Commentary From the Section on Otolaryngology-Head and Neck Surgery

Commentary From the Section on Otolaryngology-Head and Neck Surgery

Introduction

Steven E. Sobol, MD, FAAP

Affiliation: Professor, Department of Otorhinolaryngology-Head & Neck Surgery, Director of Program Integration and Wellness, Perelman School of Medicine at The University of Pennsylvania

The Section on Otolaryngology-Head and Neck Surgery (SOOHNS) was founded in 1977 as the Section on Otolaryngology and Bronchoesophagology. The first chair of the section was Charles D. Bluestone, MD, FAAP, one of the pioneers of pediatric otolaryngology and an author of one of our featured publications (see below). On May 4, 2003, the executive committee voted unanimously to change the name of the Section to the Section on Otolaryngology-Head and Neck Surgery to better reflect the interests of their members and the focus of the section. 

In the modern era, our section’s primary missions are advocating for children and their families as well as being the primary resource for otolaryngology education of pediatricians and the public. SOOHNS prides itself on being the liaison between other pediatric otolaryngology societies and the American Academy of Pediatrics (AAP). Through our combined collaborative efforts with our sister societies and by leveraging the educational resources of the AAP, SOOHNS has successfully served in its educational mission through in-person and virtual lectures; the publication of clinical reports, guidelines, and policy statements (see below); and by providing educational resources for parents. We have had many advocacy successes, including lobbying for improved supply of vital tracheostomy tubes during the recent shortage, and have been at the forefront of lobbying for safer button battery packaging and consumer education. We look forward to the next 75 years!

Pediatrics Article Summary 1948-1973 (First Quarter Century)

Jeffrey P. Simons, MD, MMM, FAAP

Highlighted Article From Pediatrics

• Paradise JL, Bluestone CD, Felder H. The universality of otitis media in 50 infants with cleft palate. Pediatrics. 1969;44(1):35-42

In our first highlighted article, published in July 1969, Paradise, Bluestone, and Felder describe the ubiquitous finding of middle ear effusions (either otitis media with effusion or acute otitis media) in infants with cleft palate. They found that in 50 infants with cleft palate who were age 20 months or younger, all 50 had either serous or suppurative otitis media. In this cohort, a myringotomy was performed in 86/100 ears, confirming the presence of middle ear effusions in all instances. The type of fluid was recorded in 76 middle ears and was found to be serous in 21/76 ears, mucoid or sero-mucoid in 36/76 ears, and mucopurulent or purulent in 19/76 ears. Twenty-one of the infants were examined within the first 3 months of life, and all of them had middle ear effusions present, suggesting that otitis media develops in all infants with cleft palate within the first few months of life. Thirteen patients were initially treated with myringotomy only (no tympanostomy tubes); all of them had re-accumulation of middle ear fluid before the first follow-up visit, requiring tympanostomy tube insertion. The authors subsequently recommended and performed tympanostomy tube insertion for the management of all infants with cleft palate and middle ear effusion.

Since the time of this study, it has been well-established that otitis media with effusion occurs in nearly all infants and children with cleft palate because of Eustachian tube dysfunction that results from abnormal insertion and orientation of the tensor veli palatini and levator veli palatini muscles.^1-4 It has also been demonstrated that chronic otitis media with effusion in children with cleft palate is almost always associated with conductive hearing loss.³ Current guidelines corroborate that tympanostomy tubes are beneficial in this population and that surveillance for middle ear disease should continue throughout childhood.^5-6 The Paradise, Bluestone, and Felder paper from July 1969 was one of the first to bring attention to the universal nature of middle ear disease in infants with cleft palate.

References:

1. Broen PA, Moller KT, Carlstrom J, Doyle SS, Devers M, Keenan KM. Comparison of the hearing histories of children with and without cleft palate. Cleft Palate Craniofac J. 1996;33(2):127-133
2. Sheahan P, Blayney AW, Sheahan JN, Earley MJ. Sequelae of otitis media with effusion among children with cleft lip and/or cleft palate. Clin Otolaryngol Allied Sci. 2002;27(6):494-500
3. Flynn T, Möller C, Jönsson R, Lohmander A. The high prevalence of otitis media with effusion in children with cleft lip and palate as compared to children without clefts. Int J Pediatr Otorhinolaryngol. 2009;73(10):1441-1446
4. Kim E, Kanack MD, Dang-Vu MD, Carvalho D, Jones MC, Gosman AA. Evaluation of ventilation tube placement and long-term audiologic outcome in children with cleft palate. Cleft Palate Craniofac J. 2017;54(6):650-655
5. Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical practice guideline: Tympanostomy tubes in children (update). Otolaryngol Head Neck Surg. 2022;166:S1-S55
6. Shaffer AD, Ford MD, Choi SS, Jabbour N. The impact of tympanostomy tubes on speech and language development in children with cleft palate. Otolaryngol Head Neck Surg. 2017;157(3):504-514

