Stephen Maturo

Submucosal minimally invasive lingual excision: an effective, novel surgery for pediatric tongue base reduction.

Objectives: The aim of this study was to develop an effective single intraoral, minimally invasive technique to reduce the enlarged tongue base in children with obstructive macroglossia. Methods: We present the anatomic dissection of fresh cadavers and a representative case series of children who underwent submucosal minimally invasive lingual excision (SMILE) with a plasma-mediated radiofrequency device (coblation) under intraoral ultrasonic and endoscopic guidance. Multiple anatomic dissections determined the relative location of the hypoglossal nerve and lingual neurovascular bundle in relation to removable tongue base musculature. A pediatric case series demonstrates the straightforward SMILE technique. Results: Laboratory anatomic dissection and clinical lingual ultrasonography revealed the surgical safety borders for SMILE. The surgical safety and efficacy of SMILE is demonstrated by preoperative and postoperative clinical examinations and polysomnograms in children with obstructive macroglossia (such as Beckwith-Wiedemann and Down syndromes and tongue vascular malformation). Coblation submucosally removes excessive tongue base tissue through a small anterior tongue incision. SMILE was performed without excessive pain, bleeding, edema, infection, or tongue dysfunction. Conclusions: SMILE is an effective novel operation that incorporates coblation with ultrasonography and endoscopic guidance for children who need tongue base reduction. Anatomic dissection and clinical cases demonstrate the potential for aggressive yet relatively safe tissue removal by this minimally invasive technique. SMILE also has significant potential for adults with obstructive sleep apnea due to a large tongue base.

Initial experience using propranolol as the sole treatment for infantile airway hemangiomas

The objective of this study is to describe the initial use of propranolol as the sole treatment for focal infantile airway hemangiomas, and to report on available literature describing the use of propranolol for airway lesions. This retrospective case series was carried out at a tertiary pediatric medical center. We obtained the following results: two children demonstrated significant response to oral propranolol therapy and avoided not only invasive surgical procedures, but also long-term administration of oral corticosteroids. This is the first report of treating infantile airway hemangiomas with only propranolol without additional surgical intervention or corticosteroid use. Review of literature reveals initial case series with similar, successful results using propranolol as an adjuvant treatment along with other medications and surgical interventions. We conclude that the initial use of propranolol as the sole treatment for infantile airway hemangioma is promising. Literature review reveals that propranolol as the sole treatment for most head and neck hemangiomas shows significant promise based on early case reports. Further studies are needed to determine the long-term effectiveness, dosing strategies, and side effect profile of propranolol treatment for hemangiomas.

Pediatric Paradoxical Vocal-Fold Motion: Presentation and Natural History

OBJECTIVES: To describe (1) a cohort of children with paradoxical vocal-fold motion (PVFM) who were referred to a multidisciplinary airway center and (2) the outcomes of various treatment modalities including speech therapy, gastroesophageal reflux disease treatment, and psychiatric treatment. PATIENTS AND METHODS: This was a case series with chart review of children younger than 18 years with PVFM evaluated at a tertiary care pediatric airway center over a 36-month period. RESULTS: Fifty-nine children with PVFM were evaluated. The cohort had a mean age of 13.64 years (range: 8–18 years) and a female-to-male ratio of 3:1. Speech therapy as an initial treatment resulted in a 63% (24 of 38) success rate after an average of 3.7 treatment sessions. Speech therapy was a more successful treatment than antireflux therapy (P = .001). Ten percent (6 of 59) of the children presented with a known psychiatric diagnosis, and 30% (18 of 59) of children in the cohort were ultimately diagnosed with a psychiatric condition. Children with inspiratory stridor at rest had a lower initial success rate with speech therapy (56%), a higher rate of underlying psychiatric disorders (75%), and a high rate of success after psychiatric treatment (100%) that required, on average, 3 sessions over a 2-month period. CONCLUSIONS: To our knowledge, this is the largest study to date on pediatric PVFM. The majority of children with PVFM improve with speech therapy. Children with PVFM at rest may be better treated with psychiatric therapy than speech therapy. Furthermore, children who present with symptoms at rest may have a higher likelihood of underlying psychiatric disease.

