Non-invasive assessment of benign vocal folds lesions in children by means of ultrasonography

Objectives

Flexible fiberoptic endoscopes have made pediatric laryngeal examinations an everyday practice, even though fiberoptic-flexible laryngoscopy (FFL) is not always well tolerated in young children because of limited cooperation. Laryngeal ultrasonography (LUS) has been applied to normal and pathological findings in infants and children, allowing the assessment of subglottic hemangiomas, laryngeal stenosis and paralysis. No previous study assessed benign vocal folds lesions by LUS in children. The aim of this study is to evaluate the possibility of LUS to detect benign vocal fold lesions in children by comparing the results of FFL in 16 children with those of LUS.

Methods

Sixteen children (9 males and 7 females) with a mean age of 7.5 ± 4.0 years were included in the study. Each child underwent FFL performed by a skilled phoniatrician and LUS performed blindly by an expert radiologist.

Results

On FFL bilateral vocal folds nodules were found in 9 patients, vocal fold cyst in 2 other patients, while in 2 children the vocal folds appeared normal. Laryngeal papyllomatosis, vocal fold polyp and vocal fold irregularity were found in only one patient. LUS enabled the diagnosis in all the 14 patients with vocal fold lesions. Bilateral hyperechoic lesions were visible in 10 patients, while hypoechoic lesions were found in three patients. No lesion were found in two children, while one patient presented with a monolateral hyperechoic lesion.

Conclusions

LUS was accurate, safe, well accepted and tolerated. LUS appears to be a useful diagnostic tool for supplementing FFL in the assessment of benign vocal fold lesions in children and may represent an interesting alternative in everyday clinical practice.     

Laser arytenoidectomy in the management of bilateral vocal cord paralysis in children

Objective

To analyse the efficacy of CO₂ laser arytenoidectomy in the management of bilateral vocal cord paralysis in children.

Methods

Retrospective series of 17 patients who underwent laser arytenoidectomy for bilateral vocal cord between 1995 and 2008 in a tertiary care institution. All patients had bilateral laryngeal paralysis, in isolation (n = 5) or associated with concomitant airway conditions (n = 12). All cases had anterior prolapse of the arytenoids with partial obstruction of the airway on inspiration. 12/17 patients (70.5%) were tracheotomy-dependant, 2/17 were in-extubatable, and 3/17 had severe airway limitation, effort dyspnea and poor sleep pattern. Main outcome measures were decannulation rate for patients with tracheotomy, occurrence of aspiration and quality of voice.

Results

The mean age was 2.8 years old. 9/12 patients with tracheotomy (75%) were decannulated with a median delay of 2 months (2 days to 18 months). Both of the intubated patients were extubated with a median delay of 36 h. One of the decannulated patients who re-presented with a residual dyspnea after the arytenoidectomy was improved by a further laser cordotomy. 2/17 patients (11.7%) had post-operative persistent aspirations (with pneumopathies in one case), 5/17 patients were dysphonic, 3 improved with speech therapy and 2 with intracordal lipoinjection.

Conclusions

Laser arytenoidectomy is effective for improving the breathing in children presenting with a bilateral vocal fold paralysis associated with obstructive arytenoid prolapse. Results are good as a first-line surgery or following laryngo-tracheal surgery. Voice outcomes are satisfactory. However, aspiration is a rare complication.     

Parental and program's decision making in paediatric simultaneous bilateral cochlear implantation: Who says no and why?

Objective

To evaluate initial candidacy for bilateral simultaneous cochlear implantation in children.

Design

Prospective case series.

Setting

Tertiary academic pediatric hospital.

Participants

As part of our research protocol all children eligible for cochlear implantation were assessed for suitability to receive a simultaneous bilateral implant. Over a 12-month period (January to December 2007) 78 children received a total of 95 cochlear implants. Children with sequential second implants (24), revision cases (4), and out of province recipients (4) were excluded. The remaining 46 patients were assessed for bilateral simultaneous implantation.

Main outcome measures

Team/parental decision to proceed with bilateral simultaneous implantation.

Results

17 children (37%) received simultaneous bilateral implants. 29 children (63%) were not considered suitable for simultaneous bilateral implantation. Reasons included developmental delay (10), residual borderline hearing in the second ear (9), parental/patient refusal (6), abnormally poor speech development for age (2), and abnormal cochlear anatomy precluding implantation (2). None were considered unsuitable for the more prolonged operative procedure on medical grounds.

