Annals of Otology Rhinology and Laryngology最新文献

Background: An endoscopic screening program following successful weaning from prolonged mechanical ventilation maintained through endotracheal tube (ET; prolonged intubation) may be justified to assess the upper (laryngotracheal) airway in children who may not always be symptomatic for intubation-related complications.

Objectives: To evaluate effects of prolonged intubation in children through endoscopic screening of the laryngotracheal airway.

Methods: In this cross-sectional pilot project, children (2 months-12 years) successfully extubated following prolonged intubation were selected, irrespective of having symptoms, for a 1-time flexible nasolaryngoscopy at third to sixth month post-extubation (follow-up window). Laryngotracheal airway changes, if present, were noted.

Results: Out of 122 children, 42 developed symptoms of complications. Five of them attended within 3 months post-extubation, the rest were evaluated in the follow-up window. Eighty children aged ≤6 years and 4 children >6 years were intubated with uncuffed ET. Symptoms, when present, included respiratory distress (100%), noisy breathing (~36%), cough (~29%), and dysphagia (~12%). Screening revealed positive findings in 40 out of 42 symptomatic children, and in 8 out of 80 asymptomatic children (χ² = 80.314; after Yate's correction; significant at P < .0001). The commonest lesion was subglottic stenosis (~54%) and intubation granuloma (~48%). Relationship between the nature of ET (cuffed/uncuffed) and complications of prolonged intubation was statistically significant (χ²46.553; significant at P < .0001).

Conclusion: The present study proposes the potential utility of follow-up endoscopic screening of upper (laryngotracheal) airway in children successfully weaned from prolonged intubation. A statistically significant relationship existed between prolonged intubation and upper airway complications that were not always symptomatic.

Objective: To evaluate whether supracricoid partial laryngectomy (SCPL) may be a viable alternative to radiation therapy (RT) for patients with glottic cT3N0M0 squamous cell carcinoma (SCC) who are surgical candidates for total laryngectomy (TL) and respond well to platinum-based induction chemotherapy.

Methods: Retrospective case series review of 18 consecutive patients with cT3N0M0 glottic SCC, initially considered surgical candidates only for TL who showed a good response to platinum-based induction chemotherapy, managed at a French university teaching institution with either SCPL (n = 9) or RT (n = 9). The main endpoints were 10-year local control and laryngeal preservation. The secondary endpoints were 10-year survival, causes of death analysis, and univariate analysis of local control and survival.

Results: The 10-year actuarial local control, laryngeal preservation, survival rates were 77.8%, 88.9%, and 66.7% after SCPL, respectively, and 72.9%, 87.5%, and 33.3%, after RT without significant statistical differences. In univariate analysis none of the clinical variables under analysis were related to local control and survival.

Conclusions: Our data suggest that SCPL may warrant further consideration as a treatment option for glottic cT3N0M0 SCC patients who respond well to platinum-based induction chemotherapy. However, additional prospective research is warranted given the retrospective, nonrandomized nature of the presented case series.

Objective: To evaluate the effectiveness of coordinated endoscopy with otolaryngology, pulmonology, and gastroenterology in diagnosing and managing recurrent croup in pediatric patients.

Methods: We reviewed our REDCap Pediatric Aerodigestive Database for patients with recurrent croup who underwent coordinated endoscopy between January 2013 and July 2023. We reviewed patient demographics, comorbidities, surgical findings, treatments, and outcomes.

Results: Twenty-five patients were identified with recurrent croup. Their mean (SD) age was 37 (27) months (range = 9-98 months) with half of the patients younger than 25 months. The most common findings noted on combined endoscopies were positive bacterial culture on BAL (n = 10), and tracheomalacia (n = 7), and subglottic stenosis (n = 4). A history of prematurity was significantly associated with the presence of SGS (p = 0.01). Snoring/sleep-disordered breathing (SDB) was associated with a positive bacterial BAL culture (p = 0.03). About half of our cohort (48%) had multiple abnormalities identified by at least 2 different specialists at the time of endoscopy.

Conclusions: For patients experiencing frequent or severe recurrent croup episodes, a thorough aerodigestive evaluation and management plan should be pursued. Coordinated endoscopy may be considered for select patients who do not respond to medical treatment.

Background: Granulation tissue formation and tracheitis are common pediatric tracheostomy complications. Ciprofloxacin/dexamethasone is frequently prescribed, but the influence of social determinants on this topic is unexplored.

Methods: This study extends a prior cohort study of pediatric tracheostomy patients at a single academic institution from 2016 to 2020. Social determinants of health, including race, insurance status, and residence characteristics, including Area Deprivation Index (ADI), were evaluated. Logistic regression, Wilcoxon rank-sum, and log-rank tests (α = .05) analyzed relationships between these determinants and prescriptions and post-tracheostomy outcomes.

