Dary J. Costa

Adenotonsillectomy for obstructive sleep apnea in obese children: A meta-analysis

Objective: The purpose of this study was to determine the effectiveness of adenotonsillectomy (T&A) for treating obstructive sleep apnea (OSA) in obese children. Data Sources: PubMed and Ovid databases. Review Methods: A meta-analysis of studies that reported sleep parameters in obese children with OSA before and after T&A. Data were analyzed using the random effects model. Statistical significance was P ≤ 0.05. Results: Data from four studies that included 110 children were analyzed. The mean sample size was 27.5 (range, 18–33). The mean body mass index z score was 2.81. The mean pre- and postoperative apnea-hypopnea index (AHI) was 29.4 (range, 22.2–34.3) and 10.3 (range, 6.0–12.2), respectively. The weighted mean difference between pre- and postoperative AHI was a significant reduction of 18.3 events per hour (95% confidence interval [CI], 11.2–25.5). The mean pre- and postoperative oxygen saturation nadir was 78.4 percent (range, 73.9%-81.1%) and 85.7 percent (range, 83.6%-89.9%), respectively. The weighted mean difference was a significant increase of the oxygen saturation nadir of 6.3 percent (95% CI, 3.9–8.7). Forty-nine percent of children had a postoperative AHI <5, 25 percent of children had a postoperative AHI <2, and 12 percent of children had a postoperative AHI <1. Conclusions: T&A improves but does not resolve OSA in the majority of obese children. The efficacy and role of additional therapeutic options require more study. The high incidence of obesity in children makes this a public health priority.

Advances in Surgical Navigation

Surgical navigation technology provides real-time intraoperative localization of surgical instruments within the field. These systems are highly accurate, assist with preoperative planning, and improve surgeon confidence. The industry has recently responded to the growing trend of treatment in ambulatory surgical centers by offering surgical navigation devices that are more compact, less expensive and more user-friendly than conventional devices. Surgical navigation is indicated for complex sinonasal disease and may reduce the risk of complications. The indications for surgical navigation continue to expand as the technology improves and imaging data synthesis evolves to include multimodality fusion and real-time intraoperative data-set updates. Although now widely available, navigation systems are still considered state of the art, and not standard of care.

Scalp Rotation Flap for Reconstruction of Complex Soft Tissue Defects

Importance Scalp reconstructions may be required after tumor resection or trauma. The inherent anatomy of the scalp presents challenges and may limit reconstructive options. Objective To describe and investigate the scalp rotation flap as a reconstructive technique for complex soft tissue defects. Design Retrospective case series with a mean follow-up of 13 months. Setting Tertiary academic center. Participants A total of 22 patients with large scalp soft tissue defects undergoing scalp rotation flap reconstruction. Interventions The flap is designed adjacent to the defect and elevated in the subgaleal plane. The flap is rotated into the defect, and a split-thickness skin graft is placed over the donor site periosteum. Main Outcomes and Measure Data points collected included defect size, operative time, hospital stay, and patient satisfaction with cosmetic outcome. Results Mean patient age was 71 years. Mean American Society of Anesthesiologist classification was 2.8. Mean defect size was 41 cm(2) (range: 7.8-120 cm(2)), and 19 of 22 defects resulted from a neoplasm resection. Mean operative time was 181 minutes, and mean hospital stay was 2.4 days. There were no intraoperative complications. Three patients with previous radiation therapy had distal flap necrosis. Twenty-one patients (95%) reported an acceptable cosmetic result. Conclusions and Relevance The scalp rotation flap is an efficient and reliable option for reconstructing complex soft tissue defects. This can be particularly important in patients with significant medical comorbidities who cannot tolerate a lengthy operative procedure.

Otolaryngologic surgery in children with trisomy 18 and 13

OBJECTIVES Trisomy 18 and 13 are the most common autosomal trisomy disorders after Down syndrome. Given the high mortality rate (5-10% one-year survival), trisomy 18 and 13 were historically characterized as uniformly lethal and palliation was the predominant management approach. Management strategy has shifted with recognition that through medical and surgical intervention, children with trisomy 18 and 13 can achieve developmental milestones, live meaningful lives, and exhibit long-term survival. Otolaryngologic surgery in children with trisomy 18 and 13 has not been described. The objective of this article is to describe the role of the otolaryngologist in the management of children with trisomy 18 and 13. METHODS AND MATERIALS Retrospective cohort analysis of the surgery registry for the Support Organization for Trisomy 18, 13 and Related Disorders for otolaryngologic surgeries reported from 1988 through June 1, 2014. RESULTS In the database of approximately 1349 children, 1380 procedures were reported, 231 (17%) of which were otolaryngologic. The most common otolaryngologic procedures were tympanostomy tube placement (57/231, 25%), cleft lip repair (40/231, 17%), tracheostomy (38/231, 16.5%), tonsillectomy and/or adenoidectomy (37/231, 16%), and cleft palate repair (30/231, 13%). Of the ten most common procedures reported, four were otolaryngologic. CONCLUSIONS Seventeen percent of procedures performed in children with trisomy 18 and 13 were otolaryngologic, highlighting the significant role of the otolaryngologist in the treatment of these patients. Surgical intervention may be considered as part of a balanced approach to patient care.

