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Purpose The use of a vascularized free fibula graft (FFF) for the reconstruction of a mandible in a child with a mandibular tumor is infrequent. The purpose of this study is to report our protocol for resection of mandibular jaw tumors and immediate reconstruction using FFF in pediatric patients. Methods This was a retrospective case series of children with a mandibular tumor, which was resected and immediately reconstructed with FFF. All patients were treated via the same staged protocol: 1) presurgical digital planning, 2) surgical intervention (resection and immediate reconstruction), 3) postoperative care in the pediatric intensive unit, and 4) prosthodontic dental rehabilitation. Outcomes were complications and recurrence. Medical records were reviewed to document demographic information, tumor details, surgical interventions, postoperative course, and prosthodontic rehabilitation. Results Fifteen patients (10 males, average age of 13.7 years) met inclusion criteria. Ten patients had mandibular ameloblastoma. All patients were treated by a dedicated pediatric team and followed the same protocol. The average tumor size was 4.87 × 3.22 × 2.03 cm. Most fibulas (n = 12) had one osteotomy to reestablish mandibular continuity and create appropriate contour. The most common microvascular anastomosis was with a facial artery (n = 13) and the external jugular vein (n = 9). At an average follow-up of 15.5 months, there were only 3 minor donor site complications. Eight implants were placed without complications. No tumors recurred. Conclusions The results of this study suggest that pediatric mandibular tumors can be successfully treated using a specific protocol involving resection and immediate reconstruction using FFF with minimal complications and without recurrence.

Objective Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies. Study design Prospective randomized controlled trial. Setting Pediatric outpatient surgery center. Methods Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction. Results In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients' fear of anesthesia induction (Cohen's d effect size = 0.94; P Conclusion The educational pop-up book offers a child-focused resource that helps alleviate children's preoperative fears, encourages positive coping, and improves caregivers' perceptions of the experience. This study was registered at ClinicalTrials.gov (NCT04796077).

Importance Initial data suggest the effectiveness of oncogene-specific targeted therapies in inducing tumor regression of diverse cancers in children and adults, with minimal adverse effects. Observations In this review, preliminary data suggest that systemic therapy may be effective in inducing tumor regression in pediatric patients with unresectable invasive thyroid cancer. Although most pediatric patients with thyroid cancer initially present with operable disease, some children have extensive disease that poses substantial surgical challenges and exposes them to higher than usual risk of operative complications. Extensive disease includes thyroid cancer that invades the trachea or esophagus or encases vascular or neural structures. Previous efforts to manage extensive thyroid cancer focused on surgery with near-curative intent. With the recent development of oncogene-specific targeted therapies that are effective in inducing tumor regression, with minimal drug-associated adverse effects, there is an opportunity to consider incorporating these agents as neoadjuvant therapy. In patients with morbidly invasive regional metastasis or with hypoxia associated with extensive pulmonary metastasis, neoadjuvant therapy can be incorporated to induce tumor regression before surgery and radioactive iodine therapy. For patients with widely invasive medullary thyroid cancer, in whom the risk of surgical complications is high and the likelihood of surgical remission is low, these agents may replace surgery depending on the response to therapy and long-term tolerance. Conclusions and Relevance With oncogene-specific targeted therapy that is associated with substantial tumor regression and low risk of adverse reactions, there appears to be an opportunity to include children with advanced invasive thyroid cancer in clinical trials exploring neoadjuvant targeted oncogene therapy before or instead of surgery.

BACKGROUND The treatment of patients with advanced stage laryngeal cancer includes surgery or concurrent chemoradiation (CRT). Although CRT has become more common in recent years, to the authors' knowledge, the effectiveness of complete CRT in improving survival over surgery has not been studied. METHODS The authors examined patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare claims-linked data set with locoregional laryngeal cancer who were diagnosed between 1997 and 2007. Multivariate Cox proportional hazard analyses were conducted to compare overall and cause-specific 5-year survival rates between treatment modalities, adjusting for patient sociodemographic and clinical characteristics. A propensity score-matched subcohort also was used to compare survival. RESULTS Of the 3212 patients in the study cohort, 42% underwent surgery and 18% underwent CRT. Only approximately one-quarter of patients who were treated with CRT completed the courses. In adjusted analyses, the authors were unable to reject the null hypothesis of no difference in 5-year all-cause or cause-specific mortality risk between patients treated with surgery and patients undergoing complete CRT (hazards ratio, 1.25 [95% confidence interval, 0.91-1.71; P = .16] and hazard ratio, 1.41 [95% confidence interval, 0.9-2.2; P = .14], respectively). Older age, not currently married, Medicaid eligibility, and prior cancer history were found to be associated with a higher risk of mortality (P

Subglottic stenosis is classified as congenital or acquired based on a history of prior airway instrumentation. Milder cases can often be managed with medical support and endoscopic procedures, while patients with more pronounced narrowing may require open surgical repair. The most severe form of stenosis—laryngeal atresia—requires immediate recognition and management in the delivery room. Patients with subglottic stenosis can benefit from multidisciplinary evaluation and management coincident pathology in the upper aerodigestive tract.