Conclusions

Although bilateral implantation is thought to produce the optimal auditory outcome, not all patients are suitable, nor do all parents wish to proceed, when assessed for simultaneous implantation. Some of these patients are likely to be candidates for sequential bilateral implantation in due course.     

Long-term voice outcome following partial cricotracheal resection in children for severe subglottic stenosis

Objective

To correlate the postoperative voice outcome to preoperative glottic involvement, following partial cricotracheal resection (PCTR) in children. The glottic involvement was analysed based on the extent of subglottic stenosis (SGS) in the endoscopic image and functional dynamic assessment using flexible endoscopy.

Methods

We conducted an interobserver study in which two ENT surgeons, blinded to one another's interpretation, independently rated the extent of SGS based on the endoscopic image along with the dynamic functional airway assessment, of 108 children who underwent PCTR for grade III or IV stenosis. Based on the observation, the glottic involvement was rated into 4 categories:

A.

SGS clear from vocal cords (3-4 mm below vocal cords).

B.

SGS reaching the free border of vocal cord and/or the posterior commissure with slightly limited abduction with no true posterior glottic stenosis (PGS).

C.

SGS with associated PGS or vocal cord fusion without cricoarytenoid ankylosis (CAA).

D.

Transglottic stenosis with/or without bilateral CAA.

Evaluation of the voice was based on a parent/patient proxy questionnaire sent in 2008 to assess the current functional status of the patient's voice.

Results

Among the 77 patients available for long-term outcome with a minimum 1-year follow-up, 31 patients had isolated SGS free from vocal cords (group A) and 30 had SGS reaching the under surface of vocal cords with partial or no impairment of abduction of vocal cords (group B). Twelve patients belonged to group C with posterior glottic stenosis and/or vocal cord fusion (without cricoarytenoid ankylosis) and 4 patients had transglottic stenosis and or/bilateral cricoarytenoid ankylosis (group D). The long-term voice outcome following PCTR as perceived by the parent or patient was normal in 18% (14 of 77 patients) and the remaining 63 patients demonstrated mild to severe dysphonia. Patients belonging to group A and B exhibited either normal voice or mild dysphonia. Patients in group C demonstrated dysphonia, which was moderate in severity in the majority (83%). All patients in group D with transglottic stenosis and/or CAA showed severe dysphonia.

Conclusion

Children with associated glottic involvement are at high risk for poor voice outcome following PCTR. The severity of dysphonia was found to be proportional to the preoperative glottic involvement. Preoperative rating of the extent of glottic involvement based on endoscopic image and dynamic assessment was found to be useful in prognosticating the voice outcome.     

Comparison of bilateral and unilateral cochlear implants in children with sequential surgery

Objective

The objective of this study was to evaluate the effect of bilateral versus unilateral cochlear implants and the importance of the inter-implant interval.

Methods

Seventy-three prelingually deaf children received sequential bilateral cochlear implants. Speech recognition in quiet with the first, second and with both implants simultaneously was evaluated at the time of the second implantation and after 12 and 24 months.

Results

Mean bilateral speech recognition 12 and 24 months after the second implantation was significantly higher than that obtained with either the first or the second implant. The addition of a second implant was demonstrated to have a beneficial effect after both 12 and 24 months. Speech recognition with the second implant increased significantly during the first year. A small, non-significant improvement was observed during the second year. The inter-implant interval significantly influenced speech recognition with the second cochlear implant both at 12 and 24 months, and bilateral speech recognition at 12 months, but not at 24 months.

Conclusions

A small, but statistically significant improvement in speech recognition was found with bilateral cochlear implants compared with a unilateral implant. A major increase in speech recognition occurred with the second cochlear implant during the first year. A shorter time interval between the two implantations resulted in better speech recognition with the second implant. However, no definitive time-point was found for when the second implant could no longer add a positive effect.     

Supraglottoplasty outcomes in relation to age and comorbid conditions

Objective

To determine if age and comorbid conditions effect outcomes in children undergoing supraglottoplasty for severe laryngomalacia.

Design

Retrospective study.

Setting

Urban tertiary-care children's hospital.

Patients

Children undergoing supraglottoplasty for severe laryngomalacia between February 2004 and July 2008. 56 patients were identified.

Outcome measures

Persistence of upper airway obstruction, revision surgery (supraglottoplasty), and additional surgery (tracheostomy).

