Jason Mouzakes

Endoscopic Posterior Cricoid Split and Rib Grafting in 10 Children

Objective: To report our experience with endoscopic posterior cricoid split and rib graft insertion (EPCS/RG) in children with posterior glottic (PGS) and subglottic stenosis (SGS). Design: Retrospective analysis of case series, with 1 to 2 year follow‐up. Setting: Tertiary‐care pediatric referral center. Patients: Ten consecutive patients undergoing EPCS/RG. Intervention: EPCS/RG is a new procedure that expands the posterior glottic opening by dividing the posterior cricoid lamina endoscopically with a laser and inserting a rib cartilage graft through the laryngoscope. Main Outcome Measures: Laryngeal function and hospital stay. Results: Successful decannulation in two of two patients with PGS and one of five patients with PGS and SGS without further surgery. Of the four not initially decannulated, two were decannulated with adjunctive procedures, and the other two can now tolerate tracheostomy capping for extended periods of time. We achieved improvement in exercise tolerance in three nontracheotomy‐dependent patients. For those with established tracheotomies, median hospital stay was 3 days and intensive care unit care was unnecessary. There were no major complications or deterioration of voice or feeding. Conclusions: EPCS/RG appears to be safe and effective in the management of PGS in selected pediatric patients. This minimally invasive procedure has advantages over traditional open approaches and destructive endoscopic techniques (cordotomy and arytenoidectomy). The role of EPCS/RG alone in the face of severe grades of SGS appears to be limited.

Tonsillectomy Does Not Improve Bedwetting: Results of a Prospective Controlled Trial

PURPOSE Sleep disordered breathing caused by tonsillar hypertrophy has been implicated as a cause of primary and secondary nocturnal enuresis in children. We prospectively studied the preoperative and postoperative rates of nocturnal and daytime incontinence in a group of children with tonsillar hypertrophy undergoing tonsillectomy compared to a matched control group undergoing surgery unrelated to the airway or urinary tract. MATERIALS AND METHODS A total of 326 toilet trained children 3 to 15 years old were included, with 257 in the tonsillectomy group and 69 in the control group. Severity of tonsillar hypertrophy was graded preoperatively on a scale of 1 to 4. A voiding questionnaire regarding number of bedwetting and daytime incontinence episodes per week, voids per day, bowel movements per week, secondary or primary enuresis and family history was completed by parents preoperatively, and at 3 and 6 months postoperatively. RESULTS Preoperatively the respective rates of nocturnal enuresis and daytime incontinence were 33% and 17% in the tonsillectomy group (p=0.89), and 35% and 14% in the control group (p=0.3). The respective cure rates for bedwetting at 3 and 6 months postoperatively were 40% and 50% in the tonsillectomy group (p=0.60), and 35% and 48% in the control group (p=0.61). Similarly no difference was seen in improvement or cure of daytime incontinence at 3 and 6 months postoperatively. CONCLUSIONS We found no association between tonsillar hypertrophy and urinary incontinence before or after tonsillectomy.

Impact of 13-valent pneumococcal conjugate vaccine on otitis media bacteriology☆

OBJECTIVES To determine the microbiology of otitis media (OM) since the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in February 2010. METHODS Middle ear effusion from a pediatric Otolaryngology population undergoing pressure equalization tube (PET) placement was obtained and sent for aerobic culture and antibiotic susceptibility testing between August 2012 and April 2013. Vaccination records were obtained and statistical analysis was completed. RESULTS During the 8-month period, 236 ears were evaluated, and of those 39 ears were found to have positive cultures. The single nonvaccine Streptococcus pneumoniae (serotype 16) isolate was obtained from a PCV7-only vaccinated patient and was penicillin susceptible. The three most common isolates were Staphylococcus coagulase negative (57%), Haemophilus influenzae (17%), and Moraxella catarrhalis (7%). CONCLUSIONS This study is the first to assess the bacteriology of OM in a pediatric population undergoing PET placement in the immediate post-PCV13 era. Our study is limited by sample size; however, the lack of S. pneumoniae cultures indicates that PCV13 has had a significant impact on pneumococcal infections during these initial years following licensure.

Tympanostomy tube placement in awake, unrestrained pediatric patients: A prospective, multicenter study