Successful endoscopic repair of the skull base may be performed with a variety of grafting materials. Graft materials discussed in this chapter are broadly categorized as autologous tissue, acellular human dermis, engineered collagen products, rigid support materials and tissue glues. Autologous tissues continue to be widely used due to their safety, availability, and low cost. Engineered collagen products and acellular dermis are favored in revision cases and larger repairs. The need for rigid support continues to be an area of controversy as pedicled grafts are increasingly used for larger defects. Tissue glues and sealants, however, are used by many authors. The components of, and evidence for, commonly used sealants are detailed. Relatively little high-quality, comparative evidence exists to guide decision making when selecting graft materials, but where available, this evidence is cited. If surgeon experience and patient characteristics are carefully considered, excellent results can be expected with most materials.

Objective: 1) Describe important points of consideration when planning cochlear implant surgery for patients at risk for cerebrospinal fluid (CSF) gusher on cochleostomy. 2) Report successful cochlear implantation in patients with X-linked mixed deafness.Method: Fraternal twins with X-linked mixed deafness were enrolled in an observational study at a tertiary academic medical center from 2010 to 2011. Subjects underwent cochlear implantation and were followed during recovery and auditory rehabilitation. Main outcome measures included successful placement of electrode arrays into the cochlea, adequate control of leaking CSF, incidence of postoperative complications, and development of listening and speaking communication skills in children with implants.Results: Electrode arrays were successfully placed despite challenging middle and inner ear abnormalities. Leaking CSF was controlled without the use of lumbar drains. No perioperative or postoperative complications occurred. Both patients progressed rapidl...

Importance The incidence and timing patterns of decannulation failure in children are unknown. There is substantial variability in the duration of inpatient hospitalization for patients undergoing decannulation, which represents an opportunity for improved resource use. Objective To determine the incidence and timing patterns of elective decannulation failure in the pediatric population and to determine an appropriate interval of inpatient observation following decannulation that optimizes both patient safety and resource use. Design, Setting, and Participants Retrospective review of medical records of consecutive patients 18 years or younger hospitalized for elective, inpatient decannulation between January 1, 2012, and October 31, 2013, at a quaternary care pediatric hospital. Main Outcomes and Measures Duration of decannulation hospitalization, failure of elective decannulation (decision not to decannulate or reinsertion of tracheostomy tube after decannulation), time interval from decannulation to failure. Results Forty-six patients completed 50 elective decannulation hospitalizations during the study period. The median duration of hospitalization for decannulation was 3.0 days. The hospitalization-specific failure rate was 16% (8 of 50), and the overall failure rate was 9% (4 of 46). Four patients were not able to tolerate capping of the tracheostomy tube and were discharged with their original tracheostomy tubes in place. Three of these patients were decannulated at a later hospitalization. In 4 patients, decannulation failed and they had to have their tracheostomy tubes replaced prior to discharge. Patients who did not tolerate decannulation were younger (mean [SD] age, 45.7 [17.0] months) than patients whose decannulation was successful (68.2 [48.0] months). All patients with unsuccessful decannulation attempts were symptomatic during capping. The longest interval from decannulation to tracheostomy reinsertion was 11 hours. Conclusions and Relevance Elective decannulation failure occurred in 9% of this population and may be more common in younger patients and those with a diagnosis of vocal fold paralysis. Patients who are symptomatic during predecannulation capping are at high risk for decannulation failure. Inpatient observation for a 24-hour asymptomatic interval after decannulation may be sufficient because late failures were not observed in this sample.

Objective: To compare the postoperative healing profiles of graft materials used for endoscopic repair of cerebrospinal fluid (CSF) leak. Design: Retrospective cohort study with 1 to 21 months of follow-up. Setting: Tertiary referral, academic medical center. Patients: Consecutive sample of patients undergoing endoscopic repair of CSF leak from March 2007 through May 2009. Intervention: Endoscopic repair of CSF leak with acellular dermis, collagen matrix, or sinonasal mucosal grafts. Graft success, time to full graft mucosalization, and duration of graft or donor site crusting were assessed during the postoperative period. Results: Forty repairs were performed on 37 patients: 17 with mucosal grafts, 10 with acellular dermis, and 13 with collagen matrix grafts. The mean follow-up time was 5.3 months (range, 0.5-21.0 months). Two patients had partial graft loss; none had a recurrence of CSF leak. There was a significant difference in time to mucosalization with acellular dermis (11.7 weeks) when compared with collagen matrices (6.6 weeks) or mucosa (4.9 weeks) (P