Larry D. Hartzell

Timing of tympanoplasty in children with chronic otitis media with effusion.

Purpose of reviewChildren with chronic otitis media with effusion resulting in repeat ventilation tube placement are at increased risk for perforation, an atelectatic ear, cholesteatoma, and hearing loss. The timing of intervention is controversial, and management strategies are variable. This update reviews the recent literature with a focus on groups at greater risk for requiring tympanoplasty, such as patients with craniofacial abnormalities including cleft palate and Down syndrome. Recent findingsPatient age continues to show a debatable relationship to tympanoplasty success. The use of cartilage grafts shows equivalent results compared with traditional techniques. Cartilage provides a more robust scaffold, which can improve outcomes in difficult ears. Patients with cleft palate or Down syndrome have a significantly increased risk of Eustachian tube dysfunction and commonly require tympanoplasty, which necessitates careful consideration of timing and technique. SummaryThe timing of tympanoplasty is still under debate, with little concrete evidence to indicate absolute guidelines. Attention to patient age, craniofacial abnormalities, and graft choice will help to improve surgical success.

Current Management of Infantile Hemangiomas and Their Common Associated Conditions

This article reviews the most current practice guidelines in the diagnosis and treatment of infantile hemangiomas. Several systemic conditions that can be associated with hemangiomas, such as PHACES syndrome, are also discussed. Propranolol has become an effective first-line treatment, and protocols for its use as well as its potential risks are outlined.

Tongue base suspension in children with cerebral palsy and obstructive sleep apnea.

OBJECTIVE Children with cerebral palsy (CP) are commonly affected by obstructive sleep apnea (OSA). This study examines the efficacy of combined surgical techniques for OSA including tongue base suspension (TBS), using perioperative polysomnograms (PSG) in pediatric patients with CP. STUDY DESIGN Case series with outcome analysis. SETTING University based tertiary care childrens hospital. METHODS A 7-year retrospective chart review of children with CP who underwent surgical management for OSA. Surgical procedures, postoperative complications, and perioperative PSG data were examined. Only patients with both preoperative and postoperative PSG results were included in the study. Based upon procedures performed patients fell into 2 equal groups for analysis. RESULTS Fourteen children were identified. Seven patients (mean age = 6.0 years) underwent combined adenotonsillectomy (T&A), uvulopalatopharyngoplasty (UPPP), and tongue base suspension (TBS). Another 7 patients (mean age = 6.3 years) underwent T&A and UPPP alone. Those who received TBS had a mean preoperative AHI of 27.2 compared to 6.8 in the group that did not have TBS. The AHI decreased by a mean of 16.5 in the TBS group and 5.0 in the non-TBS group. The mean oxygen saturation nadir improved in both the TBS (74.0-84.0) and non-TBS (64.8-84.6) groups. The arousal index also improved in the TBS (33.1-20.7) and non-TBS (11.0-5.8) groups. No surgical complications occurred. CONCLUSION This study suggests that concomitant surgical approaches for OSA in children with CP are effective. Moderate to severe OSA in this population may safely benefit from the added technique of tongue base suspension.

Accuracy and Safety of Tracheoscopy for Infants in a Tertiary Care Clinic

OBJECTIVE To assess the diagnostic accuracy and safety of office-based tracheoscopy when combined with flexible fiberoptic laryngoscopy (FFLT). Flexible laryngoscopy on infants is routinely performed by otolaryngologists in the clinic. The addition of tracheoscopy may improve overall airway assessment but is rarely performed due to the suspected risk of airway compromise. DESIGN A 6-year retrospective medical record review. SETTING Tertiary care hospital. PATIENTS Thirty-one infants younger than 1 year with complete data from preoperative FFLT and microlaryngoscopy and bronchoscopy (MLB) were examined. MAIN OUTCOME MEASURES Results from 241 MLB procedures were reviewed. RESULTS Laryngomalacia (LM) and tracheomalacia (TM) were identified more often by FFLT than by MLB. In particular, the detection rate for LM and TM by MLB, as seen preoperatively by FFLT, was 79% and 61%, respectively. Compared with FFLT, MLB accurately diagnosed the severity of LM and TM only 55% and 65%, respectively, of the time. Fiberoptic laryngoscopy revealed synchronous airway lesions in 62% of infants with LM, while MLB discovered synchronous airway lesions in 54%. Static airway lesions were more frequently diagnosed with MLB. No respiratory events occurred during FFLT. CONCLUSIONS In an appropriate patient, FFLT is a safe and effective diagnostic tool for common infant tracheal and laryngeal abnormalities. Detection and characterization of dynamic airway lesions is better achieved by FFLT than by MLB.