Butterfly cartilage tympanoplasty outcomes: A single-institution experience and literature review

PURPOSE In 1998, Dr. Eavey described the trans-canal inlay butterfly cartilage tympanoplasty technique, also known as cartilage button tympanoplasty. Many retrospective studies have since demonstrated its efficacy and decreased operative time when compared to underlay and overlay tympanoplasty techniques. The butterfly cartilage tympanoplasty approach uses only a cartilage graft to repair tympanic membrane perforations. The aim of this study was to review the literature for studies that examined butterfly cartilage tympanoplasty success rates and outcomes and compare them to outcomes from our cohort. MATERIALS AND METHODS Butterfly cartilage tympanoplasties were performed in 23 pediatric patients and 7 adult patients. We evaluated the tympanic membrane perforation closure rate and hearing results measured by closure of the air-bone gap. RESULTS The reviewed studies evaluating butterfly cartilage tympanoplasties demonstrated perforation closure rates between 71%-100%. The hearing outcomes in the reviewed literature varied, although the majority reported improved hearing. In our cohort, 21 of the 32 repaired tympanic membrane perforations demonstrated complete perforation closure. The mean follow-up length was 13.4 months. The mean air-bone gap decreased from 13.4 dB to 6.9 dB. CONCLUSIONS The butterfly cartilage/cartilage button technique is effective in closing tympanic membrane perforations and decreasing the air-bone gap in both adults and children.

A Congenital Nasal Mass Causing Respiratory Distress

A 12-day-old boy presented to the outpatient clinic with respiratory distress. He was born at 37 weeks gestation via cesarean delivery and developed noisy breathing and nasal congestion shortly after birth. Otolaryngological consultation, including fiberoptic nasopharyngolaryngoscopy, was performed, and revealed a right septal deviation. The infant was treated with topical neosynephrine and fluticasone spray and discharged home. On the eighth day of life, the patient returned with noisy breathing, retractions, and poor feeding. Flexible nasopharyngolaryngoscopy revealed a large left inferior turbinate and right septal deviation. On the 12th day of life, he presented with worsening symptoms. Physical examination revealed significant distress, retractions, and cyanosis relieved by crying. A mucosalized mass filling the left nasal cavity was visualized on anterior rhinoscopy, requiring nasal stenting to relieve obstruction. A maxillofacial computed tomographic (CT) scan demonstrated a 2.0 × 1.6-cm mass in the left mid-nasal cavity, compressing the middle turbinate and lamina papyracea (Figure, A). The cribriform plate was slightly widened prompting magnetic resonance imaging (MRI), which confirmed a 2-cm heterogeneous mass, isointense on T2 with small hyperintense areas, without intracranial extension (Figure, B). The patient underwent urgent transnasal endoscopic excision of the mass under general anesthesia. The mass was smooth, epithelialized, and pedunculated at the anterior aspect of the face of the left sphenoid sinus and medial to the middle turbinate (Figure, C). Transnasal delivery was performed with a deep margin achieved by resecting the periosteum of the sphenoid (Figure, D). Histologic examination revealed a lesion characterized by regions of cartilage admixed with irregular areas of chondromyxoid stroma containing spindle cells. Noncontrast axial CT scan A Noncontrast fat-suppressed T2-weighted MRI B Preoperative nasal endoscopy of the mass C Postoperative visualization of the wound bed D

External Auditory Canal Foreign Body Extraction Outcomes

Objectives: To compare pediatric external auditory canal (EAC) foreign body extraction outcomes by clinical setting and identify factors predictive of successful removal. Methods: Retrospective review of pediatric patients with EAC foreign bodies to a single institution emergency department (ED) and otolaryngology clinic (OTO) between January 2010 and April 2015. Patient characteristics, foreign body type, removal attempts, instrumentation utilized, and complications were evaluated with respect to clinical setting and patient outcome. Results: In all, 1197 patients with EAC foreign bodies were identified, 759 (63%) of whom presented primarily to the ED. Successful removal was achieved in OTO in 92.9% of cases and the ED in 67.9% of cases. Beads and spherical objects had the overall lowest rates of successful removal. Likelihood of removal decreased significantly after one unsuccessful attempt. Complications were reported in 35.7% of patients undergoing removal in the ED and 5.0% of patients undergoing removal in the otolaryngology clinic. Conclusions: Patients commonly present to the ED for removal of EAC foreign bodies. Referral to an otolaryngologist is recommended if the object is spherical or after one unsuccessful attempt at removal.

Tonsillectomy for Obstructive Sleep Apnea in Obese Children

Objective To determine the effectiveness of adenotonsillectomy (T&A) for treating obstructive sleep apnea (OSA) in obese children. Methods Meta-analysis of studies that reported sleep parameters in obese children with OSA before and after T&A. Data was analyzed using the random effects model. Statistical significance was P less than 0.05. Results Data from four studies that included 110 children were analyzed. Mean sample size was 27.5 (range: 18 - 33). Mean body mass index (BMI) z-score was 2.81. The mean pre-and postoperative apnea-hypopnea index (AHI) was 29.0 (range 22.2 - 34.3) and 9.9 (range 6.0 - 12.2) respectively. The weighted mean difference between pre- and postoperative AHI was a significant reduction of 18.3 events per hour (95% CI 11.2–25.5). The mean pre- and postoperative oxygen saturation nadir was 78.9% (range 73.9 -81.1%) and 85.7% (83.6 -89.9%) respectively. The weighted mean difference was a significant increase in the oxygen saturation nadir of 6.3% (95% CI 3.9 to 8.7). Approximately 43% of children had a postoperative AHI less than 5, 21% of children had a postoperative AHI less than 2, and 11% of children had a postoperative AHI less than 1. Conclusions T&A improves but does not resolve OSA in the majority of obese children. Up to 89% of obese children have persistent OSA after T&A. The efficacy and role of additional therapeutic options requires more study. The high incidence of obesity in children makes this a public health priority.