Lily H. P. Nguyen

Increased expression of interleukin-9, interleukin-9 receptor, and the calcium-activated chloride channel hCLCA1 in the upper airways of patients with cystic fibrosis.

Objectives/Hypothesis Mucus overproduction is commonly found in airway disease in patients with cystic fibrosis. Interleukin‐9 (IL‐9) has been shown to mediate airway hyper‐responsiveness and mucus overproduction. Recently, the calcium‐activated chloride channel hCLCA1 has been described to be upregulated by IL‐9 and has been thought to regulate the expression of soluble gel‐forming mucins. We sought to examine the expression of IL‐9, interleukin‐9 receptor (IL‐9R), and hCLCA1 in the upper airway of patients with cystic fibrosis in comparison to healthy control subjects and to demonstrate the relationship of IL‐9, IL‐9R, and hCLCA1 expression with mucus production.

Granular cell tumor of the trachea in a child.

Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly the tongue. They have, however, been described in all areas of the body. Their presentation in the trachea is exceedingly rare, with their presence in the pediatric trachea being an even rarer occurrence. We describe a case of a granular cell tumor of the trachea in a 10-year-old boy with a dramatic, almost lethal, presentation. This is followed by a review of the literature, including pathology and treatment options.

Extensive bilateral arteriovenous malformations of the mandible successfully controlled by combined endovascular and transcutaneous angio-embolization: case report and review of the literature.

We report a unique case of extensive bilateral arteriovenous malformation (AVMs) in a childs mandible, discuss treatment options and review literature. A healthy 8 year-old girl presented with bright blood of unknown source found on her pillow. Three large AVMs involving the symphyseal region and bilateral mandibular bodies were found on angiography. Due to the extent of surgical resection required, the patient underwent a series of endovascular and transcutaneous angio-embolization. In cases of extensive intraosseous AVMs, serial embolization procedures can be successful in controlling episodes of hemorrhage and allow for bone remineralization. A multidisciplinary approach by otolaryngologists and neurointerventional radiologists can optimize the results.

African American ethnicity as a risk factor for respiratory complications following adenotonsillectomy.

OBJECTIVEnTo evaluate whether African American ethnicity is a risk factor for major respiratory complications following adenotonsillectomy (T&A).nnnDESIGNnRetrospective cohort study.nnnSETTINGnA Canadian tertiary care center. PATIENTS Children aged 0 to 18 years who underwent T&A at our institution from 2002 to 2006 with planned or unplanned postoperative admissions.nnnMAIN OUTCOME MEASURESnWe evaluated the association between ethnicity and our main outcome measure, major perioperative respiratory complications of T&A. Parental report of ethnicity was available for 23% of our cohort. At our institution, African American children undergo a routine preoperative sickle cell test (TestSC). Data on TestSC were included for all children. We established that having a TestSC was an accurate proxy for African American ethnicity (sensitivity, 96%; specificity, 93%; positive predictive value, 77%; negative predictive value, 99%).nnnRESULTSnSeventy-four of 594 children experienced major respiratory complications (12.5%). Compared with children who did not have major respiratory complications, those who did had a TestSC (P = .01), were 2 years or younger (P < .001) and had lower weight-for-age z scores (P = .04), moderate to severe obstructive sleep apnea (P = .003), and comorbidities (P < .001). When controlling for these variables in a multivariate analysis, children of African American ethnicity (TestSC used as a proxy) were at higher risk of having major perioperative respiratory complications (adjusted odds ratio, 1.82 [95% CI 1.05-3.14]) (P = .003).nnnCONCLUSIONSnChildren of African American ethnicity (TestSC used as a proxy) are nearly twice as likely to experience major respiratory complications related to T&A. Ethnicity may be an additional independent risk factor for clinicians to consider when planning for T&A.

Novel measurements of the length of the subglottic airway in infants and young children.

BACKGROUND: To date, the lengths of the subglottic and tracheal airway segments have been measured from autopsy specimens. Images of the head and neck obtained from computerized tomography (CT) provide an alternate method. Our objective in this study was to identify anatomic landmarks from CT scans in infants and young children to estimate the lengths of the subglottic and tracheal airway segments and to correlate these lengths with age. METHODS: We performed a retrospective analysis of CT images of the neck for various diagnostic indications in children ⩽3 years. We obtained planes of reconstruction at the level of the vocal cords (VCs), cricoid cartilage, and carina (C) which were parallel to each other and perpendicular to sagittal long axis of the trachea. The lengths of the subglottic airway (LengthSG) and total length of the laryngotracheal airway (LengthVC–C) were measured from the distance between, respectively, the VC versus cricoid cartilage and the VC versus C planes of reconstruction. Tracheal length was then calculated as the difference between LengthVC–C and LengthSG. RESULTS: Fifty-six children met the inclusion criteria. There were 29 boys. The median weight was 10.7 kg (range 3.1–19.0 kg). Regression analysis yielded mean LengthSG (mm) = 7.8 + 0.03·corrected age (months), r2 = 0.07, P = 0.056; lower and upper 95% confidence interval for &bgr; = 0.03 were −0.001 and 0061. The mean LengthSG was 8.4 mm with an SD of 1.4 mm. The 95th percentile for LengthSG was 10.8 mm, and the 5% to 95% interquartile range was 4.9 mm. The estimate for the 95% confidence interval of the 95th percentile was between 10.2 and 11.3 mm. The LengthVC–C increased with age: mean LengthVC–C (cm) = 5.3 + 0.05·corrected age (months), r2 = 0.7, P < 0.001. Tracheal length also increased with age: mean tracheal length (cm) = 4.5 + 0.05·corrected age (months), r2 = 0.6, P < 0.001. CONCLUSION: We report a novel estimate method for the lengths of the airway segments between the VC and C in 56 infants and young children and suggest that the growth characteristics of the subglottic and tracheal airway may differ.

Pediatric temporal bone fractures: A case series

OBJECTIVESnTemporal bone fractures are relatively common findings in patients with head trauma. The aim of this study was to evaluate the characteristics of temporal bone fractures in the pediatric population.nnnSTUDY DESIGNnRetrospective case series. Tertiary care pediatric academic medical center.nnnMETHODSnThe medical records of patients aged 18 years or less diagnosed with a temporal bone fracture at the Montreal Childrens Hospital from January 2000 to August 2014 were reviewed. Patient demographics, clinical presentation, mechanism of injury and complications were analyzed. Imaging studies and audiograms were also evaluated.nnnRESULTSnOut of 323 patients presenting to the emergency department with a skull fracture, 61 presented with a temporal bone fracture. Of these, 5 presented with bilateral fractures. 47 patients had associated fractures, and 3 patients deceased. We observed a male to female ratio of 2.8:1, and the average age was 9.5 years. Motor vehicle accidents were the primary mechanism of injury (53%), followed by falls (21%) and bicycle or skateboard accidents (10%). The most common presenting signs included hemotympanum, decreased or loss of consciousness, facial swelling and nausea and vomiting. 8 patients had otic involvement on computed tomography scans, and 30 patients had documented hearing loss near the time of accident with a majority being conductive hearing loss. 17 patients underwent surgical management of intracranial pressure.nnnCONCLUSIONnIn children, fractures of the temporal bone were most often caused by motor vehicle accidents and falls. It is common for these patients to have associated fractures.

Leadership in crisis situations: merging the interdisciplinary silos

Purpose Complex clinical situations, involving multiple medical specialists, create potential for tension or lack of clarity over leadership roles and may result in miscommunication, errors and poor patient outcomes. Even though copresence has been shown to overcome some differences among team members, the coordination literature provides little guidance on the relationship between coordination and leadership in highly specialized health settings. The purpose of this paper is to determine how different specialties involved in critical medical situations perceive the role of a leader and its contribution to effective crisis management, to better define leadership and improve interdisciplinary leadership and education. Design/methodology/approach A qualitative study was conducted featuring purposively sampled, semi-structured interviews with 27 physicians, from three different specialties involved in crisis resource management in pediatric centers across Canada: Pediatric Emergency Medicine, Otolaryngology and Anesthesia. A total of three researchers independently organized participant responses into categories. The categories were further refined into conceptual themes through iterative negotiation among the researchers. Findings Relatively structured (predictable) cases were amenable to concrete distributed leadership - the performance by micro-teams of specialized tasks with relative independence from each other. In contrast, relatively unstructured (unpredictable) cases required higher-level coordinative leadership - the overall management of the context and allocations of priorities by a designated individual. Originality/value Crisis medicine relies on designated leadership over highly differentiated personnel and unpredictable events. This challenges the notion of organic coordination and upholds the validity of a concept of leadership for crisis medicine that is not reducible to simple coordination. The intersection of predictability of cases with types of leadership can be incorporated into medical simulation training to develop non-technical skills crisis management and adaptive leaderships skills.

Racial and Ethnic Diversity of US Otolaryngology Residents

Objective: Racial and ethnic minorities constitute a growing portion of the US population including the medical profession. The purpose of this study was to examine the evolution of racial and ethnic diversity in US otolaryngology residency programs and to compare it to minority representation in other surgical and non-surgical residency programs. Method: Information concerning minority representation in US residency programs was obtained from annually published Graduate Medical Education reports by the Journal of the American Medical Association from 1980 to 2010. The diversity of otolaryngology residents was then compared to other medical fields (general surgery, family medicine, and internal medicine). Results: Overall, minority representation among US medical residents increased dramatically from 1980 to 2010 (20% to 43.9%). However, otolaryngology residents remain a less diverse group with only 29% minority representation in 2010. In contrast to other residency programs compared, African American (AA) and Hispanic (H) representation were consistently underrepresented among otolaryngology residents (AA = 3.1%, H = 4.3%) relative to all residents (AA = 5.7%, H = 6.4%) in recent years. Conclusion: Despite rising racial and ethnic diversity among medical residents in general, minority representation in US otolaryngology residency programs is lagging. This finding is in contrast to rising trends of diversity within other residency programs including general surgery.

Multiple Mini Interview for Selection into OTL Residency

Objective: 1) To determine the reliability of the Multiple Mini Interview (MMI) for resident selection into an otolaryngology–head and neck surgery (OTL-HNS) program. 2) To assess the degree of acceptance by major stakeholders (interviewers and applicants) towards the MMI when compared to traditional interviews. Method: Canadian medical graduates applying to OTL-HNS residency programs underwent MMI in 2011 and 2012. MMI had 7 stations evaluating unique candidate attributes. Stations include surgical skills assessment and 2 simulation scenarios with standardized actors for noncognitive traits. Reliability was determined, and upon completion, stakeholders rated aspects MMI using 7-point Likert scale. Results: Data were collected from a total of 45 applicants and 19 evaluators. Overall interrater reliability of the MMI was good. The majority of applicants (>80%) felt that MMI helped them present their strengths and that it did not have any gender, cultural, or age bias. Assessors (>85%) felt that the MMI evaluated a valid range of competencies and that it tested more aspects of an applicant than traditional interviews. Both applicants and assessors (>70%) agreed that the MMI was a fair process, and both preferred the MMI over the traditional interview. Conclusion: The MMI is a reliable tool for the selection of applicants to an OTL-HNS residency program. It is well accepted by both applicants and assessors, with the majority of stakeholders preferring the MMI over traditional interviews.

Difficult intubation due to undiagnosed congenital tracheal web.

Congenital tracheal web is a rare anomaly, usually misdiagnosed as asthma or chronic obstructive lung diseases. Clinical suspicion and appropriate diagnostic imaging combined with endoscopic examinations are the mainstay approach. Symptoms of stridor, dyspnea and recurrent lower airway infections are the most common clinical presentations. We report a case of difficult intubation in a child due to an undiagnosed congenital tracheal web.