Free Tissue Reconstruction Following Excision of Head and Neck Arteriovenous Malformations

OBJECTIVE To evaluate free tissue transfer (FTT) as a safe and effective reconstructive technique to treat arteriovenous malformations. Vascular lesions that present a significant clinical challenge to the head and neck reconstructive surgeon are often difficult to treat and can leave large, complex defects. METHODS Retrospective, single-institution case series. RESULTS We describe 8 patients treated for extensive lesions in various parts of the head and neck reconstructed with free flaps. These malformations have a tendency to recur, which was the case in 75% of our patients (6 of 8) during a mean follow-up period of 5 years. Revision procedures are expected at a mean rate of 6.75 per person in our series. CONCLUSIONS Arteriovenous malformations are uncommon and challenging lesions. Use of FTT can ameliorate the large defects resulting from excision of these lesions.

Enhanced Tracheostomy Wound Healing Using Maltodextrin and Silver Alginate Compounds in Pediatrics: A Pilot Study

BACKGROUND: Tracheostomy wounds are commonly encountered in children but rarely reported. Relatively few treatments are available or have been investigated to manage this problem. Healing times for pediatric tracheostomy wounds are often unpredictable and protracted. Recent use of maltodextrin gel (MD) and a silver alginate sponge (AG) at our institution has demonstrated expedited healing and interest in this novel treatment for tracheostomy wounds. METHODS: We conducted an 11-month retrospective review of children with wound complications following tracheostomy placement at a tertiary care facility. Wounds were evaluated and rated based upon the National Pressure Ulcer Advisory Panel staging system. Subjects identified with stage 2 or greater tracheostomy-related ulcers treated with MD and/or AG were included. Subject characteristics and wound healing rates were tabulated in a database that included age, wound site, initial and final wound stage, type of treatment, length of treatment, and complications. Tracheostomy wounds treated as an out-patient were excluded from the study. RESULTS: Eighteen subjects, which included both in-patients and out-patients, were treated with AG and/or MD during the study period for tracheostomy-related wounds. Of the 26 subjects with tracheostomies performed during the study period, 10 (38.5%) were treated for postoperative wounds. A total of 11 subjects completed their in-patient wound treatment and were thus included in the study. Average subject age was 5.3 y (range 0.25–15.6 y). Wound locations were as follows: infrastomal region (n = 8), stoma (n = 2), and lateral neck (n = 1). Six subjects had stage 2 wounds, 4 had stage 3 wounds, and 1 had a stage 4 ulcer. All wounds achieved complete epithelialization following treatment with MD and/or AG. The average length of treatment was 12.8 d (range 6–28 d). No adverse effects were identified. CONCLUSIONS: Postoperative tracheostomy wounds are common. The use of MD and AG provides an effective and safe treatment for tracheostomy-related ulcers.