Results

33/56 (58.9%) patients had no comorbid conditions and 23/56 (41.1%) patients had comorbid conditions. In noncomorbid patients, 36.4% of those less than 2 months of age at the time of surgery required revision supraglottoplasty, compared to 5.3% of patients between 2 and 10 months (p < 0.05). Compared to the 2-10-month age group, there was a significantly higher percentage of patients with comorbid conditions in the >10-month group (32.1% vs. 79%, p < 0.01). Patients with comorbid conditions were diagnosed at a significantly later age than those without (6 mo vs. 2 mo, respectively), and had significantly higher rates of revision supraglottoplasty (47.8% vs. 18.2%) and tracheostomy (39.1% vs. 0.0%). 70% of children with neurological conditions required revision surgery, with 60% requiring tracheostomy. The revision surgery and tracheostomy rates were significantly higher compared to the noncomorbid group (p < 0.01 and p < 0.0001). Children with cardiac conditions had a higher rate of tracheostomy than noncomorbid children (30% vs. 0%, p < 0.01). 16.7% of children with genetic conditions required supraglottoplasty, and none required tracheostomy.

Conclusions

In noncomorbid patients, those undergoing supraglottoplasty less than 2 months of age had a significantly higher rate of revision supraglottoplasty. Patients with neurologic and cardiac comorbidities require tracheostomy at a significantly higher rate than noncomorbid patients.     

Value of ultrasonography in diagnosis of pediatric vocal fold paralysis

Objectives

To investigate the appearance of the pediatric larynx on ultrasound images and the diagnostic potential of ultrasound in cases of pediatric vocal fold paralysis.

Methods

First, we confirmed the ultrasonographic features of the laryngeal landmarks in 2 pediatric cadaveric larynxes. Secondly, 45 children were enrolled in a clinical study (13 patients with vocal fold paralysis and 32 normal children). Quantitative analysis of vocal fold mobility was carried out by measuring the maximum glottic angle (MGA) and vocal fold-arytenoid angle (VAA).

Results

All the paralyzed vocal folds showed abnormal mobility, and were flaccid during breathing and phonation. The rima glottis appeared as a hyperechoic air-column band in ultrasound images during phonation. The mean value of the MGA was 61.47 ± 9.00 in the normal larynx and 42.25 ± 10.41 in the paralyzed larynx. In the affected side of the paralyzed larynx, the VAA in maximum abduction was smaller than that in the normal larynx or in the unaffected side. The median difference of the VAA between maximum abduction and maximum adduction was less than that in the normal larynx. The kappa value was 0.96.

Conclusion

MGA and VAA are quantitative indicators of vocal fold immobility. Ultrasound is a reliable method of diagnosis of pediatric VFP. To diagnose VFP from an ultrasound image, the criteria are: (1) abnormal mobility (this was the most important and direct evidence), (2) hyperechoic air-column band of the glottic rima during phonation, (3) flaccid vocal fold and (4) asymmetry of the glottal structures.     

Congenital stridor with feeding difficulty as a presenting symptom of Dok7 congenital myasthenic syndrome

Objective

The congenital myasthenic syndromes (CMS) are a group of genetic disorders of neuromuscular transmission causing fatigable weakness. Symptoms may be present from birth, but diagnosis is often delayed for several years, notably in post-synaptic CMS due to mutations in the DOK7 gene. Recently, we noted a subgroup of children with CMS in whom congenital stridor and bilateral vocal cord palsy predated other symptoms. All had mutations in the DOK7 gene. The purpose of this study was to review our population of DOK7 CMS patients with congenital stridor and assess whether there were other phenotypic features which might raise suspicion of a diagnosis of CMS in the neonatal period, in the absence of limb weakness and ptosis and prompt earlier referral for neurophysiological investigation, genetic diagnosis and appropriate treatment.

Methods

A retrospective case review of 11 DOK7 CMS patients at a tertiary referral centre.

Results

Six patients were identified with DOK7 mutations and congenital stridor, four requiring intubation soon after birth. Four patients had a diagnosis of bilateral vocal cord palsy and three required tracheostomy, successfully decannulated in one after 3 years. All six patients had difficulty with feeding, with weak suck and swallow necessitating nasogastric feeding in five, two of whom required gastrostomy. Despite all six children having had neonatal symptoms, the mean age at CMS diagnosis was 5 years and 9 months.

Conclusion

CMS, particularly caused by mutations in the DOK7 gene, is a rare but treatable cause of congenital stridor in the neonate. A combination of congenital stridor, especially with an apparently idiopathic bilateral vocal cord palsy and weak suck and swallow should alert the clinician to the possibility of CMS and prompt early referral for neurophysiology and genetic investigations. Confirmation of a CMS diagnosis enables treatment to be initiated, informed management of the VCP and anticipation of myasthenic symptoms, particularly life-threatening respiratory decompensation. Treatment may allow early decannulation or possible avoidance of tracheostomy. At least 12 genes are known to cause CMS; the presence of congenital stridor may help target genetic diagnosis.     

Sialendoscopy in children

Background

The definitive cause of most cases of recurrent salivary gland inflammation in children remains unknown. Relatively little has been written about the use of sialendoscopy as a diagnostic and therapeutic tool in children.

Objective

To evaluate the safety and efficacy of sialendoscopy as a diagnostic and therapeutic tool for recurrent salivary gland inflammation in children.

Study Design

Retrospective case series.

Methods

Medical records of all patients who underwent sialendoscopy for recurrent salivary gland inflammation from a single tertiary-care pediatric otolaryngology practice were reviewed. Comparison of pre-procedure vs. post-procedure frequency and severity of disease was reviewed. Operative reports, images, and video were analyzed for causes of inflammation.

Results

Six patients (aged 3-16 years old) underwent sialendoscopy (3/6 bilateral parotid, 2/6 unilateral parotid, 1/6 unilateral submandibular). There were no complications. No post-operative recurrence was noted in 3/6 patients; decreased frequency of recurrence was noted in 2/6 patients; repeat sialendoscopy was required in 1/6. Operative findings from sialendoscopy from 10 parotid glands showed fibrinous debris (7/10), mucoid debris (1/10), purulent debris (1/10), or duct stenosis (1/10). No stones were noted.

Conclusions

Sialendoscopy is a safe, minimally invasive procedure that may decrease the frequency of recurrences for salivary gland inflammation in children. In contrast to previously published work, the most common cause of salivary gland obstruction in this series was debris, rather than stones. Increased use of sialendoscopy as a diagnostic and therapeutic tool will allow for improved understanding of the causes of and management for recurrent salivary gland inflammation in children.     

Laterofixation of the vocal fold using an endo-extralaryngeal needle carrier for bilateral vocal fold paralysis

Objectives

Laterofixation of the vocal fold is a simple and reliable surgical intervention for laryngeal obstruction due to bilateral vocal fold fixation to obtain sufficient glottal space. Nevertheless, it has some technical disadvantages. This report summarizes the surgical outcomes in patients who underwent laterofixation of the vocal fold with or without the use of an endo-extralaryngeal needle carrier (EENC).

Methods

A prospective study of 11 consecutive patients with bilateral vocal fold paralysis. All of the patients underwent unilateral vocal fold laterofixation. Six patients were assigned to the non-EENC group and five to the EENC group. The surgical outcomes were evaluated, including the operating time and respiratory and phonatory functions.

Results

The operating time was 44% shorter in the EENC group and less skin incisions were required. Postoperatively, the dyspnea was eliminated in all of the patients in both groups, and the six patients who required a tracheotomy were successfully decannulated. Spirometry confirmed the improvements in %FEV₁ and %PEF in the two groups. Postoperative voice function was socially acceptable in all patients, and it tended to be better in the non-EENC group. In the EENC group, one patient developed a minor submucosal hematoma and another patient had a recurrence of dyspnea 2 months postoperatively, probably due to thread disruption.

Conclusion

The present study confirms that laterofixation of the vocal fold with or without EENC relieves laryngeal obstruction. Surgery with the EENC is simpler and quicker than the conventional procedure. However, the surgery with the EENC has some disadvantages, including likely problems with the thread and downward traction on the vocal fold. Surgeons should be aware of these possible shortcomings.     

Sphenoid sinus development in choanal atresia

Objectives

To study the growth and size of the sphenoid sinuses in choanal atresia patients.

Study design

Case-control single blinded retrospective study.

Methods

Fifteen non-syndromic patients (ages 0-26 years old) were selected because they had at least one suitable CT scan (nine bilateral and 11 unilateral = total 20 scans). Twenty age-matched CT scans were used as controls. The following linear measurements were obtained: (1) fronto-zygomatic width, (2) zygomatic width, (3) width of the maxillary sinuses, (4) width of the sphenoid sinuses. Statistical analysis was performed with the exact permutation test in the framework of a parametric analysis of a randomized completed block.

