Faculty Bibliography

OBJECTIVES/HYPOTHESIS: This study investigated the differences between the standard guidelines and the practice patterns of otolaryngologists in managing "penicillin-allergic" patients. A major goal was to identify factors influencing an otolaryngologist's choice of antibiotic. STUDY DESIGN: Cross-sectional survey. METHODS: Four hundred seventy members of the American Society of Pediatric Otolaryngologists (ASPO) and 150 general otolaryngologists from the Florida Society of Otolaryngology (FSO) were surveyed. RESULTS: Ninety-six ASPO members (20.4%) and 22 members of FSO (14.6%) responded. When asked about the management of a pediatric patient with acute otitis media and a history of a nonsevere immunoglobulin E (IgE)-mediated amoxicillin allergy, 54% of ASPO respondents indicated they would initiate guideline-recommended cefdinir, whereas only 27% of FSO respondents chose cefdinir (P = .02). Otolaryngologists who are fellowship trained in pediatrics or have pediatric-focused practices were significantly more likely to prescribe cefdinir. Overall, 57% of respondents indicated that they were familiar with the literature regarding the cross-reactivity of beta-lactams, but only 25% of respondents felt that they could easily differentiate a potentially life-threatening IgE-mediated allergy from a non-IgE-mediated drug intolerance. CONCLUSIONS: The data show differences between the current recommendations and the behavior of otolaryngologists. Pediatric otolaryngologists were more familiar with the guideline-recommended therapy, likely from their frequent exposure to patients requiring a beta-lactam. Nevertheless, most otolaryngologists could benefit from increased awareness of the current literature. Patients may be receiving less than optimal medication management due to a misidentification of those at risk of life- threatening allergic cross-reactions. LEVEL OF EVIDENCE: NA Laryngoscope, 2015.

OBJECTIVES: True vocal fold (TVF) paralysis is a common cause of neonatal stridor and airway obstruction, though bilateral TVF paralysis is seen less frequently. Rare cases of familial congenital TVF paralysis have been described with implied genetic origin, but few genetic abnormalities have been discovered to date. The purpose of this study is to describe a novel chromosomal translocation responsible for congenital bilateral TVF immobility. METHODS: The charts of three patients were retrospectively reviewed: a 35 year-old woman and her two children. The mother had bilateral TVF paralysis at birth requiring tracheotomy. Her oldest child had a similar presentation at birth and also required tracheotomy, while the younger child had laryngomalacia without TVF paralysis. Standard karyotype analysis was done using samples from all three patients and the parents of the mother, to assess whether a chromosomal abnormality was responsible. RESULTS: Karyotype analysis revealed the same balanced translocation between chromosomes 5 and 14, t(5;14) (p15.3, q11.2) in the mother and her two daughters. No other genetic abnormalities were identified. Neither maternal grandparent had the translocation, which appeared to be a spontaneous mutation in the mother with autosomal dominant inheritance and variable penetrance. CONCLUSIONS: A novel chromosomal translocation was identified that appears to be responsible for familial congenital bilateral TVF paralysis. While there are other reports of genetic abnormalities responsible for this condition, we believe this is the first describing this particular translocation.

Complications from a prolonged nasogastric tube intubation, though seldom reported, are well described. Herein we describe the first two reported cases of velopharyngeal insufficiency secondary to velopharyngeal scarring and immobility from repetitive nasogastric tube insertions and prolonged use. Differing only in location, the proposed pathophysiologic mechanism of injury is identical to that of the nasogastric tube syndrome, a rare and serious, well described entity consisting of bilateral vocal fold paralysis due to pressure-induced ulceration of the posterior cricoarytenoid musculature.

OBJECTIVES/HYPOTHESIS: To examine differences between total tonsillectomy and partial intracapsular tonsillectomy techniques that may lead to differences in overall cost and resource utilization between these procedures. Preoperative, perioperative, and postoperative management and outcome factors were examined. STUDY DESIGN: Retrospective review at two university-based tertiary care hospitals from January 2007 to June 2010. METHODS: Pediatric patients with obstructive symptoms were divided into those undergoing total tonsillectomy and those undergoing partial intracapsular tonsillectomy. The records of 289 patients who underwent total tonsillectomy and 289 patients who underwent partial intracapsular tonsillectomy were reviewed. RESULTS: The average age of patients undergoing total and partial tonsillectomies was 5.0 years for both groups. Significant differences for patients undergoing total versus partial tonsillectomies were as follows: operative time (32.4 vs. 26.4 minutes, P < .0001), postanesthesia care unit (PACU) time (174 vs. 91.6 minutes, P < .0001), percent admitted postoperatively (21.5% vs. 1.7%, P < .0001), number requiring pediatric intensive care unit stay (3.5% vs. 0.3%, P < .05), number of readmissions after discharge (3.5% vs. 0.3%, P < .05), and number of postoperative emergency room visits separate from those requiring readmission (4.8% vs. 0%, P < .05). Factors that were not found to be significantly different included number of patients with postoperative hemorrhage and number requiring second operations for tonsillar regrowth. CONCLUSIONS: Previous studies have shown equivalent effectiveness between these two procedures; our study suggests decreased cost and resource utilization with partial tonsillectomy through reduced operative and PACU times and number of postoperative admissions and emergency department visits. As in all retrospective reviews, the findings are potentially confounded by unmeasured variables, including patient and demographic factors. LEVEL OF EVIDENCE: 4. Laryngoscope, 123:2868-2872, 2013.

