Introduction: Augmentation pharyngoplasty (AP) is a technique that may effectively treat velopharyngeal insufficiency (VPI), while avoiding typical short and long term surgical risks. This study seeks to determine if children with VPI treated by AP with calcium hydoxylapatite (CaHa) demonstrate clinically significant improvement in speech outcomes. Methods: Retrospective review (2012-2016) of prospectively collected database of children with VPI, cared for at a single tertiary children's hospital. Preoperative speech assessment, nasometry, and video nasendoscopy were used to identify patients with VPI treated by AP with CaHa. Demographics, surgical/speech outcomes, complications, novel surgical technique and follow-up were recorded. Main outcome measures included pre and postoperative nasality and perceptual speech assessments, based on the Pittsburgh Weighted Values for Speech (PWS). Results: 17 patients treated with AP with CaHa, as initial primary treatment for VPI, were identified. 8 patients had cleft palate, 9 patients had isolated VPI. Mean age at treatment was 6.6 years, with no operative complications. Mean nasality scores before and after surgery were 3.2 vs. 0.5 (p < 0.001). Mean PWS before and after surgery were 9.7 vs. 2.1 (p < 0.001). Based on the PWS scoring, 4/8 of cleft patients (50%) and 8/9 of isolated patients (89%) achieved a competent/borderline competent nasopharyngeal valve. 17/17 of patients (100%) had improvement in nasality. Mean length of follow-up was 32.8 months (range 10-64 months). Conclusion: In this largest series of patients to date, AP with CaHa is a safe, minimally invasive, enduring treatment for VPI in properly selected patients. Nasality and speech scores significantly improved, especially in patients with isolated VPI.

Objectives: To determine if children with recurrent croup (RC) and persistent laryngomalacia (LM) clinically improve after supraglottoplasty (SGP).Material and methods: Retrospective chart review cohort at tertiary care children's hospital consisting of patients diagnosed with LM and RC that underwent SGP from July 2011 to August 2014. Clinical history, demographics, clinical outcomes, and operative complications were reviewed. Specifically, the episodes of croup requiring systemic steroids were compared pre- and post-SGP with statistical analysis.Results: Out of 107 patients undergoing SGP for LM, 6 patients (5.6%) were diagnosed with RC. Mean age at first croup episode was 11.5 months. Mean age at SGP was 4.3 years. Mean number of emergency department visits was 3.2 (range 2-6 visits) prior to SGP. Mean number of episodes of croup requiring systemic steroids before and after SGP was 9.8 vs. 0.2 (p = 0.003). Mean length of followup after SGP was 30.5 months (range 18-46 months). There were no surgical postoperative complications.Conclusions: This is the first series to describe the clinical resolution of croup episodes in children with LM corrected by SGP. Recurrent croup should be added among other conditions associated with late onset or persistent laryngomalacia. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Objective: Children with cerebral palsy (CP) are commonly affected by obstructive sleep apnea (USA). This study examines the efficacy of combined surgical techniques for USA including tongue base suspension (TBS), using perioperative polysomnograms (PSG) in pediatric patients with CP. Study design: Case series with outcome analysis. Setting: University based tertiary care children's hospital.Methods: A 7-year retrospective chart review of children with CP who underwent surgical management for OSA. Surgical procedures, postoperative complications, and perioperative PSG data were examined. Only patients with both preoperative and postoperative PSG results were included in the study. Based upon procedures performed patients fell into 2 equal groups for analysis.Results: Fourteen children were identified. Seven patients (mean age = 6.0 years) underwent combined adenotonsillectomy (T&A), uvulopalatopharyngoplasty (UPPP), and tongue base suspension (TBS). Another 7 patients (mean age = 63 years) underwent T&A and UPPP alone. Those who received TBS had a mean preoperative AHI of 272 compared to 6.8 in the group that did not have TBS. The AHI decreased by a mean of 16.5 in the TBS group and 5.0 in the non-TBS group. The mean oxygen saturation nadir improved in both the TBS (74.0-84.0) and non-TBS (64.8-84.6) groups. The arousal index also improved in the TBS (33.1-20.7) and non-TBS (11.0-5.8) groups. No surgical complications occurred.Conclusion: This study suggests that concomitant surgical approaches for USA in children with CP are effective. Moderate to severe USA in this population may safely benefit from the added technique of tongue base suspension. Published by Elsevier Ireland Ltd.

Objectives/Hypothesis: To determine the neuropathologic findings in tissue obtained from children with laryngomalacia at a tertiary-care pediatric hospital.Study Design: Retrospective review of consecutive cohort compared with a control group.Methods: We reviewed supra-arytenoid pathology specimens from 43 children with severe laryngomalacia and 13 age-matched pediatric autopsy controls. Histopathologic comparison was made of nerve hypertrophy (including nerve perimeter and surface area) among experimental and control pathologic specimens.Results: There exists a statistically significant increase in nerve perimeter (P = .001) and nerve surface area (P = .02) in supra-arytenoid specimens in patients with severe laryngomalacia compared with age-matched autopsy supra-arytenoid tissue.Conclusions: The pathologic finding of nerve hypertrophy in children with laryngomalacia provides new evidence to support neurologic dysfunction as the etiologic theory of laryngomalacia.

Objective1) Determine the efficacy of combined surgical techniques for improving obstructive sleep apnea (OSA) in pediatric patients with cerebral palsy (CP). 2) Evaluate the addition of tongue base suspension for children with CP that have moderate to severe OSA.MethodSeven‐year retrospective chart review of 14 children with CP undergoing surgical management of OSA, including adenotonsillectomy (T&A) and uvulopalatopharyngoplasty (UPPP), with or without tongue base suspension (TBS). Response to treatment was determined by its impact on PSG parameters: apnea/hypopnea index (AHI) and arousal index (AI).ResultsChildren with CP who received TBS had a mean preoperative AHI of 27.2 compared with an AHI of 6.8 in the group that underwent only T&A and UPPP (non‐TBS). AHI decreased by a mean of 16.5 (TBS) vs 5.0 (non‐TBS); (P value. 03 vs 04). AI also improved in both groups (33.1 to 20.7 and 11.0 to 5.8); (P value. 05 vs 10). Hospital length of stay was slightly longer for the TBS groups than the non‐TBS groups (mean 9.3 days and 6.6 days) but was not statistically significant (P =. 09). Average length of follow‐up was 52 months with no surgical complications.ConclusionCombined surgical therapy improves OSA in children with CP. Children with CP and moderate to severe OSA (AHI>15) may safely benefit from the addition of tongue base suspension to T&A and UPPP to maximize treatment.

Congenital nasolacrimal duct obstruction results from anomalies of the distal and proximal portions of the canalicular system. Patients frequently present with persistent mucoid discharge from the affected eye. Maldevelopment of the nasolacrimal duct is a rare cause of obstruction. We report a case of complete absence of the intraosseus and membranous portions of the nasolacrimal duct. The patient underwent dacrocystorhinostomy and intubation with Crawford tubes which resulted in successful resolution of the obstruction.

PURPOSE OF REVIEW:Pediatric endoscopic skull base surgery (ESBS) has changed the current management of pediatric sinonasal and skull base disorders. This review focuses on the recent literature exploring pediatric ESBS, including its utility and limitations.RECENT FINDINGS:Pediatric ESBS has been established as a safe and feasible technique for a variety of disease states. Special considerations in the pediatric populations include the use of image guidance technology, potential anatomic access limitations, and skull base reconstruction with vascularized flaps to prevent cerebrospinal fluid leak. The indications for endoscopic skull base surgery continue to expand as experience and technology evolve.SUMMARY:Pediatric endoscopic skull base surgery is a proven technique established upon adult skull base experience. Despite certain limitations, the current literature would recommend consideration for this approach for many sinonasal and skull base lesions. Further research is required to determine long-term patient outcomes.

Objectives/Hypothesis: Propranolol has recently been introduced as a novel pharmacologic treatment for infantile hemangiomas Systematic examination of this treatment in a tertiary care setting has not been described This study explores the impact of propranolol on both proliferative and involuting hemangiomas at a tertiary vascular anomalies center.Study Design: Retrospective single institution reviewMaterials and Methods: We reviewed children treated with propranolol for problematic hemangiomas followed by a blinded prospective analysis of serial photographs taken during the course of their therapy Parental questionnaires were obtained to evaluate perceived therapeutic response and complications to oral propranolol.Results: Thirty-two children with complete photo documentation were treated with oral propranolol for infantile hemangiomas between September 2008 and June 2009 Twenty-seven patients began therapy during the proliferative phase of their lesions (mean age, 4 9 months), whereas five patients began during the involutional phase (mean age, 19.4 months) Ninety-seven percent of patients displayed improvement in the quality of their hemangiomas during propranolol therapy Patients were determined to be excellent responders (n = 16, 50%), partial responders (n = 15, 47%), or nonresponders (n = 1, 3%) Partial and nonresponders received adjuvant therapy (75%, laser therapy; 31%, steroid injections). Ten patients experienced minor but reportable side effects to propranolol, including somnolence (27.2%), gastroesophageal reflux (9.1%), respiratory syncytial virus exacerbation (4.5%), and rash (4.5%).Conclusions: Propranolol may revolutionize the treatment of problematic hemangiomas that cause imminent functional or cosmetic sequelae. At therapeutic doses, propranolol is safe and effective in the majority of patients. Adjunctive therapies may still be required Minor side effects, expected from beta-blocker therapy, are common but easily managed.

Early mandibular lengthening by distraction osteogenesis provides an alternative to traditional methods of airway management in infants with Pierre Robin sequence (PRS). Little evidence in the medical literature quantitatively demonstrates the changes in skeletal, soft tissue, and hypopharyngeal spaces with mandibular distraction.

Objectives: To highlight the uncommon presentation of congenital thyroid teratoma undetected by prenatal ultrasound and to review airway and operative management for congenital cervical teratomas Study Design: A retrospective case review of a single patient with congenital teratoma of the left neck. Methods: The history, physical, imaging, operative, and follow-up findings of the patient are reviewed. Airway and operative management for congenital teratoma are discussed. Results: A 37-week gestation female was born by spontaneous vaginal delivery and found to have a large left neck mass. One minute Apgar score was 2 and the infant was intubated with a 2.5 ETT. 18-week prenatal ultrasound had not detected a neck mass. Preoperative CT and MRI revealed a 7 x 6 x 6 cm left neck mass consistent with congenital teratoma. Initial alpha fetoprotein level was 47,000 ng/ml. On day of life #5, the patient was taken to the OR for surgical removal. Direct laryngoscopy revealed moderate tracheal compression. The mass was completely excised, appearing to arise from the left thyroid lobe. Continuous left recurrent laryngeal nerve monitoring revealed absence of activity as it was thinned by the teratoma. Pathology was consistent with primary congenital thyroid teratoma. At 18-month follow-up the patient has persistent left vocal cord paralysis with no stridor or feeding difficulties. There is no evidence of recurrent teratoma and a normal alpha fetoprotein level. Conclusions: Congenital teratomas of the neck are uncommon anomalies that require careful management of the airway to ensure survival. Operative technique can successfully remove the mass and relieve the airway obstruction. CASE REPORT A 37-week gestation female was born by spontaneous vaginal delivery and found to have an incidental large left neck mass. One minute Apgar score was 2 and the patient desaturated despite supplemental oxygen. The neonatology team attempted placement of a 3.5 and 3.0 ETT, but were unable to pass distal to the subglottis. The infant was successfully intubated with a 2.5 ETT and transferred to the NICU. 18-week prenatal ultrasound had not detected a neck mass, nor was it present on retrospective review. Following stabilization a preoperative CT and MRI revealed a 7 x 6 x 6 cm left neck mass consistent with congenital teratoma (Figure 1). The mass deviated the trachea significantly to the right. There was moderate posterolateral displacement of the left common carotid artery with the mass lying directly adjacent to the left common carotid artery (Figure 2). Initial alpha fetoprotein level was 47,000 ng/ml. On day of life #5, the patient was taken to the OR for surgical removal (Figure 3). Direct laryngoscopy revealed moderate tracheal compression (Figure 4a). Facial and recurrent laryngeal nerve monitoring was utilized throughout the surgery. The mass appeared to arise from the left thyroid consistent with congenital thyroid teratoma. Posterolaterally displaced, the thinned left internal jugular vein, left common carotid artery, and left vagus nerve were dissected off and preserved. Continuous left recurrent laryngeal nerve monitoring revealed absence of activity as it was thinned and intimately associated with the teratoma. The right thyroid lobe was preserved. The teratoma was adherent to the cartilaginous trachea dissected off and the tracheal defect was reapproximated with Prolene suture (Figure 5). Pathology was characterized by immature neuronal elements admixed with thyroidal tissue forms a predominantly solid and partially cystic mass (7.0 x 5.5 x 4.8 cm) consistent with primary congenital thyroid teratoma (Figure 6). A feeding tube was placed and the patient remained intubated. The patient was extubated in the OR on POD#7 with improvement of the tracheal compression (Figure 4b). At 18month follow-up the patient has persistent left vocal cord paralysis with no stridor or feeding difficulties. There is no evidence of recurrent teratoma and a normal alpha fetoprotein level. She remains on low dose levothyroxine for hypothyroidism secondary to the congenital thyroid teratoma removal.

Otolaryngology–Head and Neck SurgeryVolume 141, Issue 2 p. 292-293 Clinical Photograph Tracheal Polyps Michelle M. Roeser MD, Michelle M. Roeser MD Mayo Clinic, Rochester, MNSearch for more papers by this authorPatrick D. Munson MD, Patrick D. Munson MD Mayo Clinic, Rochester, MNSearch for more papers by this authorGary D. Josephson MD, Corresponding Author Gary D. Josephson MD [email protected] Nemours Children's Clinic, Jacksonville, FLCorresponding author: Gary D. Josephson, MD, Nemours Children's Clinic, 807 Children's Way, Jacksonville, FL 32207. E-mail address: [email protected].Search for more papers by this author Michelle M. Roeser MD, Michelle M. Roeser MD Mayo Clinic, Rochester, MNSearch for more papers by this authorPatrick D. Munson MD, Patrick D. Munson MD Mayo Clinic, Rochester, MNSearch for more papers by this authorGary D. Josephson MD, Corresponding Author Gary D. Josephson MD [email protected] Nemours Children's Clinic, Jacksonville, FLCorresponding author: Gary D. Josephson, MD, Nemours Children's Clinic, 807 Children's Way, Jacksonville, FL 32207. E-mail address: [email protected].Search for more papers by this author First published: 01 August 2009 https://doi.org/10.1016/j.otohns.2009.03.006Citations: 1 No sponsorships or competing interests have been disclosed for this article. AUTHOR CONTRIBUTIONS: Michelle M. Roeser, clinical care of patient presented, conception and design of report, author, editorial review; Patrick D. Munson, author, literature review; Gary D. Josephson, author, literature review. DISCLOSURES: Competing interests: None. Sponsorships: None. Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. REFERENCES 1Miller DR. Benign tumors of lung and tracheobronchial tree. Ann Thorac Surg 1969; 8: 543– 59. 2Petterson EJ. Benign bronchial neoplasms: broncoscopic aspects. Arch Otolaryngol 1930; 12: 739– 46. 3Gamblin TC, Farmer LA, Dean RJ, et al. Tracheal polyp. Ann Thorac Surg 2002; 73: 1286– 7. 4Drennan JM, Douglas AC. Solitary papilloma of a bronchus. J Clin Pathol 1965; 18: 401– 2. 5Tamagishi M, Harada H, Kurihara M, et al. Inflammatory endotracheal polyp resolved after antibiotic treatment. Respiration 1993; 60: 193– 6. Citing Literature Volume141, Issue2August 2009Pages 292-293 ReferencesRelatedInformation

Objectives1) Learn the indications and procedure for vagal nerve stimulator implantation (VNSI) in pediatric patients with refractory seizures. 2) Understand the surgical outcomes and complications for the procedure.MethodsA retrospective review of prospectively collected data from 2002–2007 was undertaken on VNSI. The cohort consisted of all pediatric patients ages 0–21 at a single institution tertiary children's hospital. All patients were included if they had treatment resistant seizures and had not previously undergone VNSI. The surgical indications, outcomes, complications, and follow‐up were recorded.ResultsOver the 5‐year period, 36 patients underwent VNSI. Age at surgery ranged from 3 to 20 years (mean 10.5 years). The indications for surgery for all patients included seizures refractory to antiepileptic medications (>5 medications). There were no intraoperative complications and all patients had successful electrode placement as measured by intraoperative testing. After an overnight hospital stay, patients were discharged and programmed by the pediatric neurologist at 2 weeks postoperatively. There were 2 postoperative complications (5.5%), scar hypertrophy of a chest incision and left‐sided Horner's syndrome. Both patients have been managed conservatively without sequelae. Follow‐up ranged from 6 to 72 months (mean 42 months). There were no device failures and all patients and families were subjectively satisfied with the postoperative result. Intraoperative and postoperative photos will demonstrate technique and outcomes.ConclusionsPediatric VNSI is a reliable procedure for refractory seizures with a low complication rate and can be performed safely by otolaryngologists. This represents the largest cohort of pediatric patients in the otolaryngology literature.

Objective To identify the presentation of pediatric patients with head and neck manifestations of cat‐scratch disease, one of the most common causes of subacute or chronic lymphadenitis in children, and to determine surgical indications and outcomes. Study Design Case series. Subjects and Methods All pediatric patients from infancy to age 19 years who presented with clinical symptoms of cat‐scratch disease and had an IgG serological test result of more than 1:128 for Bartonella henselae. Results Nine patients had cat‐scratch disease of the head and neck. Median age at presentation was 4 years; median time from symptom onset to presentation was 20 days. Six (67%) children underwent surgical procedures, and median time from presentation to surgical procedure was 43 days. Conclusion Despite conservative treatment, a minority of pediatric patients with cat‐scratch disease may require surgical drainage of abscess and removal of lymph nodes. Surgical treatment provides tissue for diagnosis, is generally well tolerated, affords improved recovery, and has minimal complications. © 2008 American Academy of Otolaryngology‐Head and Neck Surgery Foundation. All rights reserved.

The association between recurrent thyroglossal duct cyst (TGDC) and obstructive lingual tonsil hypertrophy has not previously been discussed. We present the case of a 7-year-old child whose medical and surgical course was complicated by these synchronous factors. The aim of this report is to present the risk factors for recurrence of TGDC and the unique challenge that concurrent lingual tonsil hypertrophy and airway obstruction present to management of patients.