Faculty Bibliography

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 reflect on lessons learned placing endotracheal nitinol stents in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: All children who underwent nitinol cervical tracheal stenting were included. Records were carefully reviewed for intraoperative and postoperative complications, management choices, outcomes, and factors that influenced results. RESULTS: Between 1999 and 2011, 7 children underwent 13 stent placements. Median follow-up was 5 years (range, 1-12 years). Six patients underwent stenting as a salvage procedure following open attempts at airway reconstruction. Four patients remain decannulated with their stent in place (median follow-up 7 years). The fifth patient had his stent removed endoscopically after 50 days because it became apparent that his obstruction was primarily laryngeal. The sixth child had his stent removed via a tracheal fissure after 14 months because of recalcitrant subglottic inflammation at the superior stent border. The seventh patient was decannulated for over 2 years but ultimately required tracheotomy replacement because of stenosis with the stent lumen. Complications included stent migration (23%), restenosis (29%), edema (29%), and granulation (57%). CONCLUSION: Endotracheal nitinol stents provide a realistic opportunity for decannulation in children for whom other options have failed but should be reserved only as a salvage procedure in severely complicated airways. Our experience has taught valuable lessons about stent indications, sizing, characteristics, and deployment, as well as means to avoid and manage their complications.

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.

OBJECTIVE: To better understand the diagnosis, treatments, and outcomes of congenitally imperforate salivary ducts. METHODS: A systematic literature review was performed using the following terms: imperforate submandibular duct, imperforate Wharton's duct, congenital atresia submandibular duct, congenital atresia sublingual duct, and congenital ranula. Only papers focusing on congenital floor of mouth cysts arising from imperforate salivary ducts were included. Two additional patients from our own experience are also discussed. RESULTS: Seventeen papers published since 1950 met inclusion criteria. A total of 26 patients underwent therapy ranging from mere observation to complete excision of the cyst with the sublingual gland. Both of our 2 additional patients both underwent simple sialodochostomy (excision of the imperforate sublingual caruncle) with cyst decompression. For all 28 patients, there have been no reported recurrences, with mean follow-up of 24.8 months and median follow-up of 14.8 months. CONCLUSIONS: Congenital floor of mouth cysts arising from imperforate salivary ducts are rare, but they may mimic the appearance of a ranula. Unlike ranulas, these cysts may be safely and effectively cured by simple sialodochostomy. To date, 26 other cases have been described in the literature, and nearly all have been successfully treated with simple incision or marsupialization without recurrence. Care should be taken to exclude ranula as a diagnosis, as incomplete excision may likely result in recurrence.

The treatment of laryngotracheal stenosis has evolved over the past several decades. Advances in technology, equipment and medication have increased our ability to treat some airway stenosis in a minimally invasive manner, and at times by an endoscopic method. With improved precision, our results with postoperative voice and swallowing should improve

OBJECTIVES: To discuss the cause and management of recurrent periorbital cellulitis (RPOC). STUDY DESIGN: Retrospective case series and review of literature. MATERIALS AND METHODS: In the past 11 years, we have treated 6 patients for recurrent periorbital cellulitis (RPOC). Inclusion criteria were a minimum of 3 episodes of periorbital cellulitis (POC) within a 1-year period, with interval convalescence lasting at least 1 month. All patients were followed for at least 1 year after resolution. RESULTS: The causes of RPOC were as follows: (1) 2 patients developed RPOC attributed to environmental allergies; (2) 1 was diagnosed with underlying recurrent sinusitis resistant to medical management with resolution attained through surgery; (3) 1 patient with vesicular RPOC was diagnosed with herpetic RPOC and treated medically with antiviral therapy; (4) 1 patient had allergic contact dermatitis from cosmetic make-up use; and (5) 1 patient was suspected of malingering via repeat subcutaneous self-injection of an irritant. CONCLUSIONS: Although periorbital cellulitis is a commonly encountered and treatable condition, recurrent periorbital cellulitis is rare and may be challenging to manage. In our experience, the causes of recurrence varied, but resolution was achieved by identifying the underlying cause through continuous clinical reassessment and by appropriate medical or surgical management. EBM rating: C-4