OBJECTIVES Tympanostomy tube (tube) placement is the most common pediatric otolaryngologic surgery in the United States. Most surgeries are performed in an operating-room setting under general anesthesia due to the lack of tolerable and reliable local anesthesia methods suitable for pediatric patients, and concerns regarding myringotomy procedures in a mobile child. This study evaluated the safety and efficacy of an iontophoresis system (IPS) to achieve local anesthesia in combination with a tube delivery system (TDS) for tube placement in pediatric patients in an office setting. METHODS A prospective, single-arm study was conducted at 9 otolaryngology sites in the United States. Participants included pediatric patients aged 6 months to less than 22 years requiring tube placement. Patients were prepared for the procedure using behavioral support techniques and tube placement was attempted under local anesthesia using the IPS in conjunction with the TDS. No physical restraints were allowed and no anxiolytics, analgesics, or sedatives were permitted. Safety was assessed through the occurrence of adverse events and success rates for tube placement under local anesthesia were determined. Tolerability of the procedure was evaluated using the 5-point Wong-Baker FACES Pain Rating Scale and parental satisfaction was assessed using a postoperative survey. RESULTS Seventy patients (127 ears) were enrolled in the study [mean (SD) age=7.0 (3.9) years]. No serious adverse events occurred in the 70 enrolled patients. Tube placement using the TDS was successful in 96.6% (114/118) of attempted ears. A single TDS was required in 105 ears, while more than 1 device was required in 9 ears. Of the 70 patients enrolled in study, 63 (90.0%) successfully received tubes in all indicated ears during their in-office visit. The mean (SD) change in pain score from pre-anesthesia to post-surgery was +0.9 (1.8). Favorable ratings for overall satisfaction with the in-office procedure were obtained from 96.9% (63/65) of respondents. Tube retention at 2 weeks was 99.1%. As only 15 patients were enrolled who were 3 years old or younger, the ability to generalize these results to younger patients is limited. CONCLUSIONS In this study, use of the IPS and TDS technologies enabled safe, reliable, and tolerable placement of tubes in awake, unrestrained pediatric patients.

Therapeutic use of the HPV vaccine in Recurrent Respiratory Papillomatosis: A case report

Recurrent Respiratory Papillomatosis (RRP) is a condition characterized by recurring squamous papillomas in the aerodigestive tract due to Human Papilloma Virus (HPV) infection. Treatment includes surgical debridement of the lesions often with adjuvant therapy. A newer adjuvant agent being tested is the HPV vaccine. The case report includes a child with RRP who underwent 10 surgeries in a year with an average inter-surgical interval (ISI) of 46 days. The patient then received the scheduled regimen of 3 doses of 9 valent HPV vaccine. Since beginning the vaccination, her average ISI increased to 113 days and as of writing of this paper only 1 surgery in the last 340 days. It is theorized that the increase in humoral response to the virus can slow the course of the disease, lengthen the ISI, and decrease morbidity. The results of this case report lends evidence to the use of the HPV vaccine as a therapeutic adjuvant therapy for RRP.

High-density FPGAs for real-time video processing

The use of an off-the-shelf general purpose processing system supplied by Giga Operations as applied to real-time video applications is described. The system is modular enough to be used in many scientific and industrial applications and powerful enough to maintain the throughput required for real-time video processing. This hardware and the associated programming environment has enabled InterScience to pursue research in real-time data compression, real-time Electronic Speckle Pattern Interferometry (ESPI) image processing, and industrial quality control and manufacturing. The system is based on Xilinx 4000 series field programmable gate arrays with associated static and dynamic random access memory in an architecture optimized for video processing on either the VL-Bus or PCI. This paper will focus on the design and development of a real-time frame subtractor for ESPI using this technology. Examples of the improvement in research capability provided by real-time frame subtraction are shown, including images from biomedical experiments. Further applications, based on this system are described. These include real-time data compression, quality control for production lines as part of an automated inspection system and a multi-camera security system allowing motion estimation to automatically prioritize camera selection.

Epidemiology of OM Pathogens of Those Undergoing Tympanostomy Tube Placement in the Era of PCV13

Objectives: Determine the microbiology of otitis media (OM) since the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in March 2010. Methods: The population included pediatric patients undergoing tympanostomy tube placement between August 2012 and June 2013. Middle ear effusion was sent for aerobic culture and antibiotic susceptibility testing. Statistical analysis will be performed to compare those who received PCV13 and those who only received the PCV7 vaccine. Preliminary data from August 2012 to December 2012 included 72 ears, of which 21 had fluid. Seven of these 21 ears cultured Staphylococcus aureus, Haemophilus influenza, and Pseudomonas aeruginosa. Three patients with positive cultures of Staphylococcus or Haemophilus were vaccinated with at least one dose of PCV13, and 2 patients that cultured Staphylococcus or Pseudomonas had the PCV7 vaccine. All of the cultures were susceptible to a quinolone. Results: Two cultures of Staphylococcus and Haemophilus were resistant to Bactrim. The impact of PCV13 on the molecular epidemiology of OM will be profound, as two of the most common pneumococcal isolates from nasopharyngeal secretions in the post-PCV7 era, serotypes 19A and 6A, are included in PCV13. This study is the first to assess the OM microbiology in a pediatric population vaccinated with PCV13. Our study is currently limited by sample size; however, this has increased, as colonization is higher in fall and winter. Conclusions: This initial lack of Streptococcus cultures indicates that PCV13 is likely to have a significant impact on antibiotic resistance and rate of pneumococcal disease during the initial years following licensure.