Pediatrics Article Summary 1974-1998 (Second Quarter Century)

Kristina W. Rosbe, MD, FAAP

Highlighted Article From Pediatrics

• Healy GB, McGill T, Strong MS. Surgical advances in treatment of lesions in the pediatric airway: the role of the carbon dioxide laser. Pediatrics. 1978;61(3):380-383

This article by some of the early giants of pediatric airway surgery describes the use of the carbon dioxide (CO2) laser as an attachment to the Zeiss operating microscope for pediatric airway pathology. The authors describe the advantages of being able to use the laser endoscopically to avoid potential increased risks and complications of open surgery and to allow our pediatric anesthesia colleagues to be able to ventilate without a tracheotomy. Other advantages of the laser that the authors mention include its hemostatic effects, minimal edema formation, rapid healing, and use as both a cutting or ablative instrument. Concurrent development of bronchoscopic equipment, such as the Hopkins telescope, helped improve access to the pediatric airway.

The authors describe use of the laser for surgical treatment of a variety of pediatric airway pathologies, including choanal atresia, oral cavity and tongue vascular malformations, laryngeal webs, nodules, granulomas, recurrent respiratory papilloma, subglottic and tracheal stenosis, subglottic hemangiomas, and hypertrophied tonsils. Although the CO2 laser is not considered state of the art in repair of choanal atresia today, due to subsequent development of transnasal endoscopic instruments in the 1970s, the combined laser and microscopic approach helped avoid the more traditional transpalatal approach associated with greater morbidity and recovery.

This paper introduces the idea of minimally invasive surgery before this term was coined. These innovative surgeons describe ways to improve surgical care quality and safety and allowed otolaryngologists and anesthesiologists to collaborate in these very small anatomic areas. For younger surgeons, it is hard to imagine that this set-up was not always part of our tool box. Do you think these authors could ever have imagined that medical therapy such as propranolol or a vaccine such as the HPV vaccine, would eradicate the need for some of these techniques?

References

1. Pirsig W. Surgery of choanal atresia in infants and children: historical notes and updated review. Int J Pediatr Otorhinolaryngol 1986;11(2):153-170
2. Bartel R, Levorato M, Adroher M, et al. Performance of endoscopic repair with endonasal flaps for congenital choanal atresia. A systematic review. Acta Otorrinolaringol Esp (Engl Ed). 2021;72(1):51-56
3. Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358(24):2649-2651
4. Meites E, Stone L, Amiling R, et al. Significant declines in juvenile-onset recurrent respiratory papillomatosis following human papillomavirus (HPV) vaccine introduction in the United States. Clin Infect Dis. 2021;73(5):885-890

Pediatrics Article Summary 1998-Present (Third Quarter Century)

David H. Darrow, MD, DDS, FAAP

During the last quarter century, readers of Pediatrics have witnessed an exponential expansion of medical literature. A 2011 study estimated that the doubling time of medical knowledge was 50 years in 1950, 7 years in 1980, and 3.5 years in 2010; the study projected a doubling time of 73 days by 2020.¹ Print journals responded by moving the plethora of articles to online platforms, searchable in seconds with a few clicks of a computer button. However, pediatric clinicians of the last 3 decades, lacking the time (and perhaps the inclination) to review this expanding volume of primary research, have sought other means to access “best practice” reviews. This need has increasingly been met by clinical practice guidelines (CPGs) that “include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”² In order to meet the needs of our pediatric colleagues in the practice, SOOHNS has been an active participant in the initiation and development of CPGs published in Pediatrics in the last 25 years, including the following 4 articles.