Results: This cohort included 182 patients; 98/182 (53.9%) were male, and 140/182 (76.9%) were White, non-Hispanic. Non-White race was associated with increased odds of receiving nebulized ciprofloxacin/dexamethasone (OR = 2.80, 95% CI = 1.25-6.29). In those with tracheal culture results available (n = 63), Staphylococcus aureus was more common with public insurance (29/47, 7 with MRSA, 61.7%) compared with private (5/16, 3 with MRSA, 31.3%; OR = 3.54, 95% CI = 1.05-11.9). ADI was greater in the 7 patients with Streptococcus pneumoniae (median = 95, IQR = 88-99) compared to without (median = 77, IQR = 65-81, P = .003). Patients with tracheitis lived further from our center (median = 44.7 miles, IQR = 27.7-91.4 miles) compared with those who did not develop tracheitis (median = 33.4 miles, IQR = 12.0-85.2 miles, P = .02). Antibiotic resistance was more prevalent in children discharged home (14/35, 40.0%) than to transitional care (3/28, 10.7%; OR = 5.56, 95% CI = 1.40-22.0) and was associated with longer hospital stays (median = 70 days, range = 34-152 vs median = 35 days, range = 15-75 days, P = .02). Non-White patients experience increased odds of decannulation over time compared with White patients (HR = 2.85, 95% CI = 1.21-6.70). Discharge locations and ADI were associated with dressing choice post-tracheostomy.

Discussion: This study revealed racial disparities in ciprofloxacin/dexamethasone usage, residence-related differences in tracheal culture results, and ADI-related dressing choices, which highlight the need for tailored, equitable care to optimize outcomes.

Level of evidence: 4.

Objective: The utility of lateral neck X-rays is unclear in pediatric otolaryngology. Past research showed that lateral neck X-ray did not change treatment decisions for children with suspected foreign body aspiration. This study examines the utility of lateral neck X-ray for patients also receiving otolaryngology consults for any indication.

Methods: This is a retrospective chart review of pediatric patients between 2012 and 2022 who received a lateral neck X-ray for any indication and an otolaryngology consultation at a tertiary pediatric hospital. X-ray indication, diagnosis, and influence on interventional decisions were recorded from chart review.

Results: Of patients who received lateral neck X-rays, 494 patients (8.17%) also had an otolaryngology consult. Average patient age was 3.15 years. The most common indications for X-ray were foreign body aspiration (22%), croup (21%), breathing difficulties (20%), abscess or retropharyngeal infection (7%), and upper airway obstruction (5%). Lateral neck X-ray changed the Otolaryngologist's decision in 15% of patients. Intervention occurred in 25% of Otolaryngology consults, and this decision was never based on the X-ray.

Conclusion: Lateral neck X-ray is unlikely to change Otolaryngology management. It is least indicated in patients presenting with concern of abscess and foreign body aspiration. Consultation with Otolaryngology before ordering diagnostic testing for those presenting with breathing difficulties, croup and upper airway obstruction may have cost savings and prevent unnecessary radiation exposure.

Objectives: The prevalence of obstructive sleep apnea (OSA) is known to be higher in children with Down syndrome (DS) than the general pediatric population, with lower rates of surgical cure. This study aims to determine the prevalence and predictors of OSA and evaluate the outcomes of surgical intervention for OSA in a cohort of Australian children with DS.

Methodology: A retrospective chart review was conducted on 156 patients with DS from 0 to 18 years who had undergone overnight, attended polysomnography (PSG) at Sydney Children's Hospital from January 2010 to July 2023. Logistic regression was used to assess associations between OSA and age, gender, body mass index (BMI), and tonsillar size. The outcomes of surgery were determined by comparing the pre-operative and post-operative PSG results.

Results: The prevalence of OSA at first PSG was 65.8%, defined by an obstructive apnea-hypopnea index (OAHI) ≥1 event/hour. Elevated BMI in children above 2 years was associated with the presence of OSA (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.02-1.71). Male gender was a predictor for an OAHI >5 events/hour (OR = 4.01, 95% CI = 1.09-14.78). Among 35 patients who underwent adenotonsillectomy and had a valid pre-operative and post-operative PSG, median OAHI was reduced from 12.6 to 3.8 events/hour (P = .002). In 13 patients who had secondary upper airway surgery, median OAHI was reduced from 8.5 to 2.6 events/hour (P = .075).

Conclusion: Children with DS and OSA who undergo surgical intervention may experience improvements to their PSG parameters.

Objectives: To describe patient positioning maneuvers that optimize visualization of the oropharynx during flexible endoscopyMethods:An institutional database of videos obtained from 2021 to 2023 during flexible endoscopy of patients with oropharyngeal carcinoma (OPC) was reviewed. Patients seen outside the specialty head and neck clinic, those with tonsillar primary tumors, and those only with videos of fiberoptic swallowing evaluations were excluded. A total of 10 videos were then independently analyzed by 2 reviewers to assess the effects of 4 maneuvers on oropharyngeal tumor visualization: chin elevation, phonation, tongue protrusion, and contralateral head turn. After segmentation analysis in Label Studio, total surface area (SA) of visualized tumor in pixels was calculated in Python and compared against the maximum width of the epiglottis to calculate relative SA.