Establishment of a Normative Pediatric Acoustic Database

OBJECTIVES To establish a normative pediatric acoustic database and to analyze the acoustic characteristics of the age groups studied. DESIGN Prospective gathering of acoustic parameters on healthy children aged 4 to 18 years. SETTING An outpatient pediatric otolaryngology clinic. PATIENTS A total of 335 children (165 girls and 170 boys) were evaluated. MAIN OUTCOME MEASURES Normative values were obtained for the acoustic parameters studied. RESULTS Discrete fundamental frequency changes occurred at ages 11 and 14 years in girls and ages 12 and 16 years in boys. Values for jitter percentage, shimmer percentage, and noise to harmonic ratio fell within the normative thresholds of adult values. CONCLUSIONS This is the largest pediatric computerized voice analysis database in the English language. This database has been designed to develop an age- and sex-based growth chart to track the developing pediatric voice as it changes with maturation. A distinct vocal profile of girls and boys is evident, with key changes noted at critical periods of development and with significant differences among fundamental frequency between and within sexes. A comprehensive database can be used to help aid future voice therapy and phonosurgical strategies and provide the foundation for future studies into the development of the pediatric voice as it matures into adulthood.

Interdisciplinary Development and Implementation of Communication Checklist for Postoperative Management of Pediatric Airway Patients

Objective. The authors describe their multidisciplinary experience in applying the Institute of Health Improvement methodology to develop a protocol and checklist to reduce communication error during transfer of care for postoperative pediatric surgical airway patients. Preliminary outcome data following implementation of the protocol and checklist are also presented. Study Design. Prospective study from July 1, 2009, to February 1, 2011. Setting. Tertiary care center. Subjects. One hundred twenty-six pediatric airway patients who required coordinated care between Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital. Methods. Two sentinel events involving airway emergencies demonstrated a critical need for a standardized, comprehensive instrument that would ensure safe transfer of care. After development and implementation of the protocol and checklist, an initial pilot period on the first set of 9 pediatric airway patients was reassessed. Subsequent prospective 11-month follow-up data of 93 pediatric airway patients were collected and analyzed. Results. A multidisciplinary pediatric team developed and implemented a formalized, postoperative checklist and transfer protocol. After implementation of the checklist and transfer protocol, prospective analysis showed no adverse events from miscommunication during transfer of care over the subsequent 11-month period involving 93 pediatric airway patients. Conclusion. There has been very little written in the quality and safety patient literature about coordinating effective transfer of care between the pediatric surgical and medical subspecialty realms. After design and implementation of a simple, electronically based transfer-of-care checklist and protocol, the number of postsurgical pediatric airway information transfer and communication errors decreased significantly.

Use of 532-nm Pulsed Potassium Titanyl Phosphate Laser and Adjuvant Intralesional Bevacizumab for Aggressive Respiratory Papillomatosis in Children: Initial Experience

OBJECTIVE To describe the initial pediatric experience with intralesional bevacizumab (Avastin) treatment for children with severe, recurrent respiratory papilloma (RRP). DESIGN Retrospective medical chart review. SETTING Tertiary care multidisciplinary aerodigestive center. PATIENTS Three children, aged 3 to 6 years, with severe RRP requiring more than 4 operative interventions in 1 year whose parents (or legal guardians) consented to adjuvant treatment with intralesional bevacizumab. INTERVENTION All 3 children were treated as follows: surgical debridement with a microdebrider, pulsed potassium titanyl phosphate laser treatments, and adjuvant intralesional injections with bevacizumab (1.25 mg total). MAIN OUTCOME MEASURES Time interval between operative interventions, Derkay severity scale for RRP, and pediatric voice-related quality of life (PVRQOL) scores. RESULTS All 3 children demonstrated increased time between operative interventions. Two children had a substantial decrease in their Derkay score and improved PVRQOL scores. One child, although time between operative interventions improved, did not have any change in Derkay score and required further adjuvant therapy. CONCLUSIONS Injectable bevacizumab appears to show some efficacy in prolonging the time between treatments and therefore reducing the number of treatments per year in children with severe RRP. However, before any meaningful conclusions can be drawn, further studies must be conducted in the form of head-to-head trials looking specifically at the issues of time between treatment intervals, efficacy of one adjunct over another, vocal outcomes, and whether several adjunctive treatments confer advantage over 1 treatment. In-depth and careful informed consent is mandatory for these studies so that parents are aware of the risks and benefits (known and unknown) before such individualized decisions are made.

