initial combined therapy of systemic corticosteroids and propranolol. He had a significant reduction in stridor within 24 hours and was weaned off corticosteroids. CONCLUSIONS Our 3 patients had severe respiratory symptoms related to their airway infantile hemangiomas. In the first patient, propranolol was used when other treatments were ineffective or associated with intolerable adverse effects. In the second and third patients, propranolol was part of a dual regimen that resulted in rapid resolution of airway symptoms and allowed for quicker weaning of corticosteroids.

Drug-Induced Sleep Endoscopy in Persistent Pediatric Sleep-Disordered Breathing After Adenotonsillectomy

OBJECTIVES To demonstrate the feasibility of drug-induced sleep endoscopy (DISE) in the pediatric population and to examine DISE results in children with persistent sleep-disordered breathing (SDB) after tonsillectomy and adenoidectomy (T&A). DESIGN Retrospective case series with medical chart review. SETTING Tertiary pediatric medical center. PATIENTS Thirteen pediatric subjects with persistent SDB after T&A are included in the study. INTERVENTION Drug-induced sleep endoscopy was per-formed on all patients with documentation of all sites of persistent airway obstruction. RESULTS Multilevel upper-airway obstruction was identified in the majority of patients, most commonly related to tongue base obstruction, adenoid regrowth, and/or inferior turbinate hypertrophy. There were no differences among the 4 subgroups. CONCLUSIONS Findings from DISE suggest that multiple factors contribute to airway obstruction in persistent SDB after T&A. Further research can address the extent to which directed surgical treatment can improve outcomes in these patients.

Airway hemangiomas in PHACE syndrome

To describe the clinical presentation and airway characteristics of infants with airway hemangiomas and concomitant PHACE syndrome and to determine the prevalence of airway hemangiomas in PHACE subjects at our institution.

Airway response to sirolimus therapy for the treatment of complex pediatric lymphatic malformations.

Head and neck lymphatic malformations can create airway management challenges requiring tracheotomy. Sirolimus, an inhibitor of mammalian target of rapamycin (mTOR), may inhibit growth of lymphatic malformations. We describe two patients born with large lymphatic malformations with improved airway symptoms following sirolimus therapy. Patient #1 underwent tracheotomy and multi-modal therapy including sirolimus with reduction in airway involvement but regrowth after discontinuation of sirolimus. Patient #2 also experienced a significant response to sirolimus allowing for extubation and discharge without tracheotomy. Early initiation of sirolimus therapy should be considered as a means to avoid tracheotomy in complex head and neck lymphatic malformations.

Comparison of imaging modalities in pediatric thyroglossal duct cysts

To determine and compare the accuracy of different imaging modalities including ultrasound (US), magnetic resonance imaging (MRI), and computed tomography (CT) in the diagnosis of thyroglossal duct cysts (TGDC) in children.

Auditory Late Effects of Chemotherapy

Sensorineural hearing loss is the primary ototoxicity of chemotherapy in pediatric CNS tumors. The majority of toxicity is secondary to the platinums, in particular cisplatin and to a lesser degree, carboplatin. Multiple risk factors have been investigated that contribute to this loss including age, cumulative dose, method of dosing, pretreatment hearing loss, renal function, cranial radiation, and individual sensitivity. A large number of chemoprotectant treatments have been studied, with varying results. In addition, recent attention has emphasized the need for early detection of hearing loss and new methodologies besides the standard audiometry that is currently being utilized. Children who are found to have speech range hearing loss will need early intervention by audiology and speech pathology in order to maximize their hearing and language development.

Sleep-disordered breathing in pediatric head and neck vascular malformations.

To determine the prevalence of sleep‐disordered breathing (SDB) symptoms among children with head and neck vascular malformations and to compare obstructive sleep apnea (OSA)‐18 scores between children with head and neck vascular malformations and children with non‐head and neck vascular malformations.

Conversion of traditional osseointegrated bone-anchored hearing aids to the Baha® Attract in four pediatric patients

Bone-anchored hearing aids are external devices attached to the skull via a titanium implant, and can be used for multiple types of hearing loss. Traditionally, osseointegrated implants have been coupled to the external processor with a percutaneous abutment, but more recently, a fully implanted, transcutaneous magnet-based system has become available. Skin reactions from the percutaneous portion are a common complication that can prevent use of the device during critical windows of language development and learning in children. We describe our experience replacing the Baha® abutment system with the Baha® Attract in four pediatric patients. Specific operative considerations for incision placement, and magnet and implant coverage are discussed. All patients maintained osseointegration, had excellent long-term wound healing without post-operative infection, and were able to wear their devices more consistently.

Eustachian tube duplication: A unique anomaly

Very few eustachian tube anomalies have been published in the literature and have consisted of descriptions of diverticula, hypoplasia/aplasia, fistula, or aberrant associated musculature. We present a girl with a novel anomaly consisting of a eustachian tube duplication that originates in the nasopharynx and exits posterior to a microtic and atretic ear. We review the literature on eustachian tube anomalies and also consider the derivation of this anomaly.

Health Disparities in Head and Neck Cancer

M IN IS E M IN A R S increased dramatically over the past several years, and many surgeons are eager to learn how and when to apply the technology. There are many logistical and technical hurdles to developing a TORS program. The learning curve for TORS is steep, but complications can be avoided with special attention to proper patient selection and technical strategies to optimize exposure and control. This miniseminar will review the experience of the authors in developing TORS programs and will include a discussion of sentinel cases that highlight specific techniques to avoid complications. The miniseminar will also include an analysis of the contemporary literature and will be presented in an open discussion format that incorporates didactic slides, videos and on-line access to helpful resources.