1. Utilize surgical procedures other than tracheotomy to manage conditions that lead to airway obstruction in infants.

2. Review the most common genetic and acquired causes of sensorineural hearing loss (SNHL).

3. Discuss the likelihood of contralateral involvement in patients with unilateral SNHL.

4. Describe the coblation tonsillectomy technique and its advantages over standard electrocautery tonsillectomy.

5. Discuss the likelihood of retro- and parapharyngeal abscess after tonsillectomy.

Avoiding Tracheotomy in Infants
David R. White, MD, Assistant Professor of Pediatric Otolaryngology, Medical University of South Carolina, Charleston

Tracheotomy: provides perfect airway, but carries morbidity and mortality; bypasses airway problem instead of addressing it primarily

Airway evaluation: in neonates, airway from tip of nose to bronchi; problems with nose include choanal stenosis or atresia, pyriform aperture stenosis, and congenital nasolacrimal duct cyst; after physical examination, perform airway endoscopy; rigid and flexible bronchoscopy complementary procedures; rigid bronchoscopy—provides better evaluation of fixed stenosis (length and character); provides only adequate view of posterior commissure; flexible bronchoscopy— provides better view of anterior commissure and better evaluation of airway dynamics; pulmonology evaluation— reveals whether lungs ready for procedure other than tracheotomy

Pierre Robin syndrome: tracheotomy and nasogastric tube classic approach; vertical positioning of tongue seen, ie, tongue projects through cleft palate into nose; tongue-lip adhesion—pulls tongue forward and down; anterior pull on tongue brings tongue base out of oropharynx; varying success rates (40%- 80%); does not address primary problem, ie, small jaw; in some children, mandibular growth catches up within first year, but many require mandibular distraction in future (usually when child >2 yr of age); distraction osteogenesis—5 basic steps include 1) cutting bone (osteotomy) to 2) initiate inflammation and osteoblastic reaction; 3) more bone formation to fill gap (similar to callus formation in healing of fracture); 4) distraction to increase size of gap (pulling 2 intact pieces of bone apart slowly); 5) filling gap with bone (osteogenesis); method—external Risdon approach; in older children, internal transoral approach used (difficult in neonates because of size of mouth); ideally, osteotomy made behind tooth buds; pins placed anterior and posterior to osteotomy; external devices placed; length between 2 pins increased at rate of 1 to 2 mm/day; usually, 2 to 2.5 cm of bone grown in 2 wk; devices then locked down, becoming external fixators for 4 to 6 wk of consolidation phase; pins then removed (solid bone present); long-term risk for bilateral facial scars

Subglottic stenosis: anterior cricoid split (ACS)—split of anterior cricoid cartilage leaves open wound to heal with endotracheal tube stenting; initial success rates 58% to 100%; stringent criteria, ie, no other problems except failure to extubate; declining success rates; experimentation with various types of cartilage augmentation; series—looked at ACS vs primary laryngotracheoplasty (LTP) in neonates; those who had cartilage augmentation or primary laryngotracheal reconstruction did much better (81% success rate); success rate of ACS 28%; speaker’s method—utilizes thyroid ala graft; performs ACS and posterior CS to decompress subglottic airway; overall, ACS results poor; LTP—results better than expected, despite higher grade of stenosis; provides more aggressive means of expanding airway; combined with other procedures to more greatly decompress larynx

Congenital tracheal stenosis: complete tracheal rings—in last few years, slide tracheoplasty procedure of choice; previously, mortality 50% to 80%, even with early identification and intervention; slide tracheoplasty—reduces length of trachea by half, but doubles diameter, reducing resistance to flow; long oblique suture line reduces amount of pull on trachea and disperses force, reducing risk for dehiscence; applicable in short- and long-segment tracheal stenosis and sometimes even with tracheal anastomosis in older patient

Conclusion: when looking at neonate with airway obstruction, consider nose; if nose normal, assess lungs; consider whether to treat primarily or bypass problem and perform tracheotomy; consider early preemptive application of procedures to avoid tracheotomy

Evaluating Sensorineural Hearing Loss
Paul R. Lambert, MD, Professor and Chair, Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston

Genetic losses: ≈50% of pediatric sensorineural hearing loss (SNHL); 75% to 80% of genetic losses autosomal recessive; small percentage syndromic; CJB2 gene that encodes for Connexin 26 (Cx 26) accounts for 50% of genetic losses; gap junctions—allow adjacent cells to communicate (exchange of ions, small molecules, and other messengers); in inner ear, prevalent in supporting cells around hair cells and in stria vascularis; within auditory system, primarily Cx 26 and occasionally Cx 30; Cx 26—relatively small; ≈100 mutations identified; majority deletion of one guanosine nucleotide at base pair 35 position (35delG); recessive trait; carrier rate 2.5% to 3%; 1 in 4000 births expected to have Cx 26 mutation; phenotypically, prelingual in onset, rarely progressive; variable severity, but majority of loss severe to profound, and bilateral (cochlear implant effective); for those with moderate loss, reassurance that loss unlikely to progress; audiogram shows flat or downsloping SNHL; studies of temporal bone show near-total degeneration of hair cells, agenesis of stria vascularis, no neural degeneration, and good population of spiral ganglion cells