OBJECTIVE: Many surgical techniques have been described to manage floor of mouth masses, but few studies have described the approach to these masses in children. This case series summarizes a single institution's experience with pediatric floor of mouth masses. METHODS: We performed a retrospective chart review of all children who presented at our tertiary care facility with FOM masses between 2007 and 2012. Charts were reviewed for clinical presentation, preoperative, intraoperative and postoperative management. RESULTS: Thirteen cases were retrieved: 6 dermoid cysts, 4 ranulas, 1 lymphatic malformation, 1 imperforate submandibular duct, and 1 enlarged salivary gland. In 10 of 13 patients, clinical diagnosis was consistent with postoperative diagnosis. Imaging was consistent with postoperative diagnosis in 8 of 9 cases. Ten of 13 masses were managed transorally; 7 were excised, 2 were marsupialized and 1 was managed with submandibular duct dilation. Three masses with a larger submental component, 2 dermoids and 1 ranula, were removed transcervically. Most patients undergoing transoral excision underwent nasotracheal intubation; patients who underwent marsupialization underwent orotracheal intubation. There were no recurrences, complications or postoperative infections. An additional surgical procedure was necessary in one patient. CONCLUSION: Our cohort displays a common distribution of lesion types when compared to the literature. Low recurrence and infection rates are observed when oral masses are removed transorally, and masses with a larger cervical component are removed transcervically. More complex masses may warrant additional surgical procedures.

OBJECTIVE: To perform a systematic literature review and data synthesis of level-1 evidence comparing recovery-related outcomes after intracapsular tonsillectomy (IT) (any technique) with those of total tonsillectomy (TT) (any technique) in a pediatric population. DATA SOURCES: Two independent reviewers searched the following databases: Ovid MEDLINE, including old MEDLINE and pre-MEDLINE, EBM reviews, Books@Ovid and Journals@Ovid, the Web of Science with Conference Proceedings, and references from indexed articles. STUDY SELECTION: Inclusion criteria were randomized controlled trials conducted on a pediatric population comparing IT performed by any technique of dissection with TT, also performed by any technique of dissection. Two independent reviewers determined included trials with difference of opinion resolved by a third reviewer. DATA EXTRACTION: Independent data extraction by 2 reviewers on the following outcomes: postoperative pain, analgesic use, recovery time, diet, bleeding rate, infection, and regrowth rate requiring further surgical intervention. DATA SYNTHESIS: Heterogeneity of outcome measures and lack of reporting of raw data precluded formal meta-analysis. For quantitative data that could be extracted, pooled data analysis was performed using nonparametric tests. CONCLUSION: Recovery-related outcomes for IT were superior to TT (secondary hemorrhage rate, number of days until pain free) in a pediatric population with obstructive symptoms (level-1 evidence).

Cystic fibrosis is a genetic disease, characterized by accumulation of thickened mucous secretions in exocrine glands. Although the major clinical manifestations of the disease are pancreatic and pulmonary disease, the majority of cystic fibrosis patients will develop sinonasal manifestations as well. This paper outlines the etiology, evaluation, and management of the nasal and sinus manifestations in patients with cystic fibrosis.

OBJECTIVES: To review our experience with intracapsular tonsillectomy using powered instrumentation (PIT) in the management of tonsillar hypertrophy. DESIGN: Retrospective database review of pediatric patients undergoing PIT. METHODS: The medical records of 636 patients under 11 years of age who underwent PIT performed by the senior author (RFW), predominantly for obstructive sleep disturbance, were reviewed. Data were subsequently analyzed from 559 of these patients for clinical evidence of tonsillar regrowth, post-operative tonsillar hemorrhage, and post-operative dehydration due to pain. Specific information for possible correlation of age at the time of surgery and any increased rate of regrowth was primarily examined. RESULTS: There were a total of 33 patients who had clinical evidence of regrowth. Children less than 5 years of age had 5 times the incidence of regrowth (p<0.001). Out of the group that exhibited regrowth, 5 patients exhibited evidence of recurrent upper airway obstruction and underwent a complete tonsillectomy. The age of this complete tonsillectomy group ranged from 1.1 to 2.7 years. Out of all patients undergoing PIT, there was 1 incident of delayed post-operative dehydration due to emesis but not due to pain. There were 2 incidents of delayed post-operative tonsillar bleeds. All three complications were self-limited and did not require re-hospitalization. CONCLUSIONS: PIT is a safe procedure with a small risk of tonsillar regrowth being age related. The incidence of postoperative complications following PIT is relatively low (0.54%).

OBJECTIVE: Endoscopic balloon dilation is increasingly popular as primary therapy for infants with subglottic stenosis. We aim to determine the maximum balloon diameter and pressure where no fracture of the cricoid would occur, minimum balloon size and pressures where a gross fracture of the cricoid occurs, and location of these fractures. We tested these objectives by performing balloon dilation in laryngotracheal complexes of eight euthanized adult male New Zealand white rabbits, with airway characteristics similar to a 3- to 9-month-old infant. METHODS: Subglottic airway diameter of each specimen was determined using endotracheal tubes (Cotton-Myer grading system). Preexistent subglottic disease was excluded by rigid endoscopy. Serial dilation with balloon catheters was performed, employing incremental balloon sizes and pressures, to determine balloon size and pressure, which resulted in a cricoid fracture. Locations of gross fractures were validated by two independent observers. RESULTS: Airway diameter of all specimens was 5.4 mm (size 4.0 endotracheal tube). Four of the seven cricoid cartilages exhibited gross fractures. Dilation with balloon diameters less than 6.0 mm failed to induce a fracture despite maximal inflation to 16.0 atmospheres. The minimum balloon size required to create a fracture was 7.0 mm, at a pressure of 6.0 atmospheres. All fractures occurred at the anterior lamina of cricoid ring. CONCLUSIONS: No fractures occurred when balloon dilation was performed with a balloon 0.6 mm or smaller than the measured subglottic diameter. Fractures of the cricoid occurred when balloon dilation was performed with a balloon 1.6 mm or larger than the subglottic diameter.