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Objectives/hypothesis: Tracheotomy is a common procedure. A reliable method of securing the tracheotomy tube is essential to minimize accidental decannulation. However, skin breakdown has been reported in ∼30% of patients. We sought to evaluate rates of skin-related complications and accidental decannulation with the use of Velcro ties compared to twill ties., Study Design: A nonblinded, randomized controlled trial comparing Velcro versus twill ties in patients undergoing tracheotomy between July 1, 2014 and January 31, 2016., Methods: Patients ≤21 years of age were recruited and randomized to receive either Velcro or twill ties. The primary outcome measure was skin-related complications. The secondary outcome measure was accidental decannulation. Outcome measures were followed through postoperative day 5., Results: Ninety-three patients were eligible, and 63 were enrolled. No patients were withdrawn. Fifty-seven patients were included in the analysis. Twenty-seven (47.4%) received Velcro, and 30 (52.6%) received twill. Five enrolled patients did not undergo tracheotomy (one Velcro, four twill). One was diagnosed with a genetic skin condition after enrollment but prior to undergoing tracheotomy. Patient characteristics were similar between groups. No significant differences were found with respect to skin-related complications (P = .59). Six patients (20%) with twill ties required early tie change compared to two (7.4%) with Velcro ties (P = .5). Two accidental decannulations occurred in the twill group compared to one in the Velcro group (P = 1.0)., Conclusions: Our study demonstrated no differences in skin-related complications or accidental decannulation between Velcro and twill tracheotomy ties in the immediate postoperative period following tracheotomy. Our study suggests that Velcro ties are a viable alternative to twill ties., Level of Evidence: 1b Laryngoscope, 127:1996-2001, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives (1) Describe the prevalence of radiographic signs of intracranial hypertension (ICH) in Ménière's disease (MD) and (2) compare the prevalence of radiographic signs of ICH in MD patients managed medically to those managed surgically. Study Design Case-control study. Setting Academic neurotologic practice. Subjects and Methods Adult MD patients (aged ≥17 years) treated from 2011 to 2015 were reviewed. Inclusion required magnetic resonance imaging (MRI) of the head and follow-up >6 months. Patients with intracranial tumors, mass effect, trauma, previous intracranial surgery, and glaucoma were excluded. MD patients were separated by administered treatment into medical and surgical subgroups. Cochlear implant (CI) recipients served as radiographic controls. Eighty-four MD patients (46 surgical, 38 medical) and 37 CI controls were assessed. MRI measurements assessed for empty/partial sella (ES/PS), dilated/tortuous optic nerve sheath (ONS), and posterior globe flattening (PGF). Results Mean age was 53.8 ± 1.3 years and median body mass index (BMI) was 28.2 kg/m 2 . Of the patients, 64% were female and 92% were white. MRI findings in the MD cohort were as follows: ES/PS, 46.4%; ONS change, 42.8%; and PGF, 8.3%. The prevalence of ONS change was higher in MD patients than in controls (42.8% vs 13.5%, P = .003). The surgical MD group had higher prevalence of ONS change (52%) compared with the medical group (31.5%, P = .05) and controls (13.5%, P = .0004). The surgical group had a higher prevalence of ≥2 simultaneous MRI findings compared with medical MD patients (39% vs 10%, P = .01) and controls (14%, P = .01). Conclusion MD patients demonstrate a high prevalence of radiographic signs of ICH. MD patients who required surgery had a greater prevalence of radiographic signs of ICH compared with non-MD patients and medically managed MD patients.

Objectives (1) Describe longitudinal trends in annual prevalence of hospital admission for pediatric acute otitis media (AOM) and complications of AOM (CAOM) since introduction of pneumococcal vaccination in 2000 and (2) describe the longitudinal trend of prevalence of hospital admission for pneumococcal meningitis in children with AOM-related diagnoses in the postvaccination era. Study Design Retrospective analysis of Kids' Inpatient Database from 2000 to 2012. Setting Community, nonrehabilitation hospitals. Subjects and Methods To determine annual prevalence of admission for AOM/CAOM, nationally weighted frequencies of children aged <21 years with acute suppurative otitis media, acute mastoiditis, suppurative labyrinthitis, and/or acute petrositis were collected. The frequency of coexisting pneumococcal meningitis diagnoses among these patients was also collected. Trend analysis of prevalences of admission for AOM/CAOM and for pneumococcal meningitis occurring in the setting of AOM/CAOM from 2000 to 2012 was performed. Results Between 2000 and 2012, annual prevalence of admission for AOM/CAOM decreased from 3.956 to 2.618 per 100,000 persons ( P < .0001) (relative risk reduction 34%). Declines in admission prevalence were most pronounced in children <1 year of age (from 22.647 to 8.715 per 100,000 persons between 2000 and 2012, P < .0001) and 1 to 2 years of age (from 13.652 to 5.554 per 100,000 persons between 2000 and 2012, P < .0001). For all ages, the admission prevalence for pneumococcal meningitis and concomitant AOM/CAOM decreased (from 1.760 to 0.717 per 1,000,000 persons, P < .0001) over the study period. Conclusions The prevalence of hospital admission for pediatric AOM/CAOM has declined since the advent of pneumococcal vaccination. Admission rates for pneumococcal meningitis with AOM/CAOM have similarly declined.

