Samantha Anne

Evaluation of unilateral sensorineural hearing loss in the pediatric patient.

OBJECTIVES This study is a review of our series of pediatric patients with unilateral sensorineural hearing loss (USNHL) to report abnormalities on imaging studies, review genetic and ophthalmologic results, and survey audiometric findings. METHODS This study is a retrospective chart review of all pediatric patients with USNHL seen between 1/1/03 and 12/31/08 at our institution. The study was approved by the institutional review board. RESULTS Eighty-nine cases were identified with audiometric findings confirming unilateral hearing thresholds greater than 20 dBHL with no conductive component. There were 48 males and 41 females. Average age of diagnosis was 7 years. One audiogram showed low-frequency loss, 17 mid-frequency, 29 high-frequency, and 32 flat. Ten patients were diagnosed by auditory brainstem response testing at another institution, with thresholds not available for review. Eleven percent of patients progressed to bilateral loss. Sixty-one patients underwent computed tomography of temporal bones (CTTB). Twenty of 61 scans identified 34 anomalies including 15 enlarged vestibular aqueducts (EVAs), 8 Mondini, and 3 superior semicircular canal dehiscences (SSCDs). Thirty-one of 89 patients underwent magnetic resonance imaging (MRI). Three of these 31 patients had positive findings including 1 EVA, 1 Mondini, and 1 asymmetric internal auditory canal. When CTTB was positive, no additional lesions were detected on MRI. When CTTB was negative and MRI was done in 20 patients, 2 additional lesions were detected by MRI. Fourteen patients had genetics evaluation of which 6 had positive findings, including CHARGE, VACTERL, Goldenhar, and 3 were heterozygous for a Connexin mutation. CONCLUSIONS CTTB is an effective diagnostic tool for USNHL. MRI should be considered in patients with negative CTTB. Genetics and ophthalmologic evaluations are recommended for patients with risk factors or an abnormal clinical examination. Close follow-up is essential due to high rate of hearing loss progression.

Rhinosinusitis in children: A comparison of patients requiring surgery for acute complications versus chronic disease ☆

BACKGROUND Patient characteristics, risk factors, and microbiology are important to consider in the management of complications of acute bacterial sinusitis (ABS) in pediatric patients. This study evaluates this subset of patients and compares them to patients that undergo surgery for chronic rhinosinusitis (CRS). METHODS This study is a retrospective review of all pediatric patients from 2002 to 2011, who underwent sinus surgery at a tertiary hospital. Patients who underwent surgery for ABS complication were compared to patients who underwent surgery for CRS. Statistical analysis was completed using chi-square test or Fishers exact test with a statistical significance set at p<0.05. RESULTS Twenty-seven patients with a complication of ABS and 77 patients with CRS were analyzed. The groups did not differ demographically. Patients with a complication were statistically less likely to have seasonal allergies, prior sinusitis, prior nasal steroid use, or adenoidectomy (p<0.05). In addition, they had more frequent involvement of ethmoid and frontal sinuses (p<0.05). The most common cultures results were no growth (30.8%), Streptococcus milleri (30.8%), and normal flora (19.2%) in ABS for the with a complication group, and normal flora (41.5%), coagulase negative Staphylococcus (22%), and Propionobacterium (19.5%) for the CRS group. Most prevalent complications were preseptal cellulitis (55.5%), orbital subperiosteal abscess (29.6%), subgaleal abscess (22%), and epidural abscess (22%). Five patients had simultaneous orbital and intracranial complications. CONCLUSIONS Patients who present with complications of ABS vary significantly from the CRS patients. Location of most commonly affected sinuses and microbiology also differ and is crucial for understanding the management of this disease process.

A Systematic Review of Perioperative Versus Prophylactic Antibiotics for Cochlear Implantation.

Background: Previous Cochrane review of prophylactic antibiotic use in clean and clean-contaminated ear surgery showed no benefit; however, these studies did not address cochlear implant (CI) surgery specifically. Objective: Systematically review effects of perioperative antibiotics on risk of infections and related complications in CI surgery Search methods: PubMed, EMBASE, Medline, CINAHL, and Cochrane library were searched from inception to March 2015. Manual searches of bibliographies were also completed. Selection Criteria: We included all studies that describe perioperative antibiotic use in CI surgery. Outcome measures included infection, meningitis, implant extrusion, and adverse antibiotics effects. Two independent evaluators reviewed each abstract and article. Results: One hundred and seventy-three studies were identified in search. Three met inclusion criteria and were reviewed. Articles were low quality; no randomized trials were identified. For included studies, numerous antibiotic types and dosing regimens were used. Recorded outcome measures were heterogeneous, and detailed information was frequently unavailable. Overall infection rate was low (3%-4.5%); single dose antibiotic prophylaxis showed low rate of complications (1%) in 2 studies. Conclusions: There is insufficient evidence to make definitive conclusions about the role of perioperative antibiotics in CI surgery. Reported infection rates are low; however, decision to use antibiotics should be based on assessment of risks and benefits to each patient.

Auditory Outcomes with Hearing Rehabilitation in Children with Unilateral Hearing Loss: A Systematic Review

Objective Options for management of unilateral hearing loss (UHL) in children include conventional hearing aids, bone-conduction hearing devices, contralateral routing of signal (CROS) aids, and frequency-modulating (FM) systems. The objective of this study was to systematically review the current literature to characterize auditory outcomes of hearing rehabilitation options in UHL. Data Sources PubMed, EMBASE, Medline, CINAHL, and Cochrane Library were searched from inception to January 2016. Manual searches of bibliographies were also performed. Review Methods Studies analyzing auditory outcomes of hearing amplification in children with UHL were included. Outcome measures included functional and objective auditory results. Two independent reviewers evaluated each abstract and article. Results Of the 249 articles identified, 12 met inclusion criteria. Seven articles solely focused on outcomes with bone-conduction hearing devices. Outcomes favored improved pure-tone averages, speech recognition thresholds, and sound localization in implanted patients. Five studies focused on FM systems, conventional hearing aids, or CROS hearing aids. Limited data are available but suggest a trend toward improvement in speech perception with hearing aids. FM systems were shown to have the most benefit for speech recognition in noise. Studies evaluating CROS hearing aids demonstrated variable outcomes. Conclusions Data evaluating functional and objective auditory measures following hearing amplification in children with UHL are limited. Most studies do suggest improvement in speech perception, speech recognition in noise, and sound localization with a hearing rehabilitation device.

Speech and Language Consequences of Unilateral Hearing Loss: A Systematic Review:

Objective Unilateral hearing loss has been shown to have negative consequences for speech and language development in children. The objective of this study was to systematically review the current literature to quantify the impact of unilateral hearing loss on children, with the use of objective measures of speech and language. Data Sources PubMed, EMBASE, Medline, CINAHL, and Cochrane Library were searched from inception to March 2015. Manual searches of references were also completed. Review Methods All studies that described speech and language outcomes for children with unilateral hearing loss were included. Outcome measures included results from any test of speech and language that evaluated or had age-standardized norms. Due to heterogeneity of the data, quantitative analysis could not be completed. Qualitative analysis was performed on the included studies. Two independent evaluators reviewed each abstract and article. Results A total of 429 studies were identified; 13 met inclusion criteria and were reviewed. Overall, 7 studies showed poorer scores on various speech and language tests, with effects more pronounced for children with severe to profound hearing loss. Four studies did not demonstrate any difference in testing results between patients with unilateral hearing loss and those with normal hearing. Two studies that evaluated effects on speech and language longitudinally showed initial speech problems, with improvement in scores over time. Conclusions There are inconsistent data regarding effects of unilateral hearing loss on speech and language outcomes for children. The majority of recent studies suggest poorer speech and language testing results, especially for patients with severe to profound unilateral hearing loss.

Tracheostomy in neurologically compromised paediatric patients: role of starplasty.

OBJECTIVES Starplasty tracheostomy is an alternative to traditional tracheostomy. This paper reviews neurologically compromised paediatric patients with tracheostomies and discusses the role of starplasty tracheostomy. METHOD A retrospective review was conducted of paediatric patients with a neurological disorder who underwent tracheostomy between 1997 and 2011. RESULTS Forty-eight patients, with an average age of 7.3 years, were identified. The most common indications for tracheostomy were: ventilator dependence (39.6 per cent), an inability to tolerate secretions or recurrent aspiration pneumonia (33.3 per cent), and upper respiratory obstruction or hypotonia (12.5 per cent). The most common underlying neurological diagnosis was cerebral palsy. There were no early complications. Eighteen (43 per cent) of 42 patients with follow up experienced at least 1 delayed complication. Only 12 patients (28.6 per cent) were decannulated. CONCLUSION Patients with primary neurological diagnoses have low rates of decannulation; starplasty tracheostomy should be considered for these patients. Patients with seizure disorder or acute neurological injury tended to have a higher short-term decannulation rate; traditional tracheostomy is recommended in these patients.

Bridging bronchus: Importance of recognition on airway endoscopy

Bridging bronchus is an anomalous bronchus, which crosses the mediastinum from the contralateral mainstem bronchus and it is commonly associated with congenital great vessel abnormalities. This is a case report of an infant that underwent airway endoscopy and attempt at cannulation of a mainstem bronchus with supposed bronchial cast after cardiac surgery in the intensive care unit. After multiple failed attempts, further workup was completed which revealed a bridging bronchus. A bridging bronchus must be suspected in a patient with abnormal appearing endoscopy in presence of great vessel anomalies to prevent accidental injury to the tracheobronchial tree.

Synchronous occurrence of nasopharyngeal carcinoma and Hodgkin lymphoma

Latent Epstein-Barr virus infection is associated with several lymphoid and epithelial malignancies. This is the first reported case of a patient presenting with synchronous nasopharyngeal carcinoma and Hodgkin lymphoma associated with Epstein-Barr virus. A 17-year-old previously healthy African-American male presented with anterior mediastinal mass and a nasopharyngeal mass. Histology from biopsy of both lesions revealed evidence of Epstein-Barr virus. The patient successfully completed sequential therapies with chemo radiation with no evidence of active disease. Simultaneous occurrence of the two malignancies is undoubtedly a rare event, and their coexistence raises the question of a common etiologic factor.

In response to "Otolaryngology workforce analysis"

The article “Otolaryngology Workforce Analysis” by Hughes et al. is an effort to understand the current otolaryngology workforce through analysis of various national databases and to identify potential confounding factors in addressing future healthcare needs. Although this is a valuable aspiration, the authors rely on data that has not been scientifically validated and present various individuals’ personal statements as support to validate conclusions. In addition, there are implications that younger age and perceived diminished work ethic will contribute to decreased productivity. To begin with, the study heavily relies on data obtained partially from “close communication and work” with the Physicians Resource Committee (PRC) committee of American Academy of Otolaryngology Head and Neck Surgery (AAO–HNS) and personal interviews with senior otolaryngologists. Committee deliberations and work are not scientifically valid data, and use of them in collaborating analysis is flawed. The authors use minutes from a PRC meeting to present survey-derived socioeconomic information that the “average practicing Otolaryngologist in the US is a 52 year old male (84% M versus 16% F), who works 51 hours a week for 48 weeks a year (2448 hours/ year) and plans to retire at 68,” and regarding physician attrition rates in 2011 versus 2014. Not only is this type of data not scientifically validated, it also is an inappropriate use of proprietary AAO–HNS information. The majority of members of the PRC did not give permission to use their deliberations in this manner and have previously recused themselves from a similar publication by one of the members, who is the senior author of the Hughes et al. article. Moreover, the details of the meeting(s) from which the minutes were gleaned were not given in the initial e-publication, making this unsearchable as a reference, and the authors subsequently added the phrase “The 2014 findings of the AAO–HNS Physicians Resource Committee, September 20, 2014, personal communication not subject to external validation” to a Conclusion paragraph to circumvent this real problem. However, it remains that minutes of AAO–HNS committee meetings are the intellectual property of the organization’s board of directors, and permission is not granted from the Academy for use of same. The authors also make various assumptions in the study without providing corroborating evidence. One such example is that the authors surmise the rate of attrition among otolaryngologists is not any different from general medicine. However, a study of attrition rate in otolaryngology residents was shown to be 1.2% in comparison to a rate of 3% for residents overall, as per the Accreditation Council for Graduate Medical Education. How this rate of attrition translates to overall otolaryngologists in practice is unknown and the assumption that the rate would equalize to general medicine physicians may not be accurate. In addition, they also go on to describe current otolaryngology practice but base it purely on the U.S. Centers for Disease Control’s National Ambulatory Medical Care Survey, for which the top diagnoses consist of otitis media, chronic sinusitis, and impacted cerumen. That grossly underestimates the specialty skill sets of a practicing otolaryngologist and is a gross misinterpretation of spectrum of otolaryngology practice pattern in that nonambulatory care is not taken into account. Another alarming aspect of the manuscript is the authors’ choice to use personal interviews to support their claims in discussion. In an article aspiring to be a scientifically based analysis, these personal remarks are a detriment. Two hand-picked individuals with various past leadership positions were quoted. Their views do not represent other leaders or the wide range of otolaryngologists, and presenting their opinions as evidence to support the authors’ statements is inappropriate and biased. Lastly, the most disturbing aspect of the article is the implied suggestion that there will be decreased productivity in the future because the current resident workforce has higher emphasis on lifestyle. The authors state the following and include a quote from Dr. Pillsbury: “His second concern involves the present resident workforce, in that ‘young people are emphasizing lifestyle more than they did previously.’ Additionally, regulations on resident work hours have decreased productivity compared to past generations [11]. Although debate exists, other authors have voiced concerns that decreasing resident work hours can impact surgical training experience [12–14].” Implying that “young people are emphasizing lifestyle” is leading to decreased productivity is misleading. They refer to three articles that voice concerns that decreased work hours lead to an impact of surgical DOI: 10.1002/lary.26502

Paradoxical vocal fold motion (PVFM) in pediatric otolaryngology

INTRODUCTION Paradoxical vocal fold motion (PVFM) is a condition in which the vocal cords exhibit inappropriate inspiratory adduction, and it has been poorly studied in the pediatric population. METHODS Pediatric patients diagnosed with PVCM by a pediatric otolaryngologist and doctor of speech pathology from 2008 to 2012 were reviewed. Patients in whom another cause for their respiratory disturbance was eventually identified were excluded. Patient demographics, characteristics, treatment, and outcomes were reviewed. The study was approved by the Institutional Review Board at our institution. RESULTS Thirty patients met criteria for inclusion; one with chiari malformation was excluded. 17/29 (59%) were female. Body mass index (BMI) numbers ranged from 16 to 25 with a mean of 21. 9/29 (31%) competed at the highest level of a sport; only 3/29 (10%) did not participate in athletics. Average age of onset was 12.0years; average diagnosis delay was 1.3years. Mean follow up was 2.3years. 24/29 (83%) were previously treated for asthma. 23/29(79%) were previously treated for reflux. 25/29(86%) completed at least one session of respiratory and laryngeal control therapy with overall average of 2.2 sessions completed. All patients who attended a second therapy session were recorded as having improvement in symptoms. CONCLUSIONS Pediatric patients with PVFM often participate in high levels of organized sports and the frequency of concurrent asthma and reflux symptoms in this population supports the theory that laryngeal hypersensitivity contributes to the pathophysiology of PVFM. These patients were not found to have any associated psychiatric diagnoses. Pediatric patients with PVFM have an excellent prognosis when treated with speech therapy and for comorbid conditions as indicated.