Results: Four different maneuvers were evaluated in this study: (1) chin elevation [n = 4]; (2) phonation [n = 9]; (3) tongue protrusion [n = 4]; and (4) contralateral head turn [n = 9]. The maneuvers on average increased the visualization of tumor surface area(SA) compared to baseline view: contralateral turn increased SA by 1.7 fold (95% CI = 1.11-2.34), phonation increased SA by 1.7 fold (95% CI = 1.11-2.37), tongue protrusion increased SA by 1.5 fold (95% CI = 1.16-1.80), and chin elevation increased SA by an average of 2.7 fold (95% CI = 0.74-4.72).

Conclusion: Instituting simple additional positioning techniques during flexible endoscopy for patients with oropharyngeal tumors can improve visualization and staging for baseline assessment and staging.

Objective: Soluble fibrinogen-like protein 2 (sFGL2) may be involved in the pathology and progression of allergic rhinitis (AR) through regulating T-helper (Th)2 cell response. This study aimed to explore the ability of sFGL2 to estimate outcomes in AR patients.

Methods: sFGL2 was detected in the serum sample of 119 AR patients at baseline and 20 healthy controls (HCs) after enrollment by enzyme-linked immunosorbent assay. In AR patients, disease severity was assessed at baseline as well as 4 weeks (W4) and 8 weeks (W8) after enrollment by the total nasal symptom score (TNSS).

Results: sFGL2 was higher in AR patients than HCs [median (interquartile range): 100.0 (70.0-154.0) vs 47.0 (31.5-78.5) ng/mL] (P < .001). In AR patients, sFGL2 was positively correlated with TNSS score (P = .002), itching score (P = .037), sneezing score (P = .012), and interleukin (IL)-4 (P = .006) at baseline. TNSS score declined from baseline to W8 in AR patients (P < .001). To further explore the association between sFGL2 levels and treatment outcomes, we compared the sFGL2 levels between patients with TNSS scores at W4 or W8 >4 and those with TNSS scores at W4 or W8 ≤4. It was found that sFGL2 was only increased in AR patients with a TNSS score at W4 >4 versus those with a TNSS score at W4 ≤4 (P = .012).

Conclusion: Serum sFGL2 is increased in AR patients, and its high level estimates an increased Th2 cytokine and disease severity as well as poor outcomes.

Parathyroid gland (PG) auto-transplantation is performed to preserve the function of de-vascularized or unintentionally removed PGs, however, little has been published about the technique and outcomes in children. In our study, we aimed to present the results of PG auto-transplantation in children undergoing thyroidectomy or parathyroidectomy at a tertiary single institution. A retrospective review identified 14 patients (<18 years of age) who underwent PG auto-transplantation from January 2000 to December 2022. 57.1% (8/14) had transient postoperative hypocalcemia and 14.3% (2/14) had permanent postoperative hypocalcemia. Eight patients had transient hypoparathyroidism, correlating with the rate of transient hypocalcemia. The most common reimplantation site was the sternocleidomastoid (11/14) and it was significantly associated with normalized calcium levels 6 months after auto-transplantation (p=0.033). Bilateral central neck dissection and surgical indication of cancer had a statistically significant association with transient hypocalcemia (p=0.03 and p=0.005, respectively). Our study provides valuable insights into the outcomes of PG auto-transplantation in pediatric patients, highlighting the potential for successful engraftment and factors associated with hypocalcemia.

Objectives: Transoral robotic surgery (TORS) for benign glottic conditions is scarcely represented in the literature. We aimed in this study to report on the technical feasibility of an explicitly transoral robotic approach for a patient with posterior glottic stenosis, and to highlight extant limitations in exposure and robotic instrumentation of the glottis.

Methods: Retrospective chart review of a single patient undergoing a TORS approach to maximize the posterior glottic aperture.

Results: A 42-year-old female patient with posterior glottic stenosis and a tracheotomy was consented for a robotic posterior glottic scar lysis, KTP-laser assisted partial arytenoidectomy, balloon dilation, and steroid injection. The da Vinci Intuitive Surgical single-port robotic platform was used with 2 robotic arms (needle driver and scissors), and an FK-WO transoral retractor with a straight tongue blade was deployed to facilitate endolaryngeal exposure. KTP laser fiber was passed through a robotic, semi-flexible drop-in guide, and manipulated with the needle driver. Case duration was 40 minutes. There were no perioperative or immediate post-operative complications noted on short-term follow-up.

Conclusion: We demonstrate technical feasibility and equipoise between an explicitly robotic approach and a standard endoscopic approach to posterior glottic stenosis, a common glottic condition. Further technological development and adaptation of surgical technique are necessary to advance benign robotic laryngeal surgery.