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Introduction: Mild sleep-disordered breathing (mSDB) in children is associated with both neurobehavioral morbidity and reduced quality of life (QOL). However, the association between symptom burden and QOL with executive function is not well understood, and it is not known whether QOL and symptom burden may help identify children with neurocognitive dysfunction., Objective: To assess associations among executive function, QOL, and symptom burden in children with mSDB., Design, Setting, and Participants: This cross-sectional study was a secondary analysis of the multicenter Pediatric Adenotonsillectomy Trial for Snoring, which included children aged 3 to 12 years randomized to watchful waiting or adenotonsillectomy for mSDB (snoring and an obstructive apnea-hypopnea index <3) between June 29, 2016, and February 1, 2021. The data for this report were analyzed between December 22, 2020, and October 3, 2024., Exposure: Pediatric mSDB., Main Outcomes and Measures: Quality of life was assessed using the Obstructive Sleep Apnea-18 (OSA-18), and symptom burden was assessed using the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder Scale (PSQ-SRBD). Executive function, including self-control and working memory, was measured using the Behavior Rating Inventory of Executive Function Global Executive Composite (BRIEF GEC), and inhibitory control and sustained attention were measured by the GoNoGo vigilance test. Partial Pearson correlations and multiple linear regression models were used to assess the associations among QOL, symptoms, and executive function., Results: The sample included 459 children (mean [SD] age, 6.1 [2.3] years; 230 female [50.1%]). Moderate correlations were found between the BRIEF GEC and the PSQ-SRBD and OSA-18 (r = 0.58 [95% CI, 0.51-0.64] and 0.59 [95% CI, 0.52-0.64], respectively). After adjusting for age, sex, race and ethnicity, body mass index percentile, household income, maternal education, attention-deficit/hyperactivity disorder, test characteristics, and disease severity, both OSA-18 and PSQ-SRBD scores were associated with the BRIEF GEC (β = 0.41 [95% CI, 0.36-0.47] and 3.66 [95% CI, 3.17-4.15], respectively). In the fully adjusted model, PSQ-SRBD was also associated with GoNoGo inhibitory control (β = -0.04 [95% CI, -0.08 to -0.01]) and sustained attention (β = -0.05 [95% CI, -0.10 to -0.01])., Conclusions and Relevance: In this study, disease-specific QOL and symptom burden were associated with executive function in children with mSDB. These findings may be useful in identifying those children who are at risk for neurocognitive dysfunction.

Importance: Upper airway stimulation (UAS) was recently approved to treat persistent obstructive sleep apnea in pediatric patients with Down syndrome. Appropriate titration of the UAS implantable device is essential to achieve optimal outcomes, but standardized titration protocols for young patients are lacking., Objective: To develop and share a UAS titration protocol for pediatric patients with Down syndrome., Design, Setting, and Participants: This small cohort study of pediatric patients with Down syndrome presents a standardized UAS stimulation titration protocol for conducting postimplantation polysomnograms. The protocol was developed through a multidisciplinary collaboration at a tertiary children's hospital with a dedicated pediatric polysomnogram laboratory. The initial titration polysomnogram was performed on the night of device activation, with subsequent titration polysomnograms performed at 1 month, 2 to 3 months, 6 months, and 12 months after implantation. The initial titration goal is acclimation, promoting AHI optimization in later polysomnograms. Pediatric patients with Down syndrome and persistent obstructive sleep apnea who have undergone UAS titration from June 2022 to January 2024 participated in this study., Exposure: A novel standardized UAS titration polysomnogram protocol., Main Outcomes and Measures: The main outcomes were apnea-hypopnea index (AHI) change and nightly device use in hours., Results: This study included 5 pediatric patients with Down syndrome who have undergone UAS implantation. Three patients were male, and 4 identified as White. The median (range) age at implantation was 15 years (12-20 years), and the median (range) preoperative AHI was 20.1 (15.6-38.8). The median (range) incoming voltage for a 1-month postimplant UAS titration polysomnogram was 1.7 V (0.4-1.7 V). All 5 patients completed UAS titration polysomnograms at the aforementioned postoperative time course; all patients also experienced an AHI reduction from baseline and adequate tolerance of UAS (ie, nightly device use of more than 6 hours). A titration protocol for UAS in pediatric patients with Down syndrome, a sample polysomnogram report form, and general information for sleep technologists are provided., Conclusions and Relevance: In this study, a standardized UAS protocol for device titration during polysomnogram promoting acclimation and optimized AHI reduction demonstrated UAS efficacy in pediatric patients with Down syndrome. The protocol can be used as a model for other institutions creating programs for UAS titration in pediatric patients with Down syndrome. As more pediatric patients undergo UAS device implants, protocols can be refined to ensure optimal outcomes.

Importance: Prior research has demonstrated an association between vitamin D deficiency and obstructive sleep apnea (OSA) in adults; however, its association with pediatric OSA is emerging., Objective: To evaluate the association of vitamin D levels with obstructive Apnea-Hypopnea Index (AHI) in children with OSA., Design, Settings, and Participants: This was a cross-sectional study of children aged 2 to 16 years with severe obstructive OSA (AHI ≥20 on polysomnogram) who were undergoing adenotonsillectomy at a tertiary care pediatric otolaryngology clinic from 2017 to 2022. Age, sex, race, body mass index, history of asthma, and season were considered in the analyses. Data were analyzed from September 3, 2021, to October 8, 2021., Main Outcomes and Measures: Serum 25-hydroxyvitamin D (25[OH]D) levels were measured and assessed for correlation with polysomnography metrics. Fasting blood samples were collected and vitamin D deficiency was defined as 25(OH)D level less than 20 ng/mL., Results: The consecutive sample included 72 patients (mean [SD] age, 6.7 [3.9] years; 34 [47.2%] females and 38 [52.8%] males). The mean (SD) AHI was 42.8 (25.5), and 35 participants (49.0%) had obesity. Vitamin D deficiency was present in 27 participants (37.5%). In univariate analysis, vitamin D deficiency was associated with younger age (difference, -5.0; 95% CI, -7.2 to -2.8), Black race (odds ratio [OR], 4.3; 95% CI, 1.4 to 14.3), female sex (OR, 4.8; 95% CI, 1.7 to 12.5), and higher obstructive AHI (difference, 13.8; 95% CI, 1.2 to 26.4). In multivariable analysis, vitamin D deficiency remained significantly associated with AHI. A 1.0-unit decrease in serum 25(OH)D levels was associated with an AHI increase of 0.7 (95% CI, 0.04 to 1.40)., Conclusions: The findings of this cross-sectional study indicate that vitamin D deficiency was common in children undergoing adenotonsillectomy for severe OSA and is significantly associated with increased OSA severity. Future research is needed on vitamin D supplementation and its association with any improvements in pediatric OSA treatment outcomes.

Objective(s): Hypoglossal nerve stimulation (HGNS) is safe and effective for patients with Down syndrome (DS) and severe persistent obstructive sleep apnea (OSA). Long-term outcomes for this patient population have not been evaluated., Methods: A prospective single-group multicenter cohort study with 1-year follow-up was conducted between 2015 and 2021 among 42 adolescent patients with DS and severe persistent OSA. Here, we evaluate long-term outcomes in this patient cohort. Patients were evaluated with polysomnogram (PSG) at three timepoints: pre-implantation (timepoint 1), 1-year post-implantation (timepoint 2), and long-term follow-up (timepoint 3)., Results: Long-term follow-up data were available for 33 of 42 patients. Mean (SD) of timepoint 3 was 4.0 (1.9) years after implantation. Using a therapy response definition of a 50% decrease in Apnea Hypopnea INdez (AHI) from timepoint 1, the response rate was 69.7% (23/33) at timepoint 2 and 87.9% (29/33) at timepoint 3. From timepoint 1, there was a mean (SD) decrease in AHI of 12.7 (13.4) events/h at timepoint 2 and 15.7 (13.1) events/h at timepoint 3. The mean percentage change in AHI between timepoints 1 and 2 was -51.1% (95% CI: -32.8% to -69.3%) and between timepoints 1 and 3 was -59.6% (95% CI: -42.0% to -77.3%)., Conclusion: Patients with DS and severe persistent OSA who undergo HGNS implantation may continue to experience improvement in PSG parameters at long-term follow-up. Future studies are needed to assess additional long-term outcomes in this patient population, including neurocognition and quality of life., Level of Evidence: 3 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: It is unknown whether adenotonsillectomy causes undesirable weight gain in children with mild obstructive sleep-disordered breathing (oSDB)., Objective: To compare changes in anthropometric measures in children with mild oSDB treated with adenotonsillectomy vs watchful waiting., Design, Setting, and Participants: This was an exploratory analysis of the Pediatric Adenotonsillectomy Trial for Snoring (PATS) randomized clinical trial of adenotonsillectomy vs watchful waiting for mild oSDB (snoring with obstructive apnea-hypopnea index of <3 events/hour) that took place at 7 pediatric tertiary care centers across the US and included 458 children aged 3.0 to 12.9 years with mild oSDB. Participants were recruited from June 29, 2016, to February 1, 2021. Anthropomorphic measures taken at baseline and 12 months after randomization were standardized for age and sex, including each participant's percentage of the 95th body mass index percentile (%BMIp95). Data analyses were performed from March 15, 2023, to April 1, 2024., Intervention: Early adenotonsillectomy (eAT) vs watchful waiting with supportive care (WWSC)., Main Outcomes and Measures: Twelve-month change in %BMIp95 from baseline and undesirable weight gain (defined as any weight gain in a child who already had overweight or obesity or an increase from baseline normal weight/underweight to overweight/obesity) at follow-up assessment., Results: The study analysis included 375 children (mean [SD] age, 6.1 [2.3] years; 188 [50.2%] females), of whom 143 (38%) had overweight or obesity at baseline. At 12 months, children in the eAT group experienced a 1.25-point increase in %BMIp95 compared with a 0.59-point increase in the WWSC group (mean difference, 0.93; 95% CI, -0.39 to 2.25). Undesirable weight gain was also similar between the eAT (n = 120; 32%) and WWSC (n = 101; 27%) groups (mean difference, 4%; 95% CI, 5% to 14%)., Conclusions and Relevance: The findings of this exploratory analysis of the PATS trial indