Jeffrey P. Simons

The role of topical antibiotic prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction.

Objectives/Hypothesis Patients undergoing contaminated head and neck surgery with flap reconstruction have wound infection rates of 20% to 25% with parenteral antibiotic prophylaxis. Studies suggest that perioperative antimicrobial mouthwash reduces oropharyngeal flora and may prevent wound infections. We hypothesized that the addition of topical antibiotics to a parenteral prophylactic regimen would reduce the incidence of wound infection in these high‐risk patients.

Injection Laryngoplasty for Type 1 Laryngeal Cleft in Children

Objective. To review the 2-year, single-institution experience with injection laryngoplasty for diagnosis and treatment of type 1 laryngeal clefts (LC-1). Study Design. Case series with chart review. Setting. Tertiary care academic children’s hospital. Subjects and Methods. Patients at our institution who underwent injection laryngoplasty for LC-1 from January 2008 to December 2009. Outcome measures included patient demographics, surgical and anesthetic technique, effect on swallowing, and complications. Preoperative and postoperative swallowing evaluations were compared, and quality and duration of effects were calculated. Results. Sixteen children, 9 male and 7 female, underwent injection laryngoplasty for LC-1. Mean gestational age was 36.4 weeks (SD, 4.0 weeks; range, 27-41 weeks). Six patients had a major congenital anomaly (37.5%). Mean age at injection was 11.8 months (SD, 8.9 months; range, 2.9-33.5 months). Nine patients (56%) demonstrated complete resolution of penetration and aspiration on postoperative modified barium swallow (MBS), 4 patients (25%) had some improvement, and 3 patients (19%) showed no change. There were no complications. Mean duration of symptom improvement was 3.3 months (SD, 3.0 months; range, 0-11 months). Five patients went on to have definitive surgical LC-1 repair. Conclusion. Injection laryngoplasty was found to have favorable results in this group of patients with LC-1. Most patients experienced complete resolution of aspiration on MBS, and no patients experienced complications. These findings support the further study of injection laryngoplasty for LC-1 as both a diagnostic and therapeutic technique. Longer follow-up intervals are necessary to elucidate the predictive value with regard to success of formal cleft repair.

Preoperative cytology with molecular analysis to help guide surgery for pediatric thyroid nodules.

OBJECTIVES To discuss the use of molecular mutation analysis in the surgical management of pediatric thyroid nodules. METHODS This study is a case series with retrospective chart review performed at a tertiary childrens hospital. Pediatric patients who presented to the Childrens Hospital of Pittsburgh of UPMC with a thyroid nodule and had subsequent fine needle aspiration with positive molecular mutation between November 2009 and February 2012 were identified and charts were reviewed. Patient demographics, presenting signs, lab results, pathologic findings, and surgical outcomes were collected. RESULTS 5 pediatric patients with positive molecular mutation studies on preoperative FNA were identified. FNA results were categorized as follows: suspicious for follicular neoplasm (n = 2), suspicious for malignant cells (n = 1), and positive for malignant cells (n = 2). The following molecular mutations were identified: BRAF (V600E) (n = 2), PAX8/PPARγ (n = 1), HRAS (n = 1), and RET/PTC (n = 1). A total thyroidectomy was performed on each patient. In all cases the final pathology was positive for malignancy (papillary thyroid carcinoma (PTC), n = 3; follicular variant of PTC, n = 2). Three of five patients had transient postsurgical hypocalcemia. There were no other postoperative complications. CONCLUSIONS This series provides evidence that preoperative FNA with reflex molecular testing in pediatric thyroid nodules can help guide surgical decision making, reduce the need for repeat surgeries, and diminish the risk of complications from a staged procedure.

