Noah P. Parker

Trends in the indications for pediatric tonsillectomy or adenotonsillectomy

OBJECTIVE To report trends in the indications for pediatric tonsillectomy or adenotonsillectomy. METHODS To identify current indications, (1) a retrospective chart review analyzed all indications for procedures performed by a pediatric otolaryngologist on patients aged 0-3, 4-10, or 11-18 years, and (2) a cross-sectional survey to members of the American Society of Pediatric Otolaryngology asked for approximate percentages of children in the same age groups receiving procedures for obstruction, infection, or another indication. To assess changing indications over time, (3) a literature review was performed. RESULTS (1) Chart review: 302 patients aged 5 months to 18 years (average: 6.34; median: 6) were analyzed. For the 0-3-year age group, obstruction was an indication in 100.0% of cases, and infection in 2.6%. For the 4-10-year age group: 91.9% and 13.4%, respectively. For the 11-18-year age group: 84.6% and 33.3%. (2) SURVEY: 120 surveys were returned (40% response rate), and 63 surveys were appropriate for analysis (21% completion rate). For the 0-3-year age group, obstruction was the primary indication in 91.8% of procedures and infection in 7.5%. For the 4-10-year age group: 73.2% and 25.3%, respectively. For the 11-18-year age group: 43.0% and 54.2%. (3) LITERATURE REVIEW: 11 articles consistently illustrated a rise in obstruction and a decline in infection as an indication since 1978. CONCLUSIONS Obstruction has become a more prominent indication than infection for pediatric tonsillectomy or adenotonsillectomy in children, especially younger children. Infection becomes a more prominent indication as age increases. Data may not be absolutely reflective of all pediatric otolaryngologists or other otolaryngologists that treat children. Comparing studies is difficult owing to the variety of surgical procedures focused upon and terms used to define indications.

The dilemma of midline destructive lesions: a case series and diagnostic review

BACKGROUND Midline destructive lesions (MDLs) of the nose are a diagnostic dilemma due to an extensive differential diagnosis and vague presenting signs and symptoms. Etiologies may be neoplastic, autoimmune, traumatic, infectious, or unknown. STUDY DESIGN Case series and review of the literature were done. METHODS Medical records of 8 patients presenting with an MDL were reviewed. RESULTS Each patient received nasal endoscopy, computed tomography scan of the sinuses, laboratory workup, culture (aerobes, anaerobes, fungus, and acid-fast bacilli), and biopsy with flow cytometry. Laboratory tests included complete blood count, basic metabolic panel, erythrocyte sedimentation rate, angiotensin-converting enzyme, antineutrophil antibodies, rheumatoid factor, anti-Ro and anti-La antibodies, Epstein-Barr virus antibodies, coccidiomycosis serology, HIV antibodies, fluorescent treponemal antibody absorption, classic antineutrophil cytoplasmic antibodies, perinuclear antineutrophil cytoplasmic antibody, proteinase 3, and myeloperoxidase. Choice of diagnostic study was individualized for each patient. Two patients were diagnosed with natural killer/T-cell lymphoma, 2 were diagnosed with Wegeners granulomatosis, and 4 remained idiopathic, despite the extensive workup. A diagnostic algorithm to aid in the approach to MDLs is presented. CONCLUSIONS The diagnosis of MDLs remains difficult but is aided by a systematic approach and familiarity with multiple diagnostic techniques. It is imperative to take multiple tissue specimens from various sites, send them fresh, and communicate suspicion of lymphoma. Despite diagnostic advances and improved understanding of the diseases underlying MDLs, an etiology is often not identified.

Endoscopic cold incision, balloon dilation, mitomycin C application, and steroid injection for adult laryngotracheal stenosis

To describe the presentation, stenosis characteristics, etiological differences, and outcomes of adult laryngotracheal stenosis treated with endoscopic cold incision, balloon dilation, topical mitomycin C application, and steroid injection.

