Prasad John Thottam

Functional endoscopic sinus surgery (FESS) alone versus balloon catheter sinuplasty (BCS) and ethmoidectomy: A comparative outcome analysis in pediatric chronic rhinosinusitis ☆

OBJECTIVE To evaluate whether the addition of BCS (balloon catheter sinuplasty) would improve the treatment outcome in children with chronic rhinosinusitis (CRS) compared to FESS (functional endoscopic sinus surgery). STUDY DESIGN Two-group, retrospective cohort with blinded chart review comparison. SETTING Childrens Hospital of Michigan, Detroit, MI. SUBJECTS AND METHODS Chart review of 15 pediatric patients who underwent BCS with ethmoidectomy and 16 who underwent FESS from 2008 to 2011 for treatment of CRS in a tertiary care, university affiliated, pediatric institution. Pre-operative CT-scans as well as pre and post-operative sinus symptoms and medications were compared. Post-surgical outcome was examined using chi square analysis. RESULTS Mean age of children at the time of the procedure was 9.3 (SD=4.19; range=3-17). Both groups had similar pre-surgical Lund-Mackay CT CRS scores (FESS: mean=9.33 and t=0.67; balloon: mean=10.58, t=0.68, and p=0.51). Analyses identified significant post-treatment reductions in overall symptoms and needed interventions in both treatment groups. Side-by-side post-operative comparison of patients who underwent balloon sinuplasty to FESS demonstrated statistically significant post-operative difference between the two groups in antibiotic requirement, sinus congestion and headaches. Though not statistically significant, 62.5% of FESS patients and 80.0% of BCS patients (χ(2)=1.15) reported improvement in their overall sinus symptoms post-operatively. CONCLUSION Both BCS and FESS are suitable treatments for CRS in children. Both treatments significantly reduced CRS complaints post-operatively and had similar overall results. BCS patients required significantly fewer antibiotics post-operatively for CRS related disease when compared to FESS. Larger prospective studies with long-term data are needed to further evaluate.

Comparative outcomes of severe obstructive sleep apnea in pediatric patients with Trisomy 21

OBJECTIVES To analyze the outcomes of severe obstructive sleep apnea (OSA) in pediatric patients with Trisomy 21 compared with non-syndromic patients. METHODS A retrospective chart review was performed for patients with a diagnosis of severe obstructive sleep apnea, (defined as, Apnea-Hypopnea index (AHI) of ≥ 10) in a tertiary childrens hospital. Data were analyzed for subjective and objective outcomes along with perioperative care and health care utilization. Patients with Trisomy 21 were compared with non-syndromic patients. RESULTS A total of 230 patients with severe OSA were included in the study. Eighteen of these patients had Trisomy 21. Adenotonsillectomy was the most common surgical intervention in both groups. There was no statistical difference in the preoperative AHI between groups. Post treatment AHI in the Trisomy 21 group changed from an average of 26.6 to an average of 11.6 as compared with 24.5 to 3.6 in the non-syndromic group. The average perioperative hospital stay was 3.8 days in Trisomy 21 group compared to 1.7 days for the non-syndromic group (p < 0.001, Mann-Whitney U test). Complete resolution was seen in 35% of the Trisomy 21 group versus 75% in the non-syndromic group. CONCLUSIONS A majority of Trisomy 21 patients with severe OSA had residual symptoms following surgical intervention. There is also an increased risk of post-operative airway intervention and increased length of hospital stay in these patients.

Role of polysomnography in the development of an algorithm for planning tracheostomy decannulation.

Objective To examine the role of polysomnography (PSG) in helping determine readiness of tracheostomized patients for decannulation. Study Design Case series with chart review of pediatric patients who underwent PSG with tracheostomy tube in place with the goal of decannulation. Setting Tertiary care pediatric center. Subjects and Methods Twenty-eight tracheostomized patients who underwent PSG from January 2006 to March 2012 were included. Outcome measures were successful decannulation, PSG results, surgical procedures, and medical comorbidities. Results Of the 28 patients, 20 (71.4%) were decannulated and 8 (28.6%) were not. One (3.6%) patient failed long-term decannulation. The average apnea-hypopnea index (AHI) with a capped tracheostomy for those successfully decannulated was 2.75 (range, 0.6-7.6), while the AHI for those not decannulated was 15.99 (range, 3.2-62). Factors associated with success or failure to decannulate were assessed, and an algorithm was developed to plan for successful decannulation. Laryngotracheal reconstruction was a significant factor in those successfully decannulated. Those who were not decannulated had multiple medical comorbidities, multilevel airway obstruction, need for additional surgery, or chronic need for pulmonary toilet. Conclusions Polysomnography may be a useful adjunctive study in the process of determining a patient’s readiness for decannulation. Our current algorithm for decannulation includes upper airway endoscopy with identification of levels of obstruction, followed by surgical correction of those obstructions; capped PSG to determine patency of the airway and help assess lung function; and overnight intensive care unit admission for capping trial, with decannulation the following day if well tolerated.