Injection Medialization Laryngoplasty in Children

OBJECTIVE To review our experience with vocal fold injection medialization in children. DESIGN Retrospective case series. SETTING Tertiary care academic childrens hospital. PATIENTS All pediatric patients at our institution who underwent injection laryngoplasty for vocal fold medialization from 2003 to 2009. MAIN OUTCOME MEASURES Age, sex, indication for injection, injection material, surgical and anesthetic technique, outcomes including effect on voice and swallowing, and complications. RESULTS Thirteen patients underwent 27 injections. Mean patient age was 8.0 years (range, 1.3-18.0 years). The causes of glottic insufficiency included prolonged intubation (6 patients, 46%), patent ductus arteriosus ligation (2 patients, 15%), other cardiac surgery (2 patients, 15%), neck surgery or trauma (2 patients, 15%), and postviral status (1 patient, 8%). Eight patients had vocal fold paralysis or paresis; 3 had vocal fold atrophy; and 2 had vocal fold scarring. Indications for surgery included hoarseness (11 patients), aspiration (5 patients), and dysphagia without aspiration (1 patient). Materials injected included Gelfoam (n = 13), Radiesse Voice (n = 10), and Radiesse Voice Gel (n = 4). The average number of injections per patient was 2.1 (range, 1-9). Patients experienced improvement in symptoms (subjective or objective) after injection in 24 of 27 cases (89%); 15 of 16 injections in patients with hoarseness led to improvement (94%); and 11 of 13 injections in patients with dysphagia or aspiration led to improvement (85%). One patient experienced 2 days of inspiratory stridor postoperatively, which resolved spontaneously. There were no other complications. CONCLUSIONS This study supports injection laryngoplasty as a safe and effective intervention for children with glottic insufficiency. Further prospective studies are necessary to confirm these findings.

Cochlear implantation in a patient with bilateral temporal bone fractures

b w r emporal bone fractures through the otic capsule freuently cause sensorineural hearing loss. Patients with ilateral temporal bone fractures and profound bilateral ensorineural hearing loss may benefit from cochlear mplantation. We present the case of a 25-year-old male ith bilateral profound sensorineural hearing loss aused by bilateral temporal bone fractures and CT can evidence of bilateral pneumolabyrinth who chieved successful aural rehabilitation after a cochlear mplantation procedure.

Effect of Adenotonsillectomy on Central and Obstructive Sleep Apnea in Children with Down Syndrome.

Objectives To determine and quantify changes in both central and obstructive sleep apnea in patients with Down syndrome (DS) after adenotonsillectomy (AT). Study Design Case series with chart review. Setting Tertiary care children’s hospital. Subjects and Methods The records of all patients with DS who underwent AT for sleep-disordered breathing between November 2008 and December 2014 were examined. In total, 113 patients were identified, and 36 of these patients had pre- and postoperative polysomnograms (PSGs) that were analyzed for obstructive and central components. Wilcoxon signed-rank test, paired t test, and McNemar test were used to examine pre- and postoperative PSG differences. Logistic regression and multivariate analysis of variance of patient characteristics (between subjects) and PSG results (within subjects) were conducted. Results The mean (SD) patient age was 5.5 (4.0) years (range, 0.9-15 years); 50.0% were male. After AT, significant reductions were identified in both obstructive apnea-hypopnea index (AHI) (P < .001) and overall AHI (P < .001). Among the 15 patients with severe obstructive sleep apnea, 86.7% experienced a significant AHI reduction to moderate or mild disease (P < .001). In addition, of the 15 patients with central sleep apnea (central apnea index [CAI] >1), 66.7% had resolution of central sleep apnea postoperatively (P = .004). There was also a significant interaction identified between CAI reduction, preoperative CO2 retention, and adenoid size, F(2, 20) = 6.87, P = .05. Conclusion Children with DS who underwent AT demonstrated significant reductions in both obstructive and central apneic indices on PSG. A significant number of patients with central sleep apnea demonstrated resolution postoperatively. Additional analysis demonstrated a significant interaction between CO2 retention, adenoid size, and postoperative CAI reduction.

Comparison of Pediatric Voice Outcome Survey, Reflux Symptom Index, Reflux Finding Score, and Esophageal Biopsy Results

OBJECTIVE To examine correlations between the Pediatric Voice Outcome Survey (PVOS) score, the Reflux Symptom Index (RSI) score, the Reflux Finding Score (RFS), and esophageal biopsy findings in children undergoing upper aerodigestive tract endoscopy. DESIGN Retrospective review of pediatric voice quality-of-life and laryngopharyngeal reflux surveys. Blinded assessment of endoscopic laryngeal images. SETTING Tertiary care childrens hospital. PATIENTS The study included 36 children with the primary problem of dysphonia (n = 28) or cough (n = 8) who underwent endoscopy. INTERVENTIONS The PVOS and the RSI were administered to the patients parents before surgery. The patients underwent laryngotracheobronchoscopy and esophageal biopsy. Four raters independently assigned an RFS to the laryngeal photographs. MAIN OUTCOME MEASURES The assessment included (1) PVOS scores, RSI scores, and RFSs; (2) internal consistency of PVOS and RSI scores; (3) RFS intrarater and interrater reliability; and (4) correlations between PVOS score, RSI score, RFS, and esophageal biopsy findings. RESULTS The mean (SD) age of the patients was 7.5 (2.6) years; the mean (SD) PVOS score, 71.9 (21.4); and the mean (SD) RSI score, 16.2 (9.1). The PVOS and the RSI scores demonstrated good internal consistency (Cronbach alpha = 0.79 and 0.78, respectively). The RFS exhibited good intrarater reliability (r = 0.66-0.98) and moderate interrater reliability (r = 0.32-0.70). The PVOS and RSI instruments displayed significant correlation (r = -0.30; P = .04). There were no other significant correlations between RFSs, esophageal biopsy results, PVOS scores, or RSI scores (P > .05). CONCLUSIONS The RSI may be a useful parent-proxy instrument in addition to the PVOS for pediatric voice patients. The RFS is reliable in children, but its validity could not be demonstrated in this patient population.

Molecular Characterization of Sporadic Pediatric Thyroid Carcinoma with the DNA/RNA ThyroSeq v2 Next-Generation Sequencing Assay

The aim of this study was to test the hypothesis that our 60-gene DNA/RNA ThyroSeq v2 next-generation sequence (NGS) assay would identify additional genetic markers, including gene fusions in sporadic pediatric differentiated thyroid carcinomas (DTC) that had no known molecular alterations. Sporadic pediatric DTCs with informative molecular testing (n = 18) were studied. We previously tested 15 cases by our standard 7-gene (BRAF, NRAS, HRAS, KRAS, RET/PTC1, RET/PTC3, PAX8/PPARg) mutation panel. Three cases were not tested previously. The standard 7-gene panel identified molecular alterations in 9 of 15 tumors (60%). Cases analyzed by ThyroSeq v2 NGS included the six previously negative cases by the standard 7-gene panel and three cases not previously tested. The NGS assay revealed new gene fusions in four of six previously negative cases (67%). These gene fusions included ETV6/NTRK3 (n = 3) and TPR/NTRK1 (n = 1). A point mutation (BRAF-V600E) was detected in one of three untested cases. While standard testing could identify only molecular alterations in 60% of cases, with the addition of the ThyroSeq v2 NGS, this increased to 87% (n = 13/15). Some cases with chromosomal rearrangements, including ETV6/NTRK3, appear to be associated with an aggressive histopathologic phenotype, but had no documented history of radiation exposure. Additional work is needed to investigate if pediatric DTCs could benefit from a reclassification based on molecular subtypes, which may better reflect their underlying biologic potential. Our data support the use of broad gene panels for the molecular diagnostics of pediatric thyroid nodules to aid future classification, treatment, and clinical management recommendations.

Predictors of Foreign Body Aspiration in Children

Objectives To examine the sensitivity and specificity of history, physical examination, and radiologic studies as predictors of foreign body aspiration in children. Study Design Case series with chart review. Setting Tertiary care children’s hospital. Subjects and Methods Medical records were reviewed for 102 children who presented to our institution from 2006 to 2013 with suspected foreign body aspiration and who underwent endoscopy. Data included symptoms, physical examination, radiologic, and endoscopy findings. Descriptive statistics, sensitivity and specificity, and univariate and multivariable analyses were performed. Results A total of 102 patients were included (62% male). The mean age was 3.3 years (SD, 3.7). A foreign body was identified on endoscopy in 69 cases (68%). The most common presenting symptoms were cough (88%), choking/gagging (67%), and wheezing (57%). Decreased breath sounds and wheezing on examination were independently associated with increased odds of foreign body. The most common abnormal radiographic finding was air trapping (33%). The most frequent items retrieved were fragments of seeds and nuts (49%). There were no serious complications related to endoscopy. The sensitivity and specificity of any finding on history, physical examination, and imaging were 100% and 3%, 90% and 33%, 61% and 77%, respectively. Having a positive history, examination, and chest radiograph combined was 46% sensitive and 79% specific. Conclusions Patients with airway foreign bodies have varied presentations. The presence of any radiologic finding suggests that endoscopy should be performed, as a foreign body is probable. The absence of any history or physical examination finding was associated with a low likelihood of a foreign body.

Laryngomalacia and swallowing function in children.

1) To determine the prevalence of dysphagia in children with laryngomalacia, 2) To ascertain whether severity of laryngomalacia influences the presence of swallowing dysfunction, and 3) To examine whether patients with medical comorbidities and laryngomalacia have a higher prevalence of swallowing dysfunction.