Faculty Bibliography

BACKGROUND: Inferior turbinate (IT) hypertrophy and adenoid hypertrophy are both causes of pediatric nasal obstruction. OBJECTIVE: The purpose of this survey was to study nasal obstruction evaluation and management among pediatric otolaryngologists with respect to IT and adenoid hypertrophy. METHODS: A questionnaire with embedded clinical videos was sent electronically to American Society of Pediatric Otolaryngology members. RESULTS: A total of 435 questionnaires were sent, and 75 were completed. Respondents were presented with scenarios that involved a 7-year-old child with nasal obstruction unresponsive to medical therapy, and the respondents were asked to choose a surgical plan, either IT reduction, adenoidectomy, or combined IT reduction and adenoidectomy. Three questions described the extent of IT and adenoid obstruction in text form, although three questions included a video of the child's nasal endoscopy. In questions with perceived or stated IT hypertrophy, the respondents chose to perform IT reduction significantly more frequently when the perceived or stated adenoid hypertrophy was less severe (p < 0.0001 for video and p = 0.039 for written questions). CONCLUSION: The decision to perform IT reduction in children is inversely related to the extent of adenoid hypertrophy. Future studies on pediatric IT surgery should include objective descriptions of the IT and adenoid in study subjects.

OBJECTIVE: To perform a systematic review of the pathogenesis of medication-induced salivary gland dysfunction (MISGD). MATERIALS AND METHODS: Review of the identified papers was based on the standards regarding the methodology for systematic reviews set forth by the World Workshop on Oral Medicine IV and the PRISMA statement. Eligible papers were assessed for both the degree and strength of relevance to the pathogenesis of MISGD as well as on the appropriateness of the study design and sample size. A total of 99 papers was retained for the final analysis. RESULTS: MISGD in human studies was generally reported as xerostomia (the sensation of oral dryness) without measurements of salivary secretion rate. Medications may act on the central nervous system (CNS) and/or at the neuroglandular junction on muscarinic, alpha-and beta-adrenergic receptors and certain peptidergic receptors. The types of medications that were most commonly implicated for inducing salivary gland dysfunction were those acting on the nervous, cardiovascular, genitourinary, musculo-skeletal, respiratory, and alimentary systems. CONCLUSIONS: Although many medications may affect the salivary flow rate and composition, most of the studies considered only xerostomia. Thus, further human studies are necessary to improve our understanding of the association between MISGD and the underlying pathophysiology

OBJECTIVES/HYPOTHESIS:To evaluate the increase in access to the maxillary sinus (MS) with transnasal endoscopic medial maxillary sinus wall transposition (TEMMT), while preserving major structures of the nasal cavity. STUDY DESIGN:The study was divided into three parts: anatomical, radiographic, and case series. METHODS:Three cadaveric dissections (total of six sides) confirmed the feasibility of the TEMMT approach. Radiographic measurements using maxillofacial computed tomography scans were taken to assess the maximal antrostomy. The TEMMT approach was performed on six consecutive patients with benign MS disease. RESULTS:The cadaveric measurements were consistent with the radiographic measurements, which confirmed the maximum access to the MS. The radiographic measurements ranged from 14.4 to 39.1 mm in the anteroposterior dimension, 8.2 to 23.7 mm in the superior-inferior dimension, and 36° to 98° in the angle between the medial and anterior wall of the MS. In the patient series, five patients presented with an odontogenic cyst, and one patient had an antrochoanal polyp in the MS. The TEMMT approach provided excellent access and adequate resection, as well as preservation of the nasolacrimal duct and inferior turbinate. Finally, the mucosal flap was sufficient to cover the inferior meatal antrostomy. CONCLUSIONS:TEMMT provides excellent access into the MS, especially the floor and anterior wall, without the morbidities of the Caldwell-Luc or medial maxillectomy approach. In addition, the transposition of the inferior turbinate and the mucosal flap provides coverage of the medial wall with preservation of the inferior meatus, inferior turbinate, and nasolacrimal duct for patients with benign MS disease. LEVEL OF EVIDENCE:NA Laryngoscope, 126:1504-1509, 2016.

Submandibular gland ptosis is a common impediment to obtaining superior surgical aesthetic results in neck lift surgery. Techniques for suspending the submandibular gland have been proposed, but these procedures have the drawbacks of disturbing the floor of the mouth mucosa and periosteum. We present an approach of submandibular gland suspension for the treatment of gland ptosis by employing a platysma and hyoid bone fascia cradle. Our technique was performed on cadaveric models. The platysma muscle and hyoid bone cradle for submandibular gland ptosis was created on the left side of the neck in two cadavers. A submental incision with sharp dissection was performed to raise a supraplatysmal flap. A subplatysmal plane was developed until the submandibular gland was identified. Sutures were used to pexy the platysma to the hyoid bone periosteum and deep cervical fascia, tightening the overlying muscle and in turn elevating the submandibular gland. Submandibular gland ptosis must be corrected in order to achieve exemplary aesthetic results. Our approach of creating a cradle with the platysma and hyoid bone avoids the potential complications of previously described sling procedures, while still maintaining the integrity of the gland and surrounding tissues.