Prospective quality of life assessment in congenital laryngomalacia

PURPOSE OF STUDY Disturbances in breathing or feeding may profoundly affect parental perceptions of a newborns health. Previous research into quality of life for patients with laryngomalacia is limited to retrospective analysis. The purpose of this study is to prospectively evaluate the quality of life of families of infants with laryngomalacia and the impact of surgical and non-surgical treatments. DESIGN AND METHOD Pilot prospective analysis using the laryngomalacia quality of life (QOL) survey in families of infants with newly diagnosed laryngomalacia under age one year. A 29-question survey regarding severity of symptoms related to overall health, airway, and swallowing is completed at initial and post-treatment visits. Responses are quantified over a range from 1 to 5 (1 never to 5 always). RESULTS Twenty-six families were enrolled in the study. Eleven patients were managed medically and fifteen underwent supraglottoplasty. The overall mean QOL score for patients treated medically was 2.57 (standard error, SE 0.16) on initial visit and 1.67 (SE 0.16) post-treatment (mean 3.9 months). Patients undergoing supraglottoplasty had an overall mean QOL score of 3.59 (SE 0.14) on initial visit and 2.22 (SE 0.22) post-treatment (mean 3.5 months). Analysis of variance (ANOVA) and post hoc testing revealed significant improvement between initial and follow-up visits in both treatment groups (p < 0.01). Patients who underwent supraglottoplasty had significantly higher scores at initial visit (p < 0.01). No statistically significant difference was noted between patient groups post-treatment (p > 0.05). CONCLUSIONS Prospective QOL assessment of children with laryngomalacia and their families reveals a significant burden of disease. Quality of life improves in all patients but may improve more significantly in patients managed surgically.

Cartilage tympanoplasty in children with cleft palate repair.

Objective To determine outcomes of type 1 cartilage tympanoplasty in a cohort of pediatric patients with a history of cleft palate repair. Patients and Outcome Measures Retrospective chart review and comparison with a historical control group of patients with no cleft palate anomaly undergoing the same procedure by the same surgeon at a tertiary care pediatric hospital. A total of 37 patients between ages 4 and 19 years inclusive (45 ears), with a history of repaired cleft palate, underwent type 1 cartilage tympanoplasty with or without primary tube insertion from September 2004 to October 2012. Demographics, type of cleft palate, surgical indication, middle ear status, complications, history of myringotomy tube insertion, and auditory outcomes were collected. Results were compared with those for a non–cleft palate cohort that had undergone the same procedure, which had been previously published. Results The unadjusted average preoperative and postoperative pure-tone averages for patients with a history of cleft palate were 22.06 and 7.29, respectively, compared with 18.34 and 8.32, respectively, for non-cleft patients. Despite significantly worse preoperative hearing levels among the cleft palate group, there was no statistically significant difference in outcomes with regard to hearing results between the two groups. One patient in the cleft palate group required revision type 1 cartilage tympanoplasty for graft failure, which is comparable to that reported for non–cleft palate patients. Post–tympanoplasty secondary tympanostomy intubation was slightly higher for the cleft palate population. Conclusion Type 1 cartilage tympanoplasty, when performed in a pediatric population with a history of cleft palate, can achieve closure and hearing results that are comparable of those in patients with no such anomaly.

Diagnosis and Management of Patients with Clefts: A Comprehensive and Interdisciplinary Approach

This article reviews the most current practice guidelines in the diagnosis and management of patients born with cleft lip and/or palate. Such patients frequently have multiple medical and social issues that benefit greatly from a team approach. Common challenges include feeding difficulty, nutritional deficiency, speech disorders, hearing problems, ear disease, dental anomalies, and both social and developmental delays, among others. Interdisciplinary evaluation and collaboration throughout a patients development are essential.

Combined Tongue-Palate Fusion With Alveolar Bands in a Patient With Pierre Robin Sequence and Van der Woude Syndrome

This report describes the presentation of a newborn male with circumferential tongue-palate fusion associated with cleft palate and alveolar bands. After intraoral adhesions lysis, the patient was diagnosed with Pierre Robin sequence. A family history of cleft lip and palate was noted, and interferon regulatory factor 6 (IRF6) sequencing revealed a heterozygous variant, confirming the diagnosis of van der Woude syndrome. The disruption of IRF6 resulted in abnormal orofacial development including micrognathia and intraoral adhesions as well as tongue-palate fusion, then resulting in glossoptosis with airway obstruction and cleft palate.