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Perspectives of facial aesthetics

Key points • The patient’s perspective and desire must be understood and discussed in detail because they might be different from that of the surgeon’s. • Dental evaluation is crucially important in the evaluation of facial aesthetics. • Psychologic consideration is paramount to final patient satisfaction. • Standardized and life-size photographic and radiographic documentation helps with thorough analysis and planning. • Systematic entire facial analysis is…

Aesthetic facial skeletal surgery—evolution of thought and technique

• The evolution of techniques in reconstructive maxillofacial surgery has led to safe and efficacious surgery of the facial soft tissue, the natural extension of which was surgery purely to enhance the appearance. • The soft tissue overlying the bone defines the contour and appearance of the face, whereas the bony foundation provides attachment and support to the soft tissue. • This interdependent relationship serves as…

Otoplasty

Introduction Auricular deformities are quite common in the general population. Children with auricular deformities, particularly prominent ears, may be the subject of teasing by peers, which can affect psychosocial development, self-esteem, and school performance. In part, this may be due to how prominent ears draw the eye of the viewer away from the central face and eyes of the subject and toward the auricular deformity. In…

Congenital and Acquired Atresia and Stenosis of the External Auditory Canal

Introduction In the management of congenital aural atresia (CAA) and congenital external auditory canal stenosis (CEACS), the surgical challenge arises from anatomic variation and absence of standard landmarks. The incidence of microtia/CAA is approximately 1 in 10,000. In a large series, 58% of cases of microtia were right-sided, 32% left-sided, and 9% bilateral. Frequently associated anomalies include facial asymmetry, seventh nerve weakness, cleft lip/palate, urogenital anomalies,…

Microtia

Introduction The prevalence rates of microtia and aural atresia vary widely in different regions of the world, from 0.83 to 17.4 per 10,000 live births. The vast majority of these anomalies are sporadic, but also they may be found in association with other congenital anomalies or known syndromes, such as oculo-auriculo-vertebral syndrome, CHARGE syndrome, or Treacher-Collins syndrome. Microtia may be unilateral or bilateral, with over 85%…

Cleft Palate and Velopharyngeal Dysfunction

Introduction Comprehensive care of cleft palate deformities and velopharyngeal dysfunction (VPD) requires a thorough understanding of the full spectrum of palatal abnormalities and their effect on feeding, airway, and speech, from infancy through adolescence. Palatal clefts may range in their severity from subclinical, submucosal clefts of the soft palate to very wide clefts of the primary and secondary palate, with significant feeding and airway concerns in…

Pediatric Cochlear Implantation

Introduction The cochlear implant (CI) is unique among medical devices in that it serves as a neurosensory prosthesis capable of restoring or providing de novo the sense of hearing to its users. As technology advances with hardware, sound processing algorithms, and mapping strategies, CI users have achieved ever more impressive outcomes in both hearing and speech development. Many children born with severe to profound hearing loss…

Congenital Malformations of the Middle Ear

Acknowledgments Drs. Donald B. Kamerer, Arpita I. Mehta, and Yael Raz are acknowledged for their contributions to the previous editions. In addition, Dr. Barton Branstetter is recognized for generously sharing radiographic images of middle ear malformations. Introduction Congenital anomalies of the ear are estimated to occur in 1 in 11,000 to 15,000 patients. Isolated middle ear anomalies with a normal pinna and external ear canal account…

Otitis Media, Myringotomy, Tympanostomy Tube, and Balloon Dilation in the Pediatric Population

Introduction Myringotomy is the creation of an opening in the tympanic membrane (TM) with the use of a knife. Tympanocentesis is defined as the performance of this operation with a needle. Myringotomy or tympanocentesis may be indicated when there is an urgent need for relief of pressure and pain, to obtain a bacterial sample before the initiation of antibiotic treatment, or when there is a high…

Mandibular Distraction

Introduction The classic Pierre Robin sequence (PRS) refers to a constellation of physical findings characterized by microretrognathia and glossoptosis; cleft palate is an associated feature but is not required for the diagnosis of PRS. The posterior displacement of the base of the tongue functionally obstructs the airway, causing apnea, stridor, difficulty with feeding, and retarded growth. The clinical severity of this obstruction can range from subtle…

Branchial Cleft Cysts and Sinuses

Introduction Anomalies of branchial derivation should always be considered in the differential diagnosis of a mass in the neck, particularly in children but also in adults. Such anomalies are second only to thyroglossal duct cysts as the most common masses of congenital origin and are the most common congenital masses presenting in the lateral neck. Depending on the branchial cleft or pouch of origin, these anomalies…

Thyroglossal Duct Cyst

Introduction Thyroglossal duct cysts (TGDCs) are the most common congenital midline cervical anomalies in children and account for approximately 70% of all congenital neck lesions. The differential diagnosis of a midline mass in the neck mass in a child includes TGDC, dermoid, lymph node, lipoma, hemangioma, ranula, and inflammatory lesion. One study that evaluated preoperative computed tomography (CT) and histopathologic findings of excised midline neck lesions…

Management of Tracheal Stenosis

Introduction Pediatric tracheal stenosis is the clinical presentation of a diverse and complex spectrum of disease processes. Etiologies range from iatrogenic injury, trauma, infection, congenital malformations, neoplasms, gastroesophageal reflux disease (GERD), autoimmune processes, and granulomatous diseases. Classification is necessary in order to better define the stenosis and the spectrum of causes and to determine appropriate management. Stenosis can be classified as acquired versus congenital, intraluminal versus…

Tracheoscopy, Bronchoscopy, and Airway Foreign Bodies

Introduction Rigid tracheoscopy and bronchoscopy are important methods for evaluating the airway in infants and children. During this procedure, a rigid telescope with or without a rigid ventilating bronchoscope is inserted transorally to evaluate the larynx, trachea, and bronchi. Rigid tracheoscopy and bronchoscopy can be both diagnostic and therapeutic, because a variety of airway abnormalities can be discovered and treated. Instruments such as optical forceps, nonoptical…

Exit Procedure

Introduction The ex utero intrapartum treatment (EXIT) procedure is a technique for managing fetal airway obstruction at the time of delivery. The key component of the procedure is that a fetal airway is established while maintaining fetal oxygenation with the uteroplacental circulation. Fetal airway obstruction is typically first identified via an incidental finding on routine prenatal ultrasonography, which then leads to more detailed imaging with fetal…

Recurrent Respiratory Papillomatosis

Video 196.1 , Video 196.2 , Video 196.3 Recurrent respiratory papillomatosis (RRP) is a disease of viral etiology, caused by human papillomavirus (HPV) types 6 and 11, associated with exophytic lesions of the airway. Although it is a benign disease, RRP has potentially morbid consequences due to its involvement of the airway, its propensity to recur, and its risk of malignant conversion. Surgical therapy for RRP…

Surgery for Aspiration : Laryngeal Cleft Repair and Laryngotracheal Separation

Introduction Feeding and swallowing problems are commonly encountered issues in pediatric otolaryngology. The incidence of feeding disorders has been estimated at 25% to 45%; the incidence of swallowing disorders is unknown but is increasing with improved life expectancy of premature babies. Oropharyngeal dysphagia has been estimated to affect up to 85% of children with underlying neurologic disorders. Dysphagia is the result of a problem during one…

Subglottic Stenosis

Introduction Subglottic stenosis (SGS) used to be primarily congenital in etiology, and managed conservatively with a tracheostomy tube. Long-term intubation, especially in premature infants, was introduced in the latter part of the 20th century and resulted in increasing rates of acquired SGS, which was associated with worse outcomes as compared with congenital SGS. Laryngotracheal reconstruction (LTR) was introduced in the 1970s, and has expanded to include…

Laryngomalacia

Video 193.1 , Video 193.2 , Video 193.3 Laryngomalacia-associated breathing was first described in 1851 by the French physician Rilliet in a case report of a benign inspiratory noise from an infant. This sound was subsequently termed stridor in 1853 by Rilliet and Barthez in their textbook, Of Diseases of Children . It was not until 1897 that the laryngoscopic physical findings associated with this disorder…

Tonsillectomy

Introduction Tonsillectomy was first performed over 2000 years ago, with the oldest reference to the procedure dating back to 1000 BC. As the safety and indications evolved, so did the popularity of tonsillectomy. Most notably, the 1970s and 1980s saw a transition of the most common indication for tonsillectomy from recurrent throat infections to sleep-disordered breathing (SDB). Today, more than 500,000 tonsillectomies are performed annually in…