Lobular Capillary Hemangioma of the Neonatal Larynx

OBJECTIVE To describe a previously unreported condition of the neonatal larynx. DESIGN Case series of 4 neonates with an uncommon laryngeal lesion. SETTING Tertiary care childrens hospital. PATIENTS Four neonates in the first 10 days of life with stridor, hoarseness, and respiratory distress. INTERVENTION The patients were examined using flexible fiberoptic laryngoscopy, and laryngeal lesions were identified and subsequently removed using microlaryngoscopy. Photodocumentation of the lesions was performed. Microscopic evaluation of biopsy specimens by a pathologist followed. MAIN OUTCOME MEASURES Each patients medical record was carefully reviewed for prenatal history, birth history, neonatal history, pathologic findings, and office follow-up. RESULTS All 4 neonates were delivered atraumatically and developed symptoms of upper airway obstruction within the first few minutes to days of life. Each neonate was found to have an obstructive laryngeal lesion requiring surgical intervention. No child had other congenital abnormalities or a history of obvious laryngeal trauma. Pathologic review of each laryngeal specimen revealed inflammatory lesions with characteristic features of a lobular capillary hemangioma (or a pyogenic granuloma). CONCLUSIONS The diagnosis of a lobular capillary hemangioma of the larynx should be considered in the differential diagnosis of a newborn with stridor, hoarseness, or respiratory distress. The cases seem to be of congenital origin, although acquired pathogenesis cannot be ruled out. Treatment of these lesions includes microscopic surgical excision.

Voice Outcomes Following Radiation Versus Laser Microsurgery for T1 Glottic Carcinoma Systematic Review and Meta-analysis

Objective Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using transoral laser microsurgery or radiation therapy. Data Sources PubMed, Web of Science, and Scopus (1997-2013). Review Methods These data sources were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed only with studies that included both treatment modalities, to reduce heterogeneity and maximize rigor; random effects modeling was used to pool results. Results Eighteen publications were identified that reported VHI data following surgery and radiotherapy for T1 glottic carcinoma. No studies were randomized. When studies that reported multiple T-stages or systematic treatment selection bias were excluded, 8 retrospective cohort studies describing 362 patients were suitable for meta-analysis. Follow-up time (mean, 47 months; range, 1-298 mo) and extent of surgical excision varied across studies. Six studies showed no VHI difference between treatment arms; 2 favored radiotherapy over surgery (1 of which reported transmuscular cordectomy for all surgical patients); and none favored surgery. Meta-analysis showed no significant difference in posttreatment VHI between radiotherapy and surgery (mean difference, –5.52; 95% confidence interval, –11.40, 0.36; heterogeneity I2 = 61%, P = .01). Conclusion VHI scores were comparable following transoral laser microsurgery and radiation therapy for T1 glottic carcinoma in the current literature, suggesting no clinically significant difference in functional voice outcomes between treatment types.

Carbon dioxide laser versus stapler-assisted endoscopic Zenker's diverticulotomy: a systematic review and meta-analysis.

To evaluate outcomes following endoscopic management of Zenker’s diverticula using a carbon dioxide laser (CO2) or stapler-assisted technique, a systematic review and meta-analysis were conducted. Seven retrospective, uncontrolled case series including 391 procedures met selection criteria. No higher quality studies were identified. Outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status (2 studies), length of hospitalization (LOH, 2 studies), and fewer postoperative fevers and abnormal chest x-rays (1 study). Outcomes favoring the CO2 technique included greater improvement in postoperative dysphagia and regurgitation scores (2 studies) and a lower revision rate (1 study). Meta-analysis demonstrated increased nondental complications in the CO2 group (odds ratio 3.81; 95% confidence interval, 1.37-10.59; P = .01) but no difference in duration of NPO (P = .06), LOH (P = .07), overall complications (P = .08), dental complications (P = .57), major complications (P = .38), or revision surgery (P = .82). Implications are limited by the quality of studies identified.

Incidence of operative endoscopy findings in recurrent croup.

Objective. Develop an evidence-based model for predicting operative endoscopy findings in patients with recurrent croup. Study Design. Case series with chart review. Setting. Tertiary care children’s hospital. Subjects and Methods. Retrospective chart review was performed on 124 patients who received consultation for recurrent croup between 2000 and 2009. Direct laryngoscopy and bronchoscopy findings were categorized as normal, mildly abnormal (incidental findings or grade I subglottic stenosis), moderately abnormal (grade II subglottic stenosis), or severely abnormal (grade III-IV subglottic stenosis). Results. Of 124 consultations for recurrent croup, 81 patients (average age 3.5 years) underwent operative endoscopy. Normal examinations occurred in 33 of 81 (41%). Abnormal findings were encountered with the following frequency: mildly abnormal, 40 of 81 (49%); moderately abnormal, 6 of 81 (7.5%); and severely abnormal, 2 of 81 (2.5%). Relative risk (RR) of either moderately abnormal or severely abnormal findings was increased for patients who had a history of previous intubation (RR = 9.8; P = .002), prematurity (RR = 6.4; P = .01), or inpatient consultation (RR = 5.3; P = .028). The rate of moderately or severely abnormal findings in patients without the risk factors of intubation and age younger than 1 year was 0 of 48 (0%; confidence interval, 0%-7.4%). Mild abnormalities in this group were encountered in 27 of 48 (56%). Conclusion. Mild airway abnormalities are common in children with recurrent croup and cannot be ruled out based on history. In the absence the risk factors of previous intubation, age younger than 1 year, or inpatient consultation, the incidence of a significantly abnormal finding is quite low. A predictive model based on this evidence is discussed.

