Faculty Bibliography

OBJECTIVES/HYPOTHESIS: To assess the current state of mentorship in otolaryngology residency. STUDY DESIGN: Internet-based anonymous survey of chief residents in otolaryngology residency. METHODS: Nonidentifying demographic information, career plans, and general questions about residency experience were queried. Participants were asked to rate their mentorship experience in general and specifically with regard to research, personal quality of life, and career preparation. Responses were scored using a five-point ordinal Likert scale, with higher scores representing more favorable responses. RESULTS: The survey was completed by 47 (17.2%) respondents. Eighteen respondents (38%) were assigned an official faculty mentor, and 23 respondents (49%) were assigned a research mentor during their residency. Thirty-nine respondents (83%) reported receiving meaningful mentorship from faculty who were not officially assigned mentors. Overall, 18 respondents (38%) were neutral or not satisfied with the mentorship they received during residency. Statistically significant higher scores were noted for mentorship in career preparation (median, 4) versus mentorship in research (median, 4; P < .001) and resident quality of life (median, 3; P < .001). Lower scores were noted for availability of mentorship in preparation for a career in private practice versus academic medicine (median, 4 vs. 5; P < .001). Residents who were officially assigned mentors reported statistically significant higher scores with regard to satisfaction with the overall mentorship experience (median, 4 vs. 3; P = .05) and different aspects of mentorship in career preparation and research training. CONCLUSIONS: The current study reveals variability in the mentorship experience in otolaryngology residency. Potential deficiencies may exist, including absence of formal mentorship in some residency programs. Increased attention to mentorship, especially with regard to research, career preparation, and quality of life may improve the overall residency experience.

OBJECTIVE: To compare outcomes with the use of thyroid ala cartilage (TAC) and costal cartilage (CC) grafts in pediatric primary anterior laryngotracheoplasty (LTP). DESIGN: Retrospective comparison study. SETTING: Tertiary, academic children's hospital. PATIENTS: Of 45 laryngotracheal operations performed between June 2001 and October 2008 for laryngotracheal stenosis, 29 were primary anterior LTPs. The procedures used either TAC (n = 24) or CC (n = 5) grafts and were planned as either single-stage (TAC group, 22 patients; CC group, 2 patients) or multistage (TAC group, 2 patients; CC group, 3 patients). MAIN OUTCOME MEASURES: Operative time, length of intubation, graft-specific complications, need for additional airway procedures, and overall decannulation rate. RESULTS: The mean (SD) operative times were 222 (56) minutes for TAC grafts and 363 (59) minutes for CC grafts (P = .005). For single-stage LTPs that were decannulated, the mean (range) length of intubation was 3.3 (1-11) days for TAC grafts (n = 18) and 3 (1-5) days for CC grafts (n = 2) (P = .90). Graft-specific complications occurred in 17% of TAC grafts (n = 4) and 20% of CC grafts (n = 1) (alpha > 0.05). Symptomatic stenosis requiring additional surgical intervention occurred in 43% of TAC grafts (n = 10) and 60% of CC grafts (n = 3) (alpha > 0.05). Patients underwent decannulation in 83% of TAC grafts (n = 19) and 80% of CC grafts (n = 4) (alpha > 0.05). CONCLUSIONS: In primary anterior LTPs, TAC grafts require significantly less operative time than CC grafts (P = .005). There were no statistically significant differences in length of intubation, frequency of graft-specific complications, or decannulation rates between TAC and CC grafts in primary anterior LTPs.

OBJECTIVES/HYPOTHESIS: To compare gene expression in oropharyngeal mucosa of children with (ex+) and without (ex-) secondhand smoke exposure. STUDY DESIGN: Prospective case-control. METHODS: Forty-one age- and gender-matched children (2-6 years old) undergoing tonsillectomy for sleep disordered breathing at a tertiary care children's hospital were assessed for secondhand smoke exposure. Parental response to a validated questionnaire relating to secondhand smoke exposure governed inclusion. Sixteen samples were selected for microarray analysis (7 ex+, 9 ex-). Following tonsillectomy, ex vivo brushing of the mucosa isolated total RNA. Genome-wide expression profiles were generated by comparing sample RNA to a reference of all samples, assessing 27,323 cDNA clones. Microarray clones were ranked according to their ability to distinguish between the two groups using a Student t test. RESULTS: A total of 318 cDNA clones distinguished the two groups (P < .01); 180 genes were overexpressed and 138 underexpressed in ex+ samples relative to the ex- group. Independent analysis of these two groups sorted genes into disease processes and molecular functional groups, including cancer (34 genes in the overexpressed group, 29 underexpressed, P < .05), cell cycle (14 and 10), and cell growth and proliferation (7 and 11). Two of the upregulated genes, LCN2 and IQGAP1, have been previously linked to inflammation in smokers and response/repair to cellular injury in bronchial epithelium. CONCLUSIONS: Findings in this pilot study support the hypothesis that secondhand smoke exposure seems to induce gene expression changes in the oropharyngeal mucosa of exposed children, which may have significant implications for current and future disease processes.

OBJECTIVES: We assessed the safety and efficacy of balloon dilation as treatment for recurrent stenosis after pediatric laryngotracheoplasty. METHODS: We studied a retrospective case series at an academic tertiary care children's hospital. We included all patients under the age of 18 years with subglottic or tracheal stenosis treated at our institution with balloon dilation between June 2007 and April 2009. The records were analyzed for patient demographics, presenting symptoms, surgical technique, and airway description. The outcome measures were airway diameter, postoperative symptoms, tracheotomy status, and complications. RESULTS: Ten patients (9 with subglottic stenosis and 1 with tracheal stenosis) underwent 20 balloon dilation procedures without complication. The average age at the time of the procedure was 17 months (range, 3 months to 9 years). The patient presenting symptoms were stridor in 7 cases and tracheotomy in 3 cases. Vascular balloons (diameter range, 6 to 12 mm; length, 20 mm) were inflated to 10 to 12 cm H2O pressure for an average of 40 seconds (range, 10 to 120 seconds). Each procedure consisted of 1 to 3 dilation cycles. The immediate postdilation airway area increased by an average factor of 4.9 (range, 1.9 to 9). Six patients had repeat procedures with an average interval between dilations of 67 days (range, 6 to 337 days). Stridor was eliminated or greatly improved in all patients on the first postoperative day; 7 patients sustained this benefit, with an average follow-up time of 10 months (range, 4 to 23 months). Six of the 10 patients had undergone previous laryngeal reconstruction (age range, 3 months to 4 years). Of these 6, 3 have no tracheotomy, with a mean follow-up of 12.5 months. The 3 children who benefited the least from dilation were noted to have more diffuse and chronic inflammation of the larynx in comparison to the responders. CONCLUSIONS: This case series suggests that balloon dilation is a relatively safe and effective procedure. It may be particularly well suited to recent stenosis after laryngotracheal reconstruction.

OBJECTIVE: To compare the outcomes of early versus late extubation after primary single-stage anterior laryngotracheoplasty (LTP) using thyroid ala graft performed at our tertiary care academic children's hospital. METHODS: Twenty-five pediatric patients underwent single-stage anterior LTP using thyroid ala grafts between September 2002 and June 2009. Initial trials of extubation were attempted in 15 patients on or prior to postoperative day (POD) 2 and in 10 patients on or after POD 3. The main outcome measures analyzed in this retrospective comparison study were complication rate, length of hospitalization, reintubation during hospitalization, need for additional airway procedures, and overall decannulation rate. RESULTS: The rates of various complications in each group were not statistically significant, with the exception of methadone taper. No patients in the early extubation group and four patients in the late extubation group required methadone taper [p<0.05]. The average length of hospitalization after extubation for the early extubation group was 16.5 days [SD=14.0] and 14.6 days [SD=7.7] for the late extubation group [p>0.05]. Six patients (40%) in the early extubation group and two (20%) in the late extubation group needed reintubation at some point during hospitalization post-LTP [p>0.05]. Ten patients [66.7%] in the early extubation group and eight [80%] in the late extubation group required additional airway procedures post-LTP [p>0.05]. Ultimately, 12 (80%) of the early extubation group and nine (90%) of the late extubation group were successfully decannulated at the time of most recent follow-up [p>0.05]. CONCLUSIONS: The differences in length of hospitalization, need for additional procedures, reintubation during hospitalization and overall decannulation rate between the early and late extubation groups after single-stage anterior LTP with thyroid ala graft were not statistically significant. Methadone taper was the only complication that was statistically significantly higher in the late extubation group.

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is commonly associated with adenotonsillar hypertrophy. We hypothesized that respiratory perturbations extend to other regions of the upper respiratory tract in such children, particularly to rhino-sinus regions. STUDY DESIGN: A prospective case control study using Magnetic Resonance Imaging (MRI) of the upper airway and surrounding tissues of OSAS and controls. Magnetic resonance imaging was used to evaluate radiographic changes within the: paranasal sinuses, middle ear and mastoid air cells, and the nasal passages. RESULTS: We studied 54 OSAS (age 5.7 +/- 3.0 years) and 54 controls (age 6.2 +/- 2.0 years, P = NS). Children with OSAS had significantly more opacification of: maxillary sinuses (P < 0.05), sphenoid sinuses (P < 0.01), and mastoid air cells (P < 0.01). They also had significantly more: middle ear effusions, (P < 0.001), prominence of inferior nasal turbinate(s) (P < 0.05), and deviation of the nasal septum (P < 0.05). CONCLUSIONS: Childhood OSAS is associated with a wide range of upper respiratory tract perturbations and is not limited to adenoid and tonsillar hypertrophy.