Highlighted Article From Pediatrics

• Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130 (3):576–584

This CPG, authored by a multidisciplinary panel including the SOOHNS, revised a 2002 guideline authored by the Section on Pulmonology. The group reviewed 3,166 articles published between 1999 and 2010 and identified 350 that provided data appropriate for inclusion. Recommendations from the resulting evidence report included:

1. All children/adolescents should be screened for snoring.
2. Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered.
3. Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy.
4. High-risk patients should be monitored as inpatients postoperatively.
5. Patients should be re-evaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy.
6. Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively.
7. Weight loss is recommended in addition to other therapy in patients who are overweight or obese.
8. Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.

SOOHNS was instrumental in ensuring that the CPG considered alternative methods of evaluation for children who might not have access to polysomnography. Many of the other concepts are echoed in the American Academy of Otolaryngology-Head & Neck Surgery CPG “Tonsillectomy in Children” (2011, 2019).³

Highlighted Article From Pediatrics

• Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. March 2013;131(3):e964–e999

This 2013 CPG focused on proper diagnosis and initial management of the child with acute otitis media (AOM). Diagnostic criteria were established as moderate to severe bulging of the ear drum, mild bulging of the ear drum associated with ear pain, or new onset otorrhea not due to otitis externa. Presence of a middle ear effusion is a necessary criterion for diagnosis. Antibiotic therapy was recommended for severe AOM (moderate or severe otalgia, otalgia for at least 48 hours, or temperature of ≥39˚C), and for non-severe bilateral AOM in children under 23 months of age. Observation with close follow-up is an option for unilateral non-severe AOM in these children. Amoxicillin is appropriate first-line therapy unless the child has had amoxicillin in the past 30 days or has purulent conjunctivitis. The guideline recommended against use of antibiotic prophylaxis but supported placement of tympanostomy tubes for at least 3 episodes within 6 months or 4 episodes within 12 months including 1 within the preceding 6 months. Recommended preventive measures included administration of pneumococcal and influenza vaccines, breastfeeding for at least 6 months, and avoidance of exposure to tobacco smoke.

Highlighted Article From Pediatrics

• Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262–e280

The most significant accomplishment of this CPG and its 2001 predecessor was to establish criteria for the diagnosis of acute bacterial pediatric sinus infection in children. The guideline committee defined the disorder as acute upper respiratory tract infection (URI) presenting with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever [temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days).

Although the 2013 revision included the new diagnostic criterion above designated “worsening course,” SOOHNS also advocated for an option for an additional observation period of 3 days as an alternative to treatment. The guideline called for limiting CT imaging to children with complications or impending complications of acute sinusitis. Amoxicillin/clavulanate is suggested in the CPG as appropriate first-line therapy for acute bacterial sinusitis.

Highlighted Article From Pediatrics

• Krowchuk DP, Frieden IJ, Mancini AJ et al. Clinical practice guideline for the management of infantile hemangiomas. Pediatrics. 2019;143(1):e20183475

SOOHNS was instrumental in developing the first US CPG for the management of infantile hemangioma. The 2015 AAP clinical report “Diagnosis and Management of Infantile Hemangioma” was proposed and first-authored by SOOHNS and served as the basis for the 2019 CPG.⁴ The guideline emphasized the importance of early identification and referral of “high-risk” hemangiomas and established appropriate qualifications for “hemangioma specialists” to whom affected patients should be referred. The guideline also proposed that imaging be limited to ultrasound in cases of uncertain diagnosis or for assessment of the liver when 5 or more cutaneous lesions are present. Propranolol was recommended as first-line intervention for lesions requiring systemic therapy, and recommendations for initiation and maintenance of treatment were provided. Early surgery was advocated primarily for ulcerated hemangiomas or those that obstruct or deform vital structures (such as the airway or orbit) or involve aesthetically sensitive areas and (1) have failed to improve with local wound care and/or pharmacotherapy, (2) are well localized such that early surgery will simplify later reconstruction, (3) are well localized within an anatomically and cosmetically favorable area, or (4) are likely to require resection in the future, and the resultant scar would be the same. Surgery was also established as a treatment option for infantile hemangiomas that, despite involution, have left significant residual skin changes.

References

1. Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58
2. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, eds. National Academies Press (US); 2011
3. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg. 2019;160: S1-S4
4. Darrow DH, Greene AK, Mancini AJ, Nopper AJ, Section on Dermatology, Section on Otolaryngology–Head and Neck Surgery, Section on Plastic Surgery. Diagnosis and management of infantile hemangioma. Pediatrics. 2015;136 (4):e1060-e1104