OBJECTIVE: To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia. METHODS: Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). RESULTS: Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy. CONCLUSION: Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

BACKGROUND: Commonly occurring in the head and neck, paragangliomas are typically benign, highly vascular neoplasms embryologically originating from the extra-adrenal paraganglia of the neural crest. Frequently, these tumors are associated with the vagus or tympanic plexus nerve or the carotid artery, or jugular bulb. Their clinical presentation can vary across a wide spectrum of signs and symptoms. METHODS: We reviewed and compared standard treatment approaches for paragangliomas of the head and neck. RESULTS: In general, surgery is the first-line choice of therapy for carotid body tumors, whereas radiotherapy is the first-line option for jugular and vagal paragangliomas. CONCLUSIONS: Because of the complexity of clinical scenarios and treatment options for paragangliomas, a multidisciplinary algorithmic approach should be used for treating paragangliomas. The approach should emphasize single-modality treatment that yields excellent rates of tumor control, low rates of severe, iatrogenic morbidity, and the preservation of long-term function in this patient population.

BACKGROUND: Tenecteplase, a modified plasminogen activator with higher fibrin specificity and longer half-life, may have advantages over alteplase in acute ischemic stroke thrombolysis. AIMS: We undertook an individual patient data meta-analysis of randomized controlled trials that compared alteplase with tenecteplase in acute stroke. METHODS: Eligible studies were identified by a MEDLINE search, and individual patient data were acquired. We compared clinical outcomes including modified Rankin Scale at three months, early neurological improvement at 24 h, intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality at three months between all dose tiers of tenecteplase and alteplase. RESULTS: Three relevant studies (Haley et al., Parsons et al., and ATTEST) included 291 patients and investigated three doses of tenecteplase (0.1, 0.25, 0.4 mg/kg). There were no differences between any dose of tenecteplase and alteplase for either efficacy or safety end points. Tenecteplase 0.25 mg/kg had the greatest odds to achieve early neurological improvement (OR [95%CI] 3.3 [1.5, 7.2], p = 0.093), excellent functional outcome (modified Rankin Scale 0-1) at three months (OR [95%CI] 1.9 [0.8, 4.4], p = 0.28), with reduced odds of intracerebral hemorrhage (OR [95%CI] 0.6 [0.2, 1.8], P = 0.43) compared with alteplase. Only 19 patients were treated with tenecteplase 0.4 mg/kg, which showed increased odds of symptomatic intracerebral hemorrhage compared with alteplase (OR [95% CI] 6.2 [0.7, 56.3]). CONCLUSIONS: While no significant differences between tenecteplase and alteplase were found, point estimates suggest potentially greater efficacy of 0.25 and 0.1 mg/kg doses with no difference in symptomatic intracerebral hemorrhage, and potentially higher symptomatic intracerebral hemorrhage risk with the 0.4 mg/kg dose. Further investigation of 0.25 mg/kg tenecteplase is warranted.

INTRODUCTION: Although rare, complications in cochlear implantation may result from surgical or technical mishaps, reaction to the foreign body, infection, or mechanical device failure. Delayed cerebrospinal fluid (CSF) leak is a rarely reported condition that may present with asymptomatic swelling over the receiver-stimulator (RS). In our practice, meticulous drilling of a bony well is important in preventing device migration and maintaining a low device profile but there is the potential for immediate or delayed complication from this technique. OBJECTIVE: We report two cases of the diagnosis and management of delayed extradural CSF collection of the RS bony well and describe its successful management. PATIENTS: Two pediatric cochlear implant patients, 10 and 17 months of age with devices from different manufacturers. INTERVENTION(S): Operative exploration and repair without device removal. MAIN OUTCOME AND RESULTS: Although the initial postoperative course was uncomplicated with both patients receiving benefit from their device, both presented at varying intervals month(s) later with swelling over the RS. There were no signs of infection but the swelling prevented use of the device. Extradural CSF collection was suspected, confirmed operatively, and repaired with complete resolution without the need for reimplantation. CONCLUSION: Delayed CSF leak may present as an asymptomatic swelling over the RS after cochlear implantation. Sterile fluid aspiration may confirm the diagnosis and management can proceed conservatively or with operative exploration and repair. Future device designs with lower profiles may facilitate device fixation while allowing for a more shallow well, further reducing the risk of this rare complication.

Brain tumors collectively represent the most common solid tumors in childhood and account for significant morbidity and mortality. Until recently, pediatric brain tumors were diagnosed and classified solely based on histologic criteria, and treatments were chosen empirically. Recent research has greatly enhanced our understanding of the diverse biology of pediatric brain tumors, their molecular and genetic underpinnings, leading to improved diagnostic accuracy and risk stratification, as well as the development of novel biomarkers and molecular targeted therapies. For subsets of patients, these new treatment options have already resulted in improved survival and decreased treatment toxicity. In this article, we provide an overview of the most common childhood brain tumors, describe recent key advances in the field, and discuss the therapeutic challenges that remain.