Background: A crayon fragment was determined to be the source of a foreign body inflammatory process in the masticator space of a 15-month-old boy. The appearance of the crayon on CT and MR imaging was unexpected, leading to a further analysis of the imaging features of crayons., Objective: To investigate and characterize the imaging appearance of crayons at CT and MRI., Materials and Methods: The authors obtained CT and MR images of 22 crayons from three manufacturers and three non-pigmented crayons cast by the authors. CT attenuation of the crayons and diameter of the MRI susceptibility signal dropout were plotted versus brand and color., Results: All crayons demonstrated a longitudinal central hypo-attenuating tract. Crayon attenuation varied by brand and color. All of the crayons demonstrated a signal void on T1 and T2 imaging and signal dropout on susceptibility-weighted imaging, the diameter of which varied by brand and color., Conclusion: Understanding the imaging appearance of crayons could help in the correct identification of a crayon as a foreign body on imaging studies, even when it is located in unusual places.

Objective: We report an unusual case of masticator space foreign body in a patient presenting with otorrhea and granulation tissue within the external auditory canal (EAC)., Methods: Case report., Results: A 16-month-old male presented with fever, unilateral otorrhea, facial swelling, leukocytosis, and granulation tissue within the EAC that failed to respond to conventional medical treatment. Computed tomography scan showed EAC and middle ear opacification and soft tissue swelling involving the masticator space. Given concerns for malignancy, biopsies of tissue within the EAC and of a newly detected right buccal mass were performed, revealing granulation tissue. Concern persisted for neoplasm, however, and magnetic resonance imaging was obtained, showing a masticator space foreign body and possible osteomyelitis of the mandible and pterygoid plates. The patient underwent urgent operative removal of a 3 cm crayon fragment from the masticator space and debridement of granulation tissue arising from a small defect at the inferior medial cartilaginous EAC. He likely sustained foreign body injury several weeks earlier upon falling from standing height while biting a crayon. Postoperatively, he was observed in hospital on intravenous antibiotics and improved significantly. He has since fully recovered., Conclusion: Masticator space foreign bodies may present with erosion and granulation tissue of the EAC., (© The Author(s) 2016.)

Objective and Importance: Preoperative chronic otitis media (COM) is a risk factor for postoperative infection after cochlear implantation (CI), but its management varies by surgeon. Our case highlights a strategy for implant preservation in a patient with a history of recurrent cochlear implant infection., Clinical Presentation: A 70-year-old woman with a history of chronic lymphocytic leukemia presented in 2005 with bilateral COM and sensorineural hearing loss meeting CI candidacy. Four months after left mastoid obliteration with abdominal fat graft and external auditory canal closure, a left CI was placed. Subsequent postauricular cellulitis resolved with oral antibiotics. A similar two-stage CI was performed on the right without complication. During the following year, numerous left-sided infections and fluid collections developed but were treated unsuccessfully with intravenous (IV) antibiotics and operative debridement. With concern for biofilm colonization, the implant was explanted and the electrode left in the cochlea. After reimplantation in 2010, infections resumed despite long-term IV antibiotics and incision and drainage. Intervention and technique In 2012, the left mastoid cavity was exteriorized and converted to standard canal wall-down anatomy. Bone pâté was placed over the electrode, followed by cadaveric acellular dermis and a split-thickness skin graft. After more than 2 years, her better-performing CI remains infection-free., Conclusion: After 6 years of postoperative infections unresponsive to aggressive medical management, surgical interventions, and period of device removal, our patient's infections resolved after mastoid exteriorization and multilayered protection of the electrode. This strategy may enable implant preservation in patients with recurrent post-CI infection in an obliterated cavity.

Objective: Increasingly, laryngomalacia and craniofacial anomalies are recognized as risk factors for obstructive sleep apnea. We sought to determine whether children with these diagnoses have become more likely to undergo inpatient polysomnogram (PSG) over time and to identify evolving trends in PSG utilization., Methods: Retrospective analysis of the Kids' Inpatient Database from 2003 to 2012. Children <21 years who underwent PSG were included. Weighted comparisons of clinical/demographic characteristics of patients undergoing PSG were performed, as were associations between clinical and demographic patient characteristics and performance of inpatient PSG., Results: Between 2003 and 2012, PSG procedures decreased from 1266 to 829 (P < .001). Among children who underwent PSG, mean age decreased from 3.9 ± 5.1 to 3.1 ± 5.2 years (P = .001), and the frequency of age <1 year increased from 47.8% to 59.5% (P < .001). The frequency of laryngomalacia increased from 2.5% to 14.3% (P < .001), while the frequency of craniofacial anomalies increased from 6.2% to 19.4% (P < .001). Laryngomalacia and craniofacial anomalies were predictive of undergoing inpatient PSG in both timeframes., Conclusion: Despite decreasing PSG volumes, diagnoses of laryngomalacia and craniofacial anomalies comprised increasing fractions of children undergoing inpatient PSG between 2003 and 2012. Laryngomalacia and craniofacial anomalies were also predictive of inpatient PSG use in both timeframes., (© The Author(s) 2015.)

Disinfection caps are increasingly being used to prevent catheter-associated bloodstream infections. These devices, designed for continuous passive disinfection of catheter hubs, are typically small and often brightly colored. As such, they have the potential to become pediatric airway and esophageal foreign bodies. We report two patients who developed esophageal foreign body following ingestion of disinfection caps. Given the increasing use of these devices, it is imperative that health care providers be aware of this potential iatrogenic problem. We propose that the use of disinfection caps may not be appropriate in pediatric patients with risk factors for foreign body ingestion., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: The American Society of Anesthesia practice guidelines recommend that pediatric and adult patients who undergo ambulatory surgery be screened for obstructive sleep apnea (OSA). With this in mind, our objective was to assess the frequency of screening by anesthesia providers for the signs and symptoms of OSA in children undergoing surgery in an ambulatory setting., Methods: Prospective single-blinded observational study of anesthesia providers' preoperative interview of caregivers of consecutive patients younger than age 18 who were scheduled for ambulatory surgery., Results: One hundred one children (30 females) were identified, with a mean age of 6.9 ± 5.0 years; 54 were classified as white, 33 as black, and 14 as other. Total OSA-18 scores ranged from 18 to 97, with a mean of 33.1 ± 14.8. The mean score for adenotonsillectomy patients was higher than that for children who underwent procedures other than adenotonsillectomy. Thirty-one percent of children were screened for OSA, and snoring was the most common symptom recorded (28%). Patients who were screened for OSA were more likely to have snoring (p < 0.001), known OSA (p = 0.006), and a scheduled adenotonsillectomy (p = 0.02)., Conclusion: OSA was not routinely screened for by anesthesia providers prior to ambulatory pediatric surgery. When screening did occur, "snoring" was the most commonly recorded symptom. Paradoxically, patients with undiagnosed OSA who would benefit the most from screening were the least likely to be screened., Commentary: A commentary on this article appears in this issue on page 697., (© 2015 American Academy of Sleep Medicine.)

Objectives/hypothesis: To determine risk factors for decannulation failure after laryngotracheal reconstruction performed at a single institution over a 10-year period., Study Design: This is a retrospective cohort study., Methods: The study population included 95 adult patients who underwent laryngotracheal reconstruction at a single tertiary care medical center between 2003 and 2012. Data were retrospectively reviewed., Results: Our cohort consisted of 95 subjects (60% female) with a median (range) age of 48 (21-82) years. Fourteen patients failed to decannulate by one postoperative year and were more likely to have diabetes, gastroesophageal reflux disease, grade 4 stenosis, T-tube requirement, secondary tracheotomy, double-stage reconstruction, and more endoscopic dilations within the first postoperative year. T-tube requirement was highly predictive of decannulation failure, with an odds ratio of 50.6 in univariate analysis and 93.7 in multivariate analysis. Grade 4 stenosis and a requirement of at least one postoperative endoscopic dilation were also found significant under both univariate and multivariate models. Gastroesophageal reflux disease was marginally significant under the univariate and multivariate models (P = .059 and .088, respectively)., Conclusions: The presence of preoperative and postoperative factors may indicate a higher risk of decannulation failure after laryngotracheal reconstruction. Patients with diabetes, gastroesophageal reflux disease, and grade 4 stenosis are at higher risk for decannulation failure. Requirement of T-tube placement and requirement of endoscopic dilation are predictive of decannulation failure., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)