clinicaltrials.gov Identifier: NCT2344108.

Objectives/Hypothesis Hypoglossal nerve (HGN) stimulation is a novel therapy for obstructive sleep apnea (OSA) in adults. Its efficacy and safety in children with Down syndrome (DS) was previously reported in a preliminary case series of six adolescents. Study Design Case series. Methods Twenty nonobese children and adolescents (aged 10–21 years) with DS and severe OSA (apnea‐hypopnea index [AHI] >10 and <50 events/hr) despite prior adenotonsillectomy were enrolled. Participants had failed a trial of continuous positive airway pressure therapy and underwent sleep endoscopy confirming surgical candidacy. The primary outcome was to assess safety and monitor for adverse events. Secondary outcomes included efficacy in reducing AHI (% reduction in AHI), adherence to therapy, and change in a validated quality‐of‐life instrument, the OSA‐18 survey. Results All 20 children (median age = 16.0 years [interquartile range = 13–17 years], 13 male) were implanted with no long‐term complications. We report two interval adverse events, both of which were corrected with revision surgery. Twenty participants completed the 2‐month polysomnogram, with median percent reduction in titration AHI of 85% (interquartile range = 75%–92%). The median nightly usage for these children was 9.21 hours/night. There was a median change in the OSA‐18 score of 1.15, indicating a moderate, yet significant, clinical change. Conclusions HGN stimulation was safe and effective in the study population. Two minor surgical complications were corrected surgically. Overall, these data suggest that pediatric HGN stimulation appears to be a safe and effective therapy for children with DS and refractory severe OSA. Level of Evidence 4 Laryngoscope, 130:E263–E267, 2020

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Our series demonstrates a higher prevalence of HPV in SNUC than previously reported. HPV-positive SNUCs may benefit from improved survival and should be investigated further in future studies.

OBJECTIVES: Misdiagnosis of acute and chronic otitis media in children can result in significant consequences from either undertreatment or overtreatment. Our objective was to develop and train an artificial intelligence algorithm to accurately predict the presence of middle ear effusion in pediatric patients presenting to the operating room for myringotomy and tube placement. METHODS: We trained a neural network to classify images as “ normal” (no effusion) or “abnormal” (effusion present) using tympanic membrane images from children taken to the operating room with the intent of performing myringotomy and possible tube placement for recurrent acute otitis media or otitis media with effusion. Model performance was tested on held-out cases and fivefold cross-validation. RESULTS: The mean training time for the neural network model was 76.0 (SD ± 0.01) seconds. Our model approach achieved a mean image classification accuracy of 83.8% (95% confidence interval [CI]: 82.7–84.8). In support of this classification accuracy, the model produced an area under the receiver operating characteristic curve performance of 0.93 (95% CI: 0.91–0.94) and F1-score of 0.80 (95% CI: 0.77–0.82). CONCLUSIONS: Artificial intelligence–assisted diagnosis of acute or chronic otitis media in children may generate value for patients, families, and the health care system by improving point-of-care diagnostic accuracy. With a small training data set composed of intraoperative images obtained at time of tympanostomy tube insertion, our neural network was accurate in predicting the presence of a middle ear effusion in pediatric ear cases. This diagnostic accuracy performance is considerably higher than human-expert otoscopy-based diagnostic performance reported in previous studies.

First-bite syndrome, characterized by excruciating pain in the parotid region after the first few bites of food, can be seen after surgery of the parapharyngeal space. Herein we describe a patient with no prior surgical history who presented with facial pain consistent with first-bite syndrome. Imaging and ultrasound-guided FNA revealed a nonpalpable mucoepidermoid carcinoma of the parotid gland, which was removed surgically with facial nerve preservation. After surgical intervention, the patient's symptoms resolved. An extensive literature review demonstrated that this is the first description of a preoperative first-bite syndrome, or first-bite syndrome associated with the presence a parotid mass.

Inpatient surgical release of lingual frenulums rose 10-fold between 1997 and 2012 despite insufficient evidence that frenotomy for ankyloglossia is associated with improvements in breastfeeding. Clear indications for surgical release remain murky, and best practice guidelines have yet to be developed.OBJECTIVE To determine whether infants referred for frenotomy to treat breastfeeding difficulties should undergo procedures after comprehensive feeding examination, during which the primary cause of feeding issues was identified, and targeted intervention was provided. DESIGN, SETTING, AND PARTICIPANTSThis observational quality improvement study followed mother-infant dyads between March and December of 2018 who were referred to our tertiary care center for difficulty with breastfeeding. All infants underwent a comprehensive feeding evaluation by speech and language pathologists who examined the infants' ability to breastfeed prior to a surgical consultation for initial frenotomy. Data analysis was performed between January 2019 and May 2019.INTERVENTIONS A multidisciplinary feeding evaluation that examined infants' oral structure and function and their ability to breastfeed and that offered techniques for mothers to address any feeding difficulties prior to surgical intervention was developed. Infants either found success in feeding and weight gain through this program or underwent procedures. MAIN OUTCOMES AND MEASURESThe primary outcome was the percentage of frenotomy procedures following implementation of a multidisciplinary feeding team evaluation. The secondary outcome was the percentage of infants referred for lingual frenotomy who later had either combined lingual and labial frenotomy or labial frenotomy alone.RESULTS Included in the study were 115 patients (median age, 34 days [interquartile range, 19-56 days], 68 (59%) were male) referred for surgical division of the lingual frenum. Following the development of a program with feeding examination with a pediatric speech and language pathologist, 72 (62.6%) patients subsequently did not undergo surgical procedures. Although all of the referrals were for lingual frenotomy, 10 (8.7%) underwent labial frenotomy alone and 32 (27.8%) underwent both labial and lingual frenotomy. CONCLUSIONS AND RELEVANCEThe majority of patients referred for ankyloglossia may benefit from alternative intervention strategies following comprehensive feeding evaluation. Close collaboration and formation of multidisciplinary teams are imperative for treating these children.

Obstructive sleep apnea (OSA) is more common in children with Down syndrome, affecting up to 60% of patients, and may persist in up to 50% of patients after adenotonsillectomy. These children with persistent moderate to severe OSA require continuous positive airway pressure, which is often poorly tolerated, or even tracheotomy for severe cases. The hypoglossal nerve stimulator is an implantable device that produces an electrical impulse to the anterior branches of the hypoglossal nerve, resulting in tongue protrusion in response to respiratory variation. It is an effective treatment of sleep apnea in select adult patients because it allows for alleviation of tongue base collapse, improving airway obstruction. Herein we describe the first pediatric hypoglossal nerve stimulator implantation, which was performed in an adolescent with Down syndrome and refractory severe OSA (apnea hypopnea index [AHI]: 48.5 events/hour). The patient would not tolerate continuous positive airway pressure and required a long-standing tracheotomy. Hypoglossal nerve stimulator therapy was well tolerated and effective, resulting in significant improvement in the patient’s OSA (overall AHI: 3.4 events/hour; AHI: 2.5–9.7 events/hour at optimal voltage settings depending on sleep stage and body position). Five months after implantation, the patient’s tracheotomy was successfully removed and he continues to do well with nightly therapy.