Acquired SNHL: cytomegalovirus (CMV)—most common intrauterine infection; seen in ≈1% of children born in United States; majority asymptomatic; presents in several ways; problem with diagnosis of CMV as etiology for hearing loss when infant >1 mo of age; unless viral DNA seen in urine or saliva in first 2 wk of life, unclear whether CMV infection congenital or postnatal; postnatal infection does not carry significant risk for hearing loss; children common carriers of CMV (in daycare setting, ≈1 in 4 children carriers or excreting virus actively)

Evaluation: history—prenatal, natal, postnatal, and family; physical examination—look for syndromic issues; in majority of cases, history and physical examination unrevealing; electrocardiography (ECG); thyroid and renal function studies; urinalysis; serologies; possibly CT; speaker’s experience that few studies show positive results; laboratory studies not helpful; over one-third of CTs positive, with enlarged vestibular aqueduct (EVA) most common finding

Vestibular aqueduct (VA): important embryologically; if abnormality seen in VA, most likely other problem occurring in inner ear; early in development, VA short, straight, and wide, but narrows with maturity; EVA—suggests arrested development; bilateral in most cases, although asymmetry in degree of hearing loss present sometimes; progression of loss seen in majority; occasionally associated with Pendred’s syndrome; occasionally associated with low-frequency mild conductive hearing loss

Mondini malformation: cerebrospinal fluid (CSF) leak into middle ear, predisposing to meningitis; bony partition between internal auditory canal and cochlea absent; constant pulsation of CSF, causing erosion of stapes footplate, leak of CSF into middle ear, and recurrent meningitis

Speaker’s approach: if SNHL unilateral, only CT performed; if bilateral, obtain Cx 26 screen first; if negative, obtain CT; ECG obtained if any suggestion of cardiac abnormality present; fluorescent treponemal antibody (FTA) test only if positive maternal history present

Progression and Contralateral Involvement in Unilateral Hearing Loss
Trina C. Uwiera, MD, Assistant Professor of Surgery, Department of Surgery, University of Alberta, and Pediatric Otolaryngologist, Stollery Children’s Hospital, Edmonton; Alessandro de Alarcon, MD, Resident Physician and Assistant Professor of Otolaryngology, Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH

Introduction: from literature, progression rate 1% to 2.5% on affected side in child with unilateral SNHL and rare involvement (<1%) of contralateral side; presence of EVA increased risk for progression to 18% to 65%

Study: retrospective database review; 198 patients with unilateral SNHL (>20 dB hearing loss on 1 frequency) and normal ear with no hearing loss (HL) in any other frequencies; mean HL 38 dB; progression defined as HL of pure-tone average change of 4 frequencies of >15 dB over 3 mo; median follow-up 25.3 mo; results—21% progression found; overall progression rate 9 dB over 1 yr; mild HL at presentation— progressed to moderate category; 10.6% (15) developed involvement of contralateral ear, 5.6% (8) of whom progressed, and 6 of these had predominantly high-frequency loss; high- frequency loss at presentation— 31% rate of contralateral ear involvement; 26 patients with other temporal bone anomalies— more frequently presented as profound SNHL; 2 patients developed contralateral HL, with no evidence of progression; conclusion—unilateral SNHL not unilateral disease; progression occurs and can involve contralateral side (seen more frequently than previously reported); development of high-frequency HL in normal ear more than previously expected; should monitor both ears for progression and bilateral involvement

The Latest Techniques in Tonsillectomy
Kay W. Chang, MD, Assistant Professor, Department of Otolaryngology, Stanford University School of Medicine, Palo Alto, CA

Tonsillectomy techniques: categories—high-energy, high-temperature subcapsular total tonsillectomy; low-energy, low-temperature technique, which includes cold dissection; intracapsular (subtotal) techniques, mostly performed with microdebrider or coblation; speaker believes no significant differences between techniques within category, but clinical differences across categories; coblation—second most commonly used tonsillectomy device in United States (after monopolar [Bovie] electrocautery); straddles 2 categories (low-temperature subcapsular total tonsillectomy and intracapsular tonsillectomy); survey—showed that for primary indication of obstructive sleep apnea (OSA), 75% of surgeons used total tonsillectomy techniques, and 25% utilized intracapsular and total tonsillectomy techniques; for recurrent tonsillitis, fewer surgeons employ intracapsular technique; monopolar electrocautery most common total tonsillectomy instrument used; subtotal tonsillectomy instrument depended on indication (for OSA, microdebrider; for infection, coblation and microdebrider)