Effects of Basic Fibroblast Growth Factor-2 and Hyaluronic Acid on Tracheal Wound Healing

To evaluate basic fibroblast growth factor‐2 (BFGF) and hyaluronic acid (HA) effects on a surgically produced tracheal defect.

Predicting surgical outcomes in pediatric cervicofacial nontuberculous mycobacterial lymphadenitis.

Objectives: We examined surgical outcomes in children with cervicofacial nontuberculous mycobacterial lymphadenitis and attempted to identify predictors of complications. Methods: A retrospective chart review from 2 tertiary pediatric centers was used to identify 11 presentation or operative variables (age at surgery, gender, symptom duration, pain, violaceous skin changes, skin breakdown, fluctuance, purified protein derivative positivity, operative procedure, use of nerve integrity monitoring, and use of skin flap advancement) and to compare these to 5 postoperative complications (facial nerve dysfunction [paresis or paralysis], poor scarring, recurrence, wound infection, and wound dehiscence without infection). Results: The 45 patients analyzed for presentation or operative variables (28 female, 17 male; average age, 31.2 months) typically presented with painless masses averaging 8.2 weeks in duration, along with violaceous skin changes in 29 of the 45 cases (64%) and skin breakdown in 9 cases (20%). The surgical procedures included parotidectomy with or without selective lymphadenectomy in 38 of the 45 cases (84%) and lymphadenectomy alone in 7 cases (16%). Skin resection and cervicofacial advancement flap reconstruction was performed in 20 cases (44%). Nerve integrity monitoring was utilized in 32 cases (71%). In the 44 patients analyzed for postoperative complications, we found facial nerve paresis in 14 (31.8%), poor scarring in 9 (20.5%), wound infection in 6 (13.6%), recurrence in 4 (9.1%), and facial nerve paralysis in 2 (4.5%). Nine of the 14 cases (64.3%) of initial facial nerve paresis resolved. At final follow-up, facial nerve paresis persisted in 5 of the 14 children (35.7%) with initial postoperative paresis and in 1 of the 2 children (50.0%) with initial postoperative paralysis. Facial nerve paralysis persisted in the other child with initial postoperative paralysis. Overall, 6 of these 7 patients (85.7%) with persistent facial nerve dysfunction had follow-up of less than 1 month. All transient and permanent facial nerve dysfunction was in the distribution of the marginal mandibular nerve only. No statistically significant predictors of complications were identified. Conclusions: We report acceptable but not insignificant rates of marginal mandibular distribution facial nerve injury, poor scarring, wound infection, and recurrence following resection of cervicofacial nontuberculous mycobacterial lymphade nitis in children that must be discussed with patients and parents before operation. No presentation or operative variables predicted the complications.

Postoperative Facial Nerve Function in Pediatric Parotidectomy A 12-Year Review

Objective To analyze the incidence of postparotidectomy facial nerve dysfunction in pediatric patients and to evaluate the association between patient demographics or underlying pathology and functional outcomes. Study Design Case series with chart review. Setting Tertiary-care pediatric hospital. Subjects and Methods We reviewed charts of patients younger than 18 years who underwent parotidectomy performed by a pediatric otolaryngologist between 1999 and 2011 at a tertiary pediatric center. Distributions of postoperative facial nerve dysfunction and timing of recovery were noted. Chi-square and t-test analyses were conducted to determine the association between demographics or pathology and functional outcomes. Results Forty-three patients met inclusion criteria: 41 underwent superficial parotidectomy, and 2 underwent total parotidectomy. Leading indications for surgery were atypical mycobacterial infection (16/43 [37.2%]) and first branchial cleft anomaly (8/43 [18.6]). The facial nerve was sacrificed in 1 (2%) patient with Ewing’s sarcoma involving the nerve. The incidence of immediate facial nerve paresis was 21% (9/43), involving the marginal mandibular nerve (n = 7), buccal branch (n = 1), and both marginal mandibular and frontal branches (n = 1). Full recovery of nerve function in patients with paresis occurred within 1 month (n = 2), 2 months (n = 1), 6 months (n = 3), or 10 months (n = 2). Conclusion Postparotidectomy paresis of distal branches of the facial nerve is a common occurrence in the pediatric population and should be discussed during preoperative evaluation. The risk is comparable to that of the adult population. Age, gender, and pathologic diagnosis were not predictive of postoperative nerve dysfunction.