Prior to 1999, the diagnosis of otomycosis as a cause of persistent otorrhea was rare. An increase incidence has been seen in among our outpatient pediatric otolaryngology practice. The purpose of this study is to assess the contribution of ototopical antibiotic drops to the development of otomycosis. DESIGN: Retrospective study. SETTING: Pediatric otolaryngology outpatient center. METHODS: Chart review of all patients diagnosed with otomycosis between June 1999 and September 2001. Twenty-six patients (ages 17 months-29 years) were diagnosed with otomycosis based on clinical and microbiological findings after treatment with topical ofloxacin antibiotic drops. All patients had used ototopical antibiotics, including ofloxacin in every case, for presumed bacterial otorrhea. Once the fungal source was recognized, therapy succeeded in each case (26/26). Physicians need an elevated suspicion of otomycosis as a cause of persistent otorrhea, especially following treatment with topical antibiotic drops. Appropriate treatment of otomycosis eliminates otorrhea. Ofloxacin remains an excellent choice for bacterial otorrhea, but it appears to increase the incidence of otomycosis. Thus, its usage warrants careful post-treatment follow-up.

OBJECTIVE: To determine the efficacy of powered intracapsular tonsillectomy (PIT, e.g. regrowth rate) in children who underwent PIT at three different institutions. We also wanted to determine if the trend to greater safety through reduced bleeding and re-admission for dehydration, noted in our initial reports, would become statistically significant in a larger sample. STUDY DESIGN AND SETTING: Multi-center retrospective case series. PATIENTS AND METHODS: We retrospectively reviewed all charts' of children who underwent PIT at three different institutions: the Children's Hospital at the Cleveland Clinic, Alfred I. DuPont Hospital for Children, and the New York Otolaryngology Institute. For comparison, we reviewed the outpatient and inpatient records of all children who underwent conventional tonsillectomy performed by the same surgeons at the Children's Hospital at the Cleveland Clinic and Alfred I. DuPont Hospital for Children during the same period. No comparison group was available for the New York Otolaryngology Institute group. Three outcome measures were recorded: regrowth, bleeding and re-admission for dehydration rates. All statistical analyses were performed using SAS, and P < 0.05 was considered statistically significant. RESULTS: We identified 870 children that underwent PIT at three different institutions. In addition, 1121 children underwent conventional tonsillectomy at two of the three institutions. The mean follow-up for the PIT group was 1.2 years (range, 0.1-2.6 years) and 1.5 years (range, 0.1-3.0 years) for the conventional tonsillectomy group. The incidence of and 95% CI for the outcome measures were as follows regrowth 0.5% (0%, 1.4%), delayed post-operative bleeding 0.7% (0%, 1.9%), re-admission for dehydration 1.3% (0.05%, 2.6%), and overall major complications 0.46% (0.009%, 0.9%). When comparing conventional tonsillectomy to PIT, the bleeding rate, re-admission for dehydration, and the overall incidence of major complications were significantly lower in the PIT group (P = 0.001, P = 0.002, and P < 0.001, respectively). CONCLUSION: PIT is a safe and effective technique in the management of obstructive sleep disordered breathing in children. PIT has the advantages of decreased pain, dehydration and post-operative bleeding, and with a mean follow-up of 1.2 years, a low incidence of tonsillar regrowth thus far

OBJECTIVES: (1) To assess the safety and efficacy of outpatient intracapsular tonsillectomy, which has been recently described as a less invasive means of treating obstructive tonsillar hypertrophy, in children younger than 3 years; and (2) to challenge the standard dictum that children younger than 3 years should be admitted to the hospital after tonsil and adenoid surgery. DESIGN: Retrospective cohort study via medical chart review and telephone interview. SETTING: Pediatric otolaryngology group practice with academic affiliation.Patients Children with symptomatic tonsillar and adenoid hypertrophy (n = 226) who underwent microdebrider-assisted intracapsular tonsillectomy between September 1, 2000, and October 1, 2002. METHODS: Comparison of study group (children <3 years old, n = 38; mean age, 30.3 months; 20 boys and 18 girls) with control group (children > or =3 years, n = 188), measuring pain, oral intake, analgesic requirements, complications, need for readmission, and relief of symptoms. RESULTS: There were no statistically significant differences in pain, oral intake, or analgesic requirements. All children, regardless of age, were discharged home within 4 hours of surgery. No child in either group required readmission, and there were no complications related to the time of discharge. Younger children experience equivalent symptomatic improvement. CONCLUSION: Children younger than 3 years may undergo intracapsular tonsillectomy as outpatients without sacrificing safety or efficacy