Review of literature: microdebrider intracapsular tonsillectomy—decreased pain and more rapid recovery observed; 3.2% regrowth rate; Solares et al (2005)—found that in addition to benefits of decreased pain and rapid recovery, bleeding rate and rate of admission for dehydration lower with intracapsular tonsillectomy; Smith et al (2007)—found no increase in infections with intracapsular technique vs standard electrocautery total tonsillectomy; Chan et al (2004)— demonstrated decreased medication and increased oral intake; at 1-yr follow-up, residual tonsil present in 73% of patients; Arya et al—on one side, coblation with total tonsillectomy technique (on other side intracapsular technique used); found no difference in pain between 2 sides (first 24 hr); intracapsular technique—variety of devices (eg, radiofrequency Surgitron Ellman device, bipolar scissors) with similar benefits; speaker prefers coblation (removes tonsillar tissue almost as fast as microdebrider without bleeding)

Coblation: uses bipolar radiofrequency energy with conductive saline medium to produce plasma field that results in dissociation of tissue molecules with minimal thermal energy release; results in surface tissue temperatures of 40° to 70°C, while electrocautery causes tissue heating of 400°C; 2 modalities—at setting of 6 to 9, generating plasma field and operating in coblation mode; at setting of 1 to 5, in resistive thermal mode, with tissue temperatures proportional to amount of power applied (coblator operating like bipolar electrocautery); lowest setting to achieve coblation is 6

Speaker’s study: 101 participants with operative indication of OSA; prospectively randomized to intracapsular coblation or standard electrocautery tonsillectomy; no complications observed in either group, with similar rates of nausea and vomiting; coblation group had less pain, able to eat more, and able to resume greater levels of normal activity at 3 time points (statistically significant from day 3 onwards); concluded that coblation-assisted intracapsular tonsillectomy resulted in better recovery than standard electrocautery tonsillectomy

Coblation technique: coblation wand not ideally suited as dissection device for making fine cuts (designed as ablation device), and necessary to modify technique; active surface electrodes must face toward tonsil and away from fossa at all times; failure to do so results in deep ablative lesions in tonsillar fossa, exposing larger blood vessels, resulting in increased intraoperative and postoperative bleeding; speaker’s study—69 children, with operative indication of OSA; randomized to intracapsular or subcapsular procedure, using coblation; pain identical in both groups on day 1; on day 5, subcapsular group doing worse than intracapsular group (although still better than electrocautery group); on days 1 and 5, intracapsular patients ate more and more active; technical tips—during learning curve, handpiece can become clogged with tissue; maintain constant tip motion and high saline flow; periodically clear saline through wand; as technique mastered, wand ceases to clog; Herd retractor used to protect pillar and helps to rotate tonsil out to expose depth of ablation; goal 90% to 95% removal, while avoiding penetrating capsule; end result to achieve smooth concavity representing tonsillar fossa; observations—clear that low-temperature techniques have advantage; study data show that primary hemorrhage rates start high but drop to zero once surgeon past 30th case; delayed hemorrhage rates also decrease as surgeons gain more experience with coblation;

Conclusions: coblation suboptimal technique (ideal tonsillectomy device should have much shallower learning curve and feel natural and safe to use after few cases); search for ideal device ongoing; should consider adding intracapsular techniques to armamentarium (demonstrated benefits to recovery considerable and risk for bleeding decreased); major disadvantages of regrowth and infection not clinically significant

Association Between Retropharyngeal and Parapharyngeal Abscesses and Adenotonsillectomy
Melanie Duval, MD, Faculty of Medicine, McGill University, Montreal

Introduction: retropharyngeal and parapharyngeal abscesses uncommon infections associated with potentially severe complications; hypothesis that since adenoids and tonsils lymphoid tissues that act as filters for pharyngeal infection, their removal would increase likelihood of pharyngeal abscesses; multiple studies demonstrate that after tonsillectomy, decrease in level of immunoglobulins seen; decrease in IgM, IgG, and IgE levels 38 mo after tonsillectomy; however, another study showed that children with tonsil disease who do not undergo surgery have decrease in IgM and IgG levels comparable to that seen after surgery; children 4 to 8 yr of age at time of tonsillectomy have significant decrease in IgE

Study: found that children with retro- or parapharyngeal abscess 7 times more likely to have had tonsillectomy and adenoidectomy (T and A; statistically significant); majority developed abscess 1 yr after surgery; however, unable to confirm whether direct result of T and A or whether children predisposed to develop abscesses for other reasons