Outcomes and predictors of surgical management in type 1 laryngeal cleft swallowing dysfunction.

To examine the effect of and predict the success of type 1 laryngeal cleft (LC‐1) augmentation through swallowing evaluations.

Incidence of Pediatric Superior Semicircular Canal Dehiscence and Inner Ear Anomalies: A Large Multicenter Review.

Objective: To determine the pediatric incidence and association of superior semicircular canal dehiscence (SSCD) with inner ear (IE) anomalies. Study Design: Retrospective chart review. Setting: Two tertiary referral centers. Patients: Children less than 18 years who received a 0.5 mm or less collimated computed tomography study including the temporal bones between 2010 and 2013 for reasons including, but not limited to, hearing loss, trauma, and infection. Interventions: Images were reformatted into Pöschl and Stenver planes. Five hundred three computed tomography studies (1,006 temporal bones) were reviewed by experienced, blinded neuroradiologists. Main Outcome Measures: Incidence of SSCD and IE anomalies. Patient age, sex, and diagnosis were recorded. Statistical analysis was performed to compare outcome measures among patient demographics. Results: The incidence of SSCD was 6.2% (31/503) and an IE anomaly was 15.1% (76/503) of individuals. The incidence of SSCD with an IE anomaly was not significantly correlated (1.1%, 40/1,006; p = 0.23; LR = +1.29). The mean age of children with SSCD was lower (5.9 versus 9.8 yr; p = 0.002). SSCD incidence decreased with age (ages <2, 2–8, and 9–18 yr were 36.7%, 5.6%, and 3.2%; p<0.001) and SSC bone thickness nonsignificantly increased with age. Children with SSCD were commonly male (74.2%, p = 0.041). Conclusion: SSCD and IE anomalies are unlikely related. SSCD incidence is highest in children <2 years, with SSC bone increasing until 2 to 8 years of age. This supports the theory of a congenital precedent to SSCD, with overlying bone maturation occurring during early childhood. Age <2 years was a significant predictor of SSCD.

Type 1 Laryngeal Clefts

As healthcare provider and parental awareness of swallowing dysfunction has increased over the past several years, the identification of laryngeal cleft (LC) anomalies has also increased. Previously, the incidence of laryngeal cleft was estimated to be 1:10,000–1:20,000 patients, but it is now estimated that laryngeal clefts are present in 5–7.6% of patients with chronic aspiration/penetration with swallowing [1, 2]. With this new mindfulness, treatment options have increased to benefit patients with these anomalies.

Iatrogenic Membranous Tracheal Tear in the Setting of Relapsing Polychondritis

Importance: Relapsing polychondritis is a rare immune mediated disease disorder characterized by episodic inflammation of cartilaginous tissues with sequelae affecting virtually every major organ system. Recurrent destruction of these cartilaginous tissues leads to eventual weakening, and may predispose the patient to complications requiring airway intervention. Observations: This case report details the management of an iatrogenic 10 cm membranous tracheal tear in 27-year-old female suffering from relapsing polychondritis. Conclusions and Relevance: Conservative management coupled with starplasty and cervical approach tracheopexy was successful in complete closure of a complex tracheal tear. To our knowledge this is the first case report of a tracheal perforation in the setting of active relapsing polychondritis.

The Utility of Various Common Surgical Instruments for Pediatric Adenotonsillectomy: Analysis of Time, Hemorrhage, and Cost:

Objectives: Evaluate the correlation between surgical instrumentation and intraoperative surgical time, postoperative hemorrhage and associated health care cost for pediatric adenotonsillectomy. Methods: Retrospective chart analysis from a tertiary care pediatric hospital of patients who underwent adenotonsillectomy from 2011 to 2013. Monopolar electrocautery, radiofrequency ablation, and PlasmaBlade instruments were compared for intraoperative surgical time and postoperative hemorrhage rate. Univariate analysis of variance (ANOVA) and chi-square analysis was used to evaluate differences between instrumentation and variables. Cost analysis examining instrumentation and intraoperative anesthesia was also reviewed. Results: A total of 1280 patients who underwent adenotonsillectomy were evaluated. There was no significant overall difference in age, sex, or preoperative diagnosis identified between the 3 instrumentation groups. When examining the various instruments’ effects on procedure time in minutes, univariate ANOVA did demonstrate a significant difference overall between the 3 groups (F = 8.79; P < .001). Post hoc pairwise comparisons identified significantly faster surgical times for monopolar cautery than either both PlasmaBlade (P = .03) or radiofrequency ablation (P < .001). The difference in the number of patients who experienced a postoperative bleed by instrument was not statistically significant (χ2 = 2.36; P = .31). After instrumentation expenses were added to anesthesia cost, the overall average costs by instrument and surgical time were estimated as

FESS versus Balloon Sinuplasty as Long-term Treatment for Pediatric Chronic Rhinosinusitis: A 2-Year Postoperative Analysis

30.04 for monopolar cautery,

Sleep Architecture Patterns in Enuretic Children with OSA

246.95 for PlasmaBlade and