Results

The width measurements of the choanal atresia CT scans did not show any statistically significant difference when compared to their control CT scans except for the zygomatic width in the bilateral choanal atresia patients. In the latter, the width was smaller (p = 0.03).

Conclusions

In unilateral and bilateral choanal atresia patients, there is normal growth of the width of the sphenoid sinuses.     

Difficulties in diagnosis of laryngeal cysts in children

Introduction

In larynx cysts may be localized in different regions: glottis, laryngeal pouch, epiglottis, aryepiglottic folds and subglottic area. It is difficult to estimate if the cyst is acquired or congenital. Symptoms of laryngeal cyst depend on the size and localization of the cyst and include: change in the tone of voice, dysphonia, hoarseness, dysphagia, laryngeal stridor and dyspnoea. Cysts of the larynx in infants are rare but the treatment is easy once the diagnosis is made. If mismanaged, the resulting respiratory obstruction can lead to serious complications.

Objective

Analysis of cases of laryngeal cyst in children treated in the Department of Paediatric ENT Medical University of Warsaw.

Materials and methods

A retrospective analysis of 10 cases of laryngeal cyst in children treated in the Department of Paediatric ENT in Warsaw between 2000 and 2008 was made.

Results

The authors analyzed indications to directoscopy, endoscopic presentation, problems with establishing the right diagnosis and management.

Conclusions

Using a direct laryngoscopy as a golden standard in children with stridor will reduce a number of false diagnosis.     

Bilateral versus unilateral cochlear implantation in young children

Objectives

To compare the preverbal communication skills of two groups of young implanted children: those with unilateral implantation and those with bilateral implantation.

Material and methods

The study assessed 69 children: 42 unilaterally and 27 bilaterally implanted with age at implantation less than 3 years. The preverbal skills of these children were measured before and 1 year after implantation, using Tait Video Analysis that has been found able to predict later speech outcomes in young implanted children.

Results

Before implantation there was no significant difference between the unilateral group and the bilateral group. There was still no difference at 12 months following implantation where vocal autonomy is concerned, but a strongly significant difference between the groups for vocal turn-taking and non-looking vocal turns, the bilateral group outperforming the unilateral group. Regarding gestural turn-taking and gestural autonomy, there was a strongly significant difference between the two groups at the 12 month interval, and also a difference before implantation for gestural autonomy, the unilateral group having the higher scores. Multiple regression of non-looking vocal turns revealed that 1 year following implantation, bilateral implantation contributed to 51% of the variance (p < 0.0001), after controlling for the influence of age at implantation and length of deafness which did not reach statistical significance.

Conclusions

Profoundly deaf bilaterally implanted children are significantly more likely to use vocalisation to communicate, and to use audition when interacting vocally with an adult, compared with unilaterally implanted children. These results are independent of age at implantation and length of deafness.     

Laryngovideostroboscopy in children--diagnostic possibilities and constraints

Objective

The aim of this study was to report our experience with laryngovideostroboscopy (LVS) in consecutively examined children patients.

Methods

The study included 150 children (2.5-14 years of age) diagnosed with dysphonia. Patients were divided into three age groups: group I - from 2.5 to 6 years of age (n = 31), group II - from 6 to 10 years of age (n = 73), and group III - from 10 to 14 years of age (n = 46). LVS was performed during the second visit. 3.5 mg of dormicum were administered orally 30 min prior to LVS in all children from group I and in some patients belonging to group II. Local anesthesia of the pharyngeal mucosa was not needed in any case.

Results

In nine out of 150 children, it was not possible to perform LVS during the first attempt. In eight of these children, the examination was performed successfully during another visit with satisfactory LVS images obtained. LVS revealed soft vocal fold nodules in 85 patients along with other organic changes found in five children: congenital laryngeal web (n = 1), vocal fold cysts (n = 3), and vocal fold paralysis (n = 1). Hyper-functional dysphonia was diagnosed in the remaining 60 subjects.

Conclusions

In order to perform successful LVS in children patient, the purpose and methodology of this examination should be explained to parents on the first visit whereas an attempt to perform LVS should be undertaken during the second visit. Oral administration of dormicum 30 min prior to the examination is advisable, particularly in younger children, and allows us to avoid the use of local anesthetics.     

