What is already known on this topic. Button battery ingestion poses a growing and often undetected threat to children, with limited preventative strategies that maintain battery functionality. What this study adds. This study shows that coating button batteries with NeverWet or Plasti Dip can preserve function while significantly delaying esophageal injury. How might this study affect research, practice, or policy. These findings support the use of household-applied or manufacturer-integrated coatings as a feasible strategy to improve pediatric battery safety.

The management of children with cholesteatoma has advanced over the course of this century thanks to innovations in surgical instrumentation and other aspects of care. A narrative review giving a perspective on the contributions of advances such as dedicated equipment for endoscopic ear surgery including powered instrumentation and KTP laser, and other areas including CT and MRI imaging, is provided. These have helped raise the standard of care from achieving a "safe dry ear" potentially with a mastoid cavity, to less invasive approaches that can deliver a functionally and cosmetically normal ear in many cases. Areas in need of further innovative approaches persist in the control of residual and recurrent cholesteatoma and hearing loss. Surgeons are advised to be wary of over-reliance on the use of untested hypothetical mechanisms when considering the adoption of new technologies, such as Eustachian tube balloon dilatation. Improved standards for data collection, analysis and reporting will help ensure that efficacious and cost-effective innovations are adopted in future to further improve outcomes from the care of paediatric cholesteatoma.

Obstructive eustachian tube dysfunction (ETD) contributes to a spectrum of middle ear disorders, including otitis media with effusion (OME), tympanic membrane retraction, and barochallenge-induced symptoms. This review summarizes evidence-based treatment outcomes, focusing on efficacy derived from systematic reviews and safety from additional sources. Medical management has no proven benefits for obstructive ETD. Tympanostomy tubes and adenoidectomy demonstrate age-specific effectiveness for pediatric OME with accepted risks. Some manifestations of ETD may benefit from balloon dilation of the eustachian tube (BDET), or sinonasal surgery, but much evidence is of low quality; indications, long-term benefits, and safety are not clearly established for BDET.

Ossiculoplasty outcomes depend on anatomic reconstruction, middle-ear health, and patient perception of benefit, which depends partly on hearing status of the contralateral ear. Grading systems have evolved from simple anatomic staging to multivariable indices, culminating recently in the well-validated Ear Environment Risk (EER) score. EER best predicts postoperative hearing, with worse results after multiple revisions or tympanic membrane lateralization. Well-presented outcome studies follow American Academy of Otolaryngology-Head and Neck Surgery reporting guidelines, and convey hearing benefit more clearly by including Amsterdam benefit plots and patient-reported outcome measures. Good preoperative counseling requires integrating such predictors and outcomes with individual patient circumstances.

Chronic pediatric middle ear disease is commonly ascribed to Eustachian tube dysfunction (ETD). This article reviews the role of obstructive and patulous ETD in otitis media with effusion, tympanic membrane retraction, cholesteatoma, and perforation. It highlights the lack of reliable diagnostic tests to measure ETD. The contribution of different causes of obstructive ETD is discussed, including the influence of mechanical obstruction, inflammation, allergy, mucociliary dysfunction, and craniofacial anomalies. ETD management has traditionally bypassed the Eustachian tube, for example, with tympanostomy tubes. Balloon dilatation remains controversial in children due to unproven efficacy and safety and the heterogeneous underlying mechanisms of ETD.

OBJECTIVE:To determine whether transcanal surgery without mastoidectomy, canal wall up (CWU), canal wall down (CWD), or CWU mastoid obliteration (MO) surgery for pediatric cholesteatoma has a more favorable effect on middle ear pressure (MEP) homeostasis. METHODS:Data from children having mastoid surgery for acquired cholesteatoma were collected prospectively. Tympanometric values of MEP were compared after transcanal, CWU, CWD, and MO surgery analyzing (i) a single measure per ear from last clinic visit, and (ii) linear mixed-effects modeling (LMEM) to control for multiple measures, surgeries, age, and cholesteatoma severity (EAONO-JOS stage). RESULTS:742 surgeries on 471 ears and 2382 tympanograms were completed. At last visit, (average age 15.6 years [6.0-19.3]), Type a tympanograms were present in 80/173 (46%) of transcanal surgeries, 64/132 (48%) CWU, 15/32 (47%) CWD, and 11/25 (44%) MO (Chi-square, p = 0.19), but 185/209 (89%) contralateral ears without cholesteatoma (Chi-square: p = 1.08 × 10-7). Median MEP was -47 daPa (IQR: 133) after transcanal, -65 daPa (IQR: 156) after CWU, -90 daPa (IQR: 151) after CWD, and -31 daPa (IQR: 151) after MO surgery and (Kruskal-Wallis: p = 0.4) but 5 daPa (IQR: 45) in normal contralateral ears (Wilcoxon: p = 7.92 × 10-13). LMEM showed MEP was dependent on age (p = 6.3 × 10-7) but not type of mastoid surgery (p = 0.70) or EAONO-JOS stage (p = 0.51). CONCLUSION:MEP after surgery for pediatric cholesteatoma is similar after transcanal, CWU, CWD, or MO surgery and remains lower than normal. Hypotheses that propose beneficial effects of these different surgical approaches on MEP homeostasis are not supported, so should not be used to influence choice of surgical approach. LEVEL OF EVIDENCE: 3:

HYPOTHESIS:International consensus exists on optimal measures for reporting outcome from cholesteatoma surgery. This consensus can be used to create a core outcome set (COS) for publication standards. BACKGROUND:Systematic reviews show that the quality of published evidence available to inform surgical decision-making in the management of cholesteatoma is limited with inadequate distinction between residual and recurrent cholesteatoma, use of survival analysis or audiometric reporting standards. METHODS:The International Otology Outcome Group (IOOG) followed COS-STAD and COS-STAR guidelines to develop a COS document. A systematic literature review, which included stakeholder consultation, guided outcome selection. Using a Delphi process, IOOG members and the boards of 5 large otological societies refined the document using on-line survey and email. Consensus was defined as ≥85% agreement among participants across 2 survey rounds. Final outcome measures were categorized as principle (mandatory) or suggested (recommended) standards. RESULTS:Principle reporting standards included: distinction of residual from recurrent cholesteatoma, with use of survival analysis for outcome at 5 years, description of technique for detection of residua, use of audiometric reporting standards, and distinction between complications from cholesteatoma and surgery. Suggested standards covered reporting of cholesteatoma severity, surgical nomenclature, and further audiometric measures. Patient-reported outcome measures are recognized as important, but too few responses were received to define an optimal PROM. CONCLUSION:This COS provides a consensus-based framework for standardized reporting in cholesteatoma surgery. Adoption of the COS as a publishing standard should improve the quality of evidence available to guide surgical care.

Outcomes from cholesteatoma surgery are improved by using endoscopes to guide dissection as the wide-angled view facilitates more complete removal of cholesteatoma matrix, reducing the risk of residual disease. Furthermore, surgery can often be completed transcanal, reducing postoperative morbidity. The decision to complete cholesteatoma removal endoscopically transcanal is made from a combination of preoperative imaging and intraoperative findings. A one-handed approach to operating is required as the other hand is used to optimize endoscope positioning. Aspects of technique and instrumentation particular to endoscopic cholesteatoma surgery are presented.

Objective: To evaluate factors that influence the rate of cholesteatoma recurrence (growth of new retraction cholesteatoma) in children. Methods: Review of children with primary acquired or congenital cholesteatoma. Severity was classified by extent and EAONO-JOS stage, and surgery by SAMEO-ATO. Primary outcome measure was 5-year recurrence rate using Kaplan–Meier or Cox regression analysis. Results: Median age was 10.7 years for 408 cholesteatomas from which 64 recurred. Median follow up was 4.6 years (0–13.5 years) with 5-year recurrence rate of 16% and 10-year of 29%. Congenital cholesteatoma (n = 51) had 15% 5-year recurrence. Of 216 pars tensa cholesteatomas, 5-year recurrence was similar at 14%, whereas recurrence from 100 pars flaccida cholesteatomas was more common at 23% (log-rank, p = 0.001). Sub-division of EAONO-JOS Stage 2 showed more recurrence in those with than without mastoid cholesteatoma (22.1% versus 10%), with more in Stage 3 (31.9%; p = 0.0003). Surgery without mastoidectomy, including totally endoscopic ear surgery, had 11% 5-year recurrence. Canal wall-up tympanomastoidectomy (CWU) and canal wall-down/mastoid obliteration both had 23% 5-year recurrence. Multivariate analysis showed increased recurrence for EAONO-JOS Stage 3 (HR 5.1; CI: 1.4–18.5) at risk syndromes (HR 2.88; 1.1–7.5) and age < 7 years (HR 1.9; 1.1–3.3), but not for surgical category or other factors. Conclusion: Young age and more extensive cholesteatoma increase the risk of recurrent cholesteatoma in children. When controlling for these factors, surgical approach does not have a significant effect on this outcome. Other objectives, such as lower post-operative morbidity and better hearing outcome, may prove to be more appropriate parameters for selecting optimal surgical approach in children.

Objective: Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies. Methods: We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated. Results: Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%. Conclusion: Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications.

OBJECTIVE:To review surgical techniques used in the endoscopic transnasal repair of pediatric basal meningoencephaloceles and compare perioperative outcomes in children <2 and ≥2 years old. DATA SOURCES:MEDLINE, EMBASE, and CENTRAL. REVIEW METHODS:Data sources were searched from inception to August 22, 2022, using search terms relevant to endoscopic transnasal meningoencephalocele repair in children. Reviews and Meta-analyses were excluded. Primary outcomes were the incidence of intraoperative and postoperative complications, including cerebrospinal fluid leak, recurrence, and reintervention. Quality assessments were performed using Newcastle-Ottawa Scale, ROBIN-I, and NIH. RESULTS:Overall, 217 patients across 61 studies were identified. The median age at surgery was 4 years (0-18 years). Fifty percent were female; 31% were <2 years. Most defects were meningoencephaloceles (56%), located transethmoidal (80%), and of congenital origin (83%). Seventy-five percent of repairs were multilayered. Children ≥2 years underwent multilayer repairs more frequently than those <2 years (P = 0.004). Children <2 years more frequently experienced postoperative cerebrospinal fluid leaks (P = 0.02), meningoencephalocele recurrence (P < 0.0001), and surgical reintervention (P = 0.005). Following multilayer repair, children <2 years were more likely to experience recurrence (P = 0.0001) and reintervention (P = 0.006). CONCLUSION:Younger children with basal meningoencephaloceles appear to be at greater risk of postoperative complications following endoscopic endonasal repair, although the quality of available evidence is weakened by incomplete reporting. In the absence of preoperative cerebrospinal fluid leak or meningitis, it may be preferable to delay surgery as access is more conducive to successful repair in older children.

IntroductionButton battery (BB) ingestion injuries are a devastating and preventable event within the pediatric population. Efforts to reduce the prevalence of esophageal button battery ingestion injuries include primary preventative measures. It is integral to assess the public's baseline knowledge about BB injuries to tailor future primary prevention efforts.MethodsThis is a crowdsourcing survey-based study. Participants were notified through our institution's Twitter and Instagram accounts.ResultsThere were 930 completed survey responses from May to June 2022. The survey found that 87% (791/910) knew that swallowing a BB could cause injury and 71% knew that it could cause death (642/905). Eight-five percent of respondents did not know what signs and symptoms to look for after BB ingestion, only 30% (99/340) of healthcare professionals felt they would know. Only 10.1% (94/930) of participants knew to give children over 12 months old honey after suspected BB ingestion. Thirty-four percent (311/930) knew that complications could still occur even after BB were removed. Seventy-seven percent (719/930) knew that a dead BB could cause injury but only 17% knew the correct way to dispose of a dead button battery (158/930). Only 8% (72/930) of participants were knew that wrapping dead BB in tape could potentially prevent injury.ConclusionThe current study reveals gaps in the public's understanding of BB injury including: the presentation of BB injuries; the delayed harm of BB impactions; management and mitigation strategies, and BB disposal methods. This survey provided imperative insights to help guide future education and primary prevention initiatives.Level of evidence3.

BACKGROUND: The objective of this study was to evaluate the utility of a caprine model in endoscopic ear surgical education using the index procedures of tympanoplasty and ossiculoplasty. Specifically, this study assessed the face and content validity of the caprine model, and the potential impact of anatomical differences on trainee understanding of human middle ear anatomy. METHODS: Twelve otolaryngology trainees attended a 3-hour endoscopic ear surgery course utilizing the caprine model in which they completed canalplasty, tympanoplasty, and ossiculoplasty. Prior to the course, the trainees completed a self-reported needs assessment and knowledge assessment of human middle ear anatomy. Following the course, the trainees repeated the knowledge assessment and completed evaluation and validation questionnaires. Five-point Likert scores were used for the needs assessment and validation questionnaire. RESULTS: Of the 12 trainees, 9 participated in the study. All domains of the learner needs assessment showed an average improvement of 1 point on the post-course evaluation with 6 of 9 domains being significantly improved using the Wilcoxon signed-rank test (P <.05). The model achieved validation in the domains of face, content, and global content validity with an average Likert score > 4. Knowledge assessment scores increased by 7% (P =.23) after the course compared to before. CONCLUSION: The caprine model offers an effective surgical simulation model for endoscopic ear surgery training with good face and content validity. We find it to be readily available and affordable. We currently use it routinely to give otolaryngology residents the experience of endoscopic ear surgery before operating on patients.

BACKGROUND:Sotos syndrome is a rare genetic disorder characterized by neurodevelopmental delay and excessive childhood growth including macrocephaly. In this study, we present our experience of children with Sotos syndrome and cholesteatoma.METHODS:Retrospective case note review and cross-referencing with hospital picture archive and communication systems or cases identified from a prospective database of consecutive cholesteatoma surgeries.RESULTS:A total of 400 children underwent surgery for acquired cholesteatoma and 5 (1%) had Sotos syndrome (1 bilaterally). In comparison, 42(11%) had cleft palate which is around 10 times more common than Sotos syndrome, 5 (1%) had Down syndrome, and 3 (1%) had Turner syndrome. The median age at primary surgery was 8 years old (3.5-10.9 years), 124 children with Sotos syndrome were identified in picture archive and communication systems (4% with cholesteatoma) of which temporal bone imaging was available in 86 (70%) at the median age of 9 years (0-17.2), and 33/86 (38%) had normal ears bilaterally on all imaging. Changes consistent with fluid or inflammation were present in 9/30 (30%) computed tomography and 24/72 (33%) magnetic resonance imaging scans. Development of mastoid pneumatization was impaired in 20/30 (67%) computed tomography and 8/72 (11%) magnetic resonance imaging scans. At 5 years, children with Sotos syndrome (33%) had greater recidivism than those with cleft palate (15%) (Kaplan-Meier log-rank analysis, P=.001) CONCLUSION: Children with Sotos syndrome appear to be at increased risk of developing acquired cholesteatoma. Impaired temporal bone pneumatization is a common incidental finding in Sotos syndrome in keeping with this risk. Further study of this previously unreported association may improve the understanding of pathogenetic mechanisms in cholesteatoma.

Objective: To present the design choices, modelling of bending stiffness and experimental validation of a novel notched Nitinol compliant wrist that enables tip articulation and suction during endoscopic and robotic middle ear surgery. Methods: The wrist consists of an inner wrist tube (IWT) assembled within an outer wrist tube (OWT). The OWT was selected from five concept designs that were evaluated based on stiffness and compact bending. An analytical model was developed based on Castigliano’s $2^{nd}$ Theorem and a finite element model (FEM) was developed to predict tip stiffness under soft-tissue surgical interactions and compared to experimental results. Results: The FEM and analytical models predicted tip displacement due to an applied force within 25% and 12 % of the experimental results, respectively. The complete wrist prototype withstood 700–1000 cycles before fracture when it was articulated up to 145° – 178°, corresponding to 9.6 N – 12.4 N of cable tension. Conclusion: A wristed tool is presented to facilitate endoscopic ear surgery and its mechanical behaviour in surgically relevant loading conditions. Significance: This instrument could be adapted to provide suction and soft tissue dissection capabilities for future minimally invasive endoscopic or robotic surgery, through the ear canal or other natural orifices.

Aim Most button battery (BB) ingestions in children are unwitnessed leading to prolonged exposures and severe complications. One third of ingestions occur from free BB, that are stored or awaiting disposal. Recommendations have been made to cover the terminals of discarded BB with adhesive tape; however, it is unclear if this practice prevents injury. Our aim was to determine if tape could prevent oesophageal injury in a cadaveric porcine model. Methods Electrical, masking, packing and duct tape were compared. One BB was left untaped. Taped BBs were placed in a cadaveric porcine oesophagus controlled for temperature and humidification. Specimens were assessed at 0, 0.5, and hourly for 6 h by visual inspection, temperature and pH. BB voltage was measured before and after testing. All tests were repeated in triplicate. Results Oesophageal specimens demonstrated burn prevention in the packing and duct tape trials. Burns were seen in 2/3 trials with electrical tape and 3/3 trials with masking tape. pH remained neutral throughout the study for all packing and duct tape specimens. pH remained neutral initially for masking tape but increased rapidly to 12 by 2 h. There was no change in battery voltage for the packing tape and duct tape trials. There was a 16.3% reduction in voltage for masking tape which was similar to controls. Conclusions Taping BB with packing tape and duct tape prevented oesophageal burns. This may provide a novel method of burn prevention for loose BB intended for disposal.

IMPORTANCE Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions. OBJECTIVE To review airway injuries, including long-term sequelae, after BB ingestion in children. EVIDENCE REVIEW For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twentythree children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis. CONCLUSIONS AND RELEVANCE Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

BACKGROUND: The aim of this article is to assess the efficacy of esterified hyaluronic acid as a barrier to formation of adhesions and improvement of tympanomastoid ventilation. METHODS: A prospective cohort analysis was performed at a tertiary referral centre. 126 ears were analysed in children with cholesteatoma. Esterified hyaluronic acid was placed on the promontory of 63 ears at primary canal wall intact surgery for cholesteatoma. No esterified hyaluronic acid was used in 63 control ears. Cholesteatoma recurrence, histopathological analysis of scar tissue following second-stage procedure, and middle ear pressure were the main outcome measures. RESULTS: At 5 years, esterified hyaluronic acid (7%) and non-esterified hyaluronic acid (10%) did not differ in cholesteatoma recurrence (KaplanMeier log rank analysis, P= .52). Esterified hyaluronic acid (n =11) and non-esterified hyaluronic acid (n = 2) ears formed scar at the site of packing material (n =11) (Fisher's exact test, P = .04). Foamy histiocytes/macrophages were found in esterified hyaluronic acid (n = 15) and non-esterified hyaluronic acid ears (n =1) (Fisher's exact test, P <.001). Middle ear pressure was measurable in 32/43 (74%) esterified hyaluronic acid ears and 36/52 (69%) non-esterified hyaluronic acid ears (P = .58, chi-square test). Median post-operative middle ear pressure in esterified hyaluronic acid (-115.0 daPa) and non-esterified hyaluronic acid ears (-85 daPa) did not differ significantly (Mann-Whitney U-test, -30.0 daPa, P = .33). Middle ear pressure was normal (> -125 daPa) in 44% (14/32) esterified hyaluronic acid ears and 42% (15/36) non-esterified hyaluronic acid ears (P = 1.0, Fisher's exact test). CONCLUSIONS: We have discontinued the use of esterified hyaluronic acid in cholesteatoma surgery due to lack of detectable benefit. Esterified hyaluronic acid in the middle ear neither reduces cholesteatoma recurrence nor appears to improve the ventilation of the middle ear. Furthermore, esterified hyaluronic acid alters the inflammatory process within the middle ear, the significance of which remains unclear.