PARATHYROID CARCINOMA IN MULTIPLE ENDOCRINE NEOPLASIA TYPE 1 WITH A CLASSIC GERMLINE MUTATION

OBJECTIVE To report the case of a patient with multiple endocrine neoplasia type 1 (MEN 1) syndrome with con-comitant parathyroid carcinoma and a classic MEN1 germline mutation. METHODS We present the clinical findings, laboratory results, imaging studies, and surgical histopathologic features in a woman with MEN 1 syndrome and concomitant parathyroid carcinoma. We also review the literature regarding patients with similar clinical entities and the use of adjuvant radiotherapy for parathyroid carcinoma. RESULTS A 53-year-old woman presented with nausea and severe primary hyperparathyroidism. Computed tomography revealed parathyroid masses, shown later to be bilateral parathyroid carcinomas and adenomas. Magnetic resonance imaging demonstrated a pituitary macroadenoma, and gastrinomas were confirmed by computed tomography and a secretin stimulation test. She was successfully treated with total thyroidectomy, subtotal parathyroidectomy, and adjuvant radiotherapy. Genetic analysis revealed a classic MEN1 germline mutation. CONCLUSION This report describes a patient with parathyroid carcinoma occurring in conjunction with MEN 1, further characterizing this rare condition. In contrast to previously described patients, our patient is the first with a classic MEN1 germline mutation, confirming that parathyroid cancer can occur in association with classic MEN 1 genetics.

Coblation lingual tonsillectomy

Lingual tonsillectomy is one of the most loathsome procedures in otolaryngology. Difficult exposure, slow dissection, poor visualization, difficult hemostasis, airway edema, and excessive postoperative pain prevent many otolaryngologists from considering this procedure. Retrolingual airway obstruction from lingual tonsillar hypertrophy is a more common cause of obstructive sleep apnea (OSA) than previously realized. We have increasingly found that lingual tonsil hypertrophy is an overlooked anatomical obstruction site in some patients with continued obstructive sleep apnea after surgical intervention. We’ve tried suction bovie, laser, and an assortment of other tools. We still found the procedure awkward and morbid. Although there is notable controversy whether or not to use coblation for palatine tonsillectomy, we have found that coblation is very helpful for lingual tonsillectomy. Our Australian colleague, Robinson, et al, recently described a novel method of lingual tonsillectomy employing coblation, suspension laryngoscopy, and an operating microscope. Better exposure, faster dissection, better visualization, improved hemostasis, less airway edema with no tracheotomy, and less postoperative pain are touted advan-

Quantitative distinction of unique vocal fold subepithelial architectures using optical coherence tomography.

Objectives: The primary objective of this study was to quantitatively analyze ex vivo porcine, fetal human, and adult human vocal folds by use of optical coherence tomography (OCT). A secondary objective was to quantitatively discriminate among 1-, 2-, and 3-layer lamina propria structures. Methods: We performed an analysis of the vocal folds of 10 adult pig, 3 adult human, and 2 fetal human vocal fold specimens using OCT and histologic techniques. We present a quantitative comparison of the OCT results and histologic findings. Results: We found that OCT allowed for the visualization of the subepithelial vocal fold architecture of all imaged tissue, and that it revealed distinct characteristic signal intensities for each type of specimen. Conclusions: Optical coherence tomography was developed for in vivo imaging of biological microstructures. This study demonstrates the ability of OCT to differentiate between the vocal fold architectures of 3 histologically distinct types of vocal folds. Future studies aim to develop a quantitative optical imaging algorithm that can be used to facilitate an in vivo longitudinal clinical investigation of the changes that occur in this layered structure over time and maturation.

MRI with synchronized audio to evaluate velopharyngeal insufficiency.

Objective To demonstrate the feasibility of simultaneous-acquired magnetic resonance imaging (MRI) and high-quality synchronized audio recording for evaluating velopharyngeal closure. Design Institutional Review Board–approved case series. Setting Tertiary care hospital. Patients Three healthy adult volunteers with a normal speech pattern. Interventions MRI with simultaneous recorded audio files evaluating velopharyngeal closure. Main outcome measure Precise imaging and audio coordination of specific phonatory tasks. Results Synchronization of MRI and audio in all three adults. Conclusion Our novel imaging and audio protocol provides simultaneous acquired MRI with synchronized high quality audio for evaluating velopharyngeal closure. This technique may provide the opportunity to improve diagnosis and surgical planning in patients with velopharyngeal insufficiency.