Quantification of vocal tract configuration of older children with Down syndrome: A pilot study

Objective

To quantify the vocal tract (VT) lumen of older children with Down syndrome using acoustic reflection (AR) technology.

Design

Comparative study.

Setting

Vocal tract lab with sound-proof booth.

Participants

Ten children (4 males and 6 females), aged 9-17 years old diagnosed with Down syndrome. Ten typically developing children (4 males and 6 females) matched for age, gender, and race.

Intervention

Each participant's vocal tract measurements were obtained by using an Eccovision Acoustic Pharyngometer.

Main outcome measures

Six vocal tract dimensional parameters (oral length, oral volume, pharyngeal length, pharyngeal volume, total vocal tract length, and total vocal tract volume) from children with Down syndrome and the typically developing children were measured and compared.

Results

Children with Down syndrome exhibited small oral cavities when compared to control group (F(1, 18) = 6.55, p = 0.02). They also demonstrated a smaller vocal tract volumes (F(1, 18) = 2.58, p = 0.13), although the results were not statistically significant at the 0.05 level. Pharyngeal length, pharyngeal volume, and vocal tract length were not significantly different between the two groups.

Conclusion

Children with Down syndrome had smaller oral cavities, and smaller vocal tract volumes. No significant differences were found for pharyngeal length, pharyngeal volume, and vocal tract length between these two groups.     

Congenital incudostapedial anomalies in adult stapes surgery: a case-series review

Objectives

The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologist's diagnostic skills and flexibility in technique and prosthesis choice. We review our experience in managing various incudostapedial developmental anomalies discovered during middle ear exploration for suspected otosclerosis in adult patients.

Design

A retrospective case-series review was used.

Setting

The study was set at a military tertiary referral center.

Patients and other Participants

A review of 185 stapes procedures yielded 8 cases of identified congenital anomalies of the stapes or incudostapedial complex including congenital absence of the oval window with malformed incus and stapes, columellar-type stapes with promontory fixation, stapes superstructure fixation to the fallopian canal, and malformed incus with stapes superstructure fixation to the promontory.

Interventions

The developmental anatomy and surgical technique in each case were reviewed. The surgical technique used in each case varied depending on the specific ossicular abnormality found and whether both the stapes and incus were affected.

Main outcome measures

Comparison of preoperative and postoperative audiometric testing results was performed.

Results

All 8 ears (7 patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudostapedial anomaly had a favorable hearing outcome, with 7 ears improving to within 10-dB and 1 ear to within 13-dB air-bone gap on postoperative audiometry.

Conclusions

Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible management approach can lead to successful hearing outcomes.     

Screening for delayed-onset hearing loss in preschool children who previously passed the newborn hearing screening

Objective

The goal of this study was to investigate the prevalence of delayed-onset hearing loss in preschool children who previously passed newborn hearing screening in Shanghai, China.

Methods

Between October 2009 and September 2010, 21,427 preschool children were enrolled from five areas of Shanghai, who had passed newborn hearing screening. Children were screened for delayed-onset hearing loss with pediatric audiometers. Children with positive results in initial and re-screening tests were assessed audiologically and for risk indicators according to the Year 2007 Statement of the American Joint Committee on Infant Hearing (JCIH).

Results

During the study period, 445 children (2.08%) were referred for audiologic assessment; 16 (0.75/1000, 95% CI 0.38-1.12) had permanent delayed-onset hearing loss. Of these, five (0.23/1000) had bilateral moderate hearing loss; seven (0.33/1000) had mild bilateral hearing loss; and four (0.19/1000) had unilateral moderate or mild hearing loss. JCIH risk indicators were established for six children (6/16, 37.5%), including parental concern regarding speech and language developmental delay, neonatal intensive care unit with assisted ventilation or hyperbilirubinemia, recurrent otitis media with effusion, craniofacial malformation, and family history (n = 1 for each). The remaining ten (62.5%) had no related risk factors.

Conclusions

A significant proportion of preschool children have undiagnosed delayed-onset hearing loss. Hearing screening in preschool is recommended for an early detection.     

A 13-year experience and predictors for success in transnasal endoscopic repair of congenital choanal obliteration

Objective

To express a 13-year experience in transnasal endoscopic repair of congenital choanal obliteration and to analyze the different predictors that may affect the surgical outcome.

Design

Retrospective clinical study.

Setting

Otolaryngology Department, Tanta University Hospital, Egypt.

