Douglas Sidell

Standardized Outcome and Reporting Measures in Pediatric Head and Neck Lymphatic Malformations

Objective To develop general and site-specific treatment effect and outcome measures to standardize the reporting of head and neck lymphatic malformation (HNLM) treatments. Study Design Consensus statement/expert opinion. Setting Multiple tertiary academic institutions. Subjects and Methods The modified Delphi method is an iterative process of collecting expert opinions, refining opinions through discussion and feedback, statistically aggregating opinions, and using these aggregates to generate consensus opinion in the absence of other data. The modified Delphi method was used by a multi-institutional group of otolaryngology and interventional radiology experts in the field of vascular anomalies to formulate a list of recommended reporting outcomes for the study and treatment of head and neck lymphatic malformations. Results Through 3 rounds of iteration, 10 expert panelists refined 98 proposed outcome measures and 9 outcome categories to a final consensus set of 50 recommended outcome measures in 3 global categories (general, demographics, and treatment complications) and 5 site-specific categories (orbit, oral cavity, pharynx, larynx, and neck). Conclusions We propose the first consensus set of standardized reporting measures for clinical and treatment outcomes in studies of HNLMs. Consistent outcome measures across future studies will facilitate comparison of treatment options and allow systematic review. We hope that these guidelines facilitate the design and reporting of subsequent HNLM studies.

Diagnostic accuracy of ultrasonography for midline neck masses in children.

Objectives. To evaluate the diagnostic accuracy and to assess the utility of preoperative ultrasonography in the pediatric patient with a midline neck mass. Study Design. Diagnostic test study. Setting. Tertiary care university hospital. Subjects and Methods. An institutional review board (UCLA Office of the Human Research Protection Program)–approved retrospective review of pediatric patients undergoing excision of a midline neck mass between 1999 and 2010 at a tertiary care institution was performed. The preoperative imaging modality, imaging diagnosis, and pathologic results were evaluated. Results. Forty patients were included in this review. This study failed to demonstrate an association between preoperative ultrasound-based diagnoses and postoperative pathologic results (P > .99). Conclusion. Ultrasonography is commonly used in the workup of a midline neck mass in the pediatric population. Despite the utility of preoperative ultrasonography, the diagnostic accuracy of this imaging modality may have significant limitations.

Demographic influences on antibiotic prescribing for pediatric acute otitis media.

Objective. To understand the epidemiologic antibiotic treatment patterns and the potential impact of race and insurance status on the medical management of acute otitis media (AOM). Study Design. Cross-sectional analysis of a national database. Setting. National ambulatory care setting. Methods. Cases of isolated AOM in children ≤16.0 years were extracted from the National Ambulatory Medical Care Survey (2006-2008). The frequency and type of antibiotic prescribed were extracted. A multivariate logistic regression model incorporating age, sex, race, ethnicity, and insurance type was used to determine the influence of these demographic variables on antibiotic prescribing patterns. Results. A total of 15.8 ± 1.5 million cases of AOM were studied (mean age, 3.6 ± 0.3 years; 55.1% ± 2.9% male). Of the children, 15.0% ± 2.8% were Hispanic and 10.4% ± 3.1% were black. Medicaid/State Children’s Health Insurance Program and private insurance covered 30.6% ± 4.4% and 69.4% ± 4.4% of children, respectively. Overall, 83.1% ± 2.2% of children received an antibiotic prescription. The most commonly prescribed antibiotics were amoxicillin (6.5 ± 0.9 million), beta-lactamase inhibitors (2.6 ± 0.4 million), and third-generation cephalosporins (2.3 ± 0.4 million prescriptions). On multivariate analysis, insurance status, ethnicity, race, age, and sex did not influence the likelihood of an antibiotic being prescribed during the visit (P = .884, .909, .849, .102, and .931 respectively). Conclusions. Most children receiving medical treatment for AOM receive an antibiotic prescription during their visit. Ethnicity, race, and insurance type do not significantly influence antibiotic prescribing rates for AOM, and nearly all patients have medical insurance.

Obesity and the risk of chronic rhinosinusitis, allergic rhinitis, and acute otitis media in school-age children

To determine if obesity is a significant risk factor for acute otitis media (AOM), allergic rhinitis (AR), or chronic rhinosinusitis (CRS) in children and to understand the potential otolaryngological implications of childhood obesity.

High-Dose Sublesional Bevacizumab (Avastin) for Pediatric Recurrent Respiratory Papillomatosis

Objectives: We review and report the use of high-dose bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP) in pediatric patients. Methods: We included all patients with pediatric-onset RRP who underwent bevacizumab (25 mg/mL) injections by a single practitioner. A series of 5 consecutive subepithelial injections were administered at 4- to 6-week intervals with concomitant 532 nm KTP laser ablation. The lesions were staged according to the Derkay staging system. The outcomes included pretreatment and posttreatment Derkay scores, the time interval between procedures, and voice outcomes. The demographic data extracted included sex, age at diagnosis, and current age. Results: Nine patients were included in this study, with 1 patient lost to follow-up; their median age was 8 years (range, 3 to 21 years). The mean bevacizumab dose was 14.25 mg (range, 5 to 45 mg). There was a median Derkay score of 11.5 (range, 4 to 23) at the time of diagnosis and a median 58% improvement following therapy. All patients demonstrated an increased time interval between injections, for a median improvement of 2.05× (range, 1.6× to 3.25×). Conclusions: Evidence exists in support of vascular endothelial growth factor as an important factor in the development of RRP. Although some variability in response is demonstrated by this study, high-dose bevacizumab appears to yield promising results for pediatric patients with RRP.

Management and outcomes of laryngeal injuries in the pediatric population.

Objectives: Pediatric laryngeal trauma is an uncommon event. The purpose of this study was to identify outcomes following surgical procedures for pediatric laryngeal trauma, and to provide an in-depth review of the literature. Methods: The National Trauma Data Bank was utilized to identify pediatric laryngeal trauma incidents with admission years 2002 through 2006. Patient demographics, injury type, surgical procedures, hospital and intensive care unit durations, ventilator duration, and discharge disposition were abstracted. Results: There were 69 laryngeal trauma incidents identified, with a median patient age of 12.8 years and an overall mortality rate of 8.7%. Laryngeal injury was frequently blunt-force in nature (82.8%) and often occurred in conjunction with trauma to multiple organ systems (76.8%). Tracheotomy (16 procedures), laryngeal suturing (13 procedures), and laryngeal fracture repair (10 procedures) were the most frequent procedures identified. Laryngeal fracture repair was noted to increase the overall hospital duration (p = 0.040). The communication scores were affected only by tracheotomy (p = 0.013). Surgical intervention did not significantly affect the frequency of home discharge. Conclusions: Pediatric laryngeal trauma is an uncommon event that can be evaluated with the National Trauma Data Bank. Although patients who undergo laryngeal fracture repair appear to have an increased duration of hospitalization, patients who undergo tracheotomy or laryngeal suturing do not have increased durations of ventilator dependence, stay in an intensive care unit, or hospitalization.

Malignant Phosphaturic Mesenchymal Tumor of the Larynx

Phosphaturic mesenchymal tumors are rare neoplasms predominantly originating in the trunk and extremities. Malignant variants are exceedingly rare, and can present significant diagnostic challenges to the pathologist and otolaryngologist alike. This report describes the first case of malignant phosphaturic mesenchymal tumor involving the larynx, and emphasizes the importance of vigilance in both histopathologic and clinical actions so that appropriate treatment can be provided in a timely manner. The clinical presentation, radiologic and histologic features, and management are discussed.

Unsedated office-based tracheoesophageal puncture using a novel guidewire technique

Tracheoesophageal puncture (TEP) is an effective and preferred means by which alaryngeal patients can achieve post-laryngectomy speech. While TEP has traditionally been performed in the operating room (OR) with the patient under general anesthesia, the availability of the transnasal esophagoscope has allowed TEP to be performed as an unsedated, office-based procedure. Additional advantages include a reduction in surgery time and procedure-related cost, and improved collaboration between the otolaryngologist and the speech pathologist to achieve improved clinical outcomes. Despite its advantages, office-based TEP is occasionally difficult to perform due to variations in tracheoesophageal anatomy. The puncture is typically performed using a transnasal esophagoscope (TNE) to insufflate the esophagus and visualize the puncture site while a variety of instruments (needles, knife blades, and hemostats) are used to probe, puncture, and enlarge the TEP. Ideally, the esophagus at the puncture site can be continuously insufflated and the esophageal lumen will not collapse during the puncture. However, inadequate visualization of the puncture site causing difficulty with the use of knife blades or hemostats is occasionally encountered. In addition, these patients may still pose a challenge in the OR because of esophageal stenosis, trismus, or neck flexion. Therefore, we have sought ways to perform in-office TEP in these patients, and have adopted a wire-guided method. In this report, we perform an institutional review board–approved retrospective review of office-based wire-guided TEP and describe the technique.

Pediatric squamous cell carcinoma: Case report and literature review.

Describe a rare pediatric malignancy. Discuss the clinical, diagnostic, and therapeutic differences between squamous cell carcinoma (SCC) of the adult and pediatric population.

Adult Intralesional Cidofovir Therapy for Laryngeal Papilloma: A 10-Year Perspective

OBJECTIVE To assess the long-term efficacy of intralesional cidofovir therapy in a previously reported cohort of adult subjects with laryngeal papilloma. DESIGN Retrospective review. SETTING Tertiary care medical center. PATIENTS We previously reported on the favorable clinical response to intralesional cidofovir therapy in 13 adult subjects. The subjects were enrolled in an open-trial prospective study (1997-2001) and completed the injection-only treatment protocol, and all subjects achieved a disease remission after a mean of 6 injections. In the present study, we review the clinical course of these subjects during an extended observational period (2001-2006). INTERVENTION Patients with documented relapse of disease underwent additional intralesional cidofovir injections. MAIN OUTCOME MEASURES Additional interventions, disease severity, and adverse outcomes are reported. RESULTS Following the original cidofovir protocol, 6 patients (46%) received no further interventions. The remaining 7 patients (54%) required further treatment for disease relapse, with a mean duration of remission before relapse of 1.05 years. Of the 7 patients who experienced disease relapse, 2 continued to have stable disease with regular injections, 2 were lost to follow-up during relapse treatment, and 3 achieved disease remission again. For this latter cohort, the mean number of injections per year necessary to achieve a second remission was 3.82. This compares with a mean of 1.77 injections per year that these patients received on an as-needed basis prior to the original study. CONCLUSION Intralesional cidofovir injections have been shown to be an effective therapy for adult laryngeal papilloma and should be considered in those patients who experience disease relapse.