Patients and methods

Over a 13-year period (from January 1996 to December 2008), 54 children aged between 7 day and 14 year old at the time of surgery underwent transnasal endoscopic repair of an unilateral (32 cases) and bilateral (22 cases) congenital choanal obliteration using conventional instruments and microdebrider/drill to remove the atretic plate, bony boundaries, and vomer. A laterally based mucosal flap was routinely used to resurface most of the raw areas of the lateral and superior borders of the created choana followed by shortened period stenting (5-7 days). Patients were then clinically and endoscopically monitored for nasal obstruction and healing for a mean follow-up of 46 ± 6 months. Demographic characteristics of these patients, associated anomalies, surgical technique, postoperative stenting, complications, postoperative care, and surgeons’ learning curve were discussed in the light of the findings of the surgical outcomes.

Results

There were 33 females (61.1%) and 21 males (38.9%). A total of 12 patients (22.2%) presented with associated anomalies. There were no major intra-operative or postoperative complications. The success rate for bilateral choanal obliteration was 86.4% and for unilateral choanal obliteration 96.9% with an overall success rate 92.3%. Revision surgery of the relapsed cases using the same technique without mucosal flap was successful 100%.

Conclusion

Transnasal endoscopic repair of congenital choanal obliteration is an easy and evolving technique with adequate safety and high success rate. Early diagnosis and good preparation of the patients for surgery, adequate resection of the bony boundaries of the obliterated choana and vomer, shortened period nasal stenting, strict early and late follow-up, and the growing experience of the surgeons, all were prognostic factors for success. Associated anomalies and use of mucosal flap did not seem to affect the prognosis. Inadequate bone resection, bilaterality, pure bony obliteration, the younger the age of the patient, and early developing experience of the surgeons, all were possible predictive factors for relapse.     

Tympanostomy tube outcomes in children at-risk and not at-risk for developmental delays

Objectives

To assess outcomes after tympanostomy tubes in children at-risk or not-at-risk for developmental delays based on criteria from the American Academies of Pediatrics, Family Physicians, and Otolaryngology - Head and Neck Surgeons.

Methods

Historical cohort study in a pediatric otolaryngology practice at an urban, not-for-profit hospital. All children had baseline audiometry followed by bilateral tube insertion with a Likert-type outcome questionnaire administered to the caregiver by telephone (86%) or mail (14%).

Results

We identified 229 eligible children aged .5-13 years, of which caregivers of 168 children (73%) were available for follow-up at a median time of 2.0 years (range .7-3.1 years). Most children (55%) had at least one condition placing them at-risk for developmental delays. The mean pure-tone average at baseline for the better-hearing ear was 32 dB HL (10.4 SD). After tube insertion most caregivers (89%) stated that their child's life “much better,” and that expectations were met (60%) or exceeded (38%). Speech and language was “much better” for 55%, more often in at-risk children (odds ratio 4.6, 95% CI 2.4-8.8). Similarly, learning or school performance was “much better” after tubes for 55%, more often in at-risk children (odds ratio 3.1, 95% CI 1.6-5.9). Improved hearing was reported by 84% with no relationship to at-risk status.

Conclusions

Caregivers reported favorable outcomes regardless of their child's at-risk status, but children at-risk for delays had better reported outcomes for speech, language, learning, and school performance. Results are limited by lack of a control group and reliance on caregiver-report, but add to the very limited data currently available about predictors of benefit from tubes.     

Characteristics of hearing impairment in Yemeni children with chronic suppurative otitis media: A case-control study

Background

Chronic suppurative otitis media (CSOM) is a serious disorder particularly in low resource settings. It can lead to disabling hearing impairment and sometimes life-threatening infective complications.

Objective

The aim of the present study was to describe the characteristics of hearing impairment associated with CSOM in Yemeni children.

Methods

A case-control study of 75 children with CSOM and 74 healthy controls. Hearing was assessed by behavioural testing and audiometry.

Results

Cases had lower academic performance than controls (OR 15.31, 95% CI 1.99-322.14, p < 0.001). Disabling hearing impairment >30 dB was present in 51.5% (right ear) and 66.7% (left ear) of children with CSOM.

Conclusion

Disabling hearing impairment was identified as a major health problem in these Yemeni children with CSOM. There is a need for investment to reduce the burden of CSOM and its complications in these communities. Greater attention to the chronic disabling effects of CSOM in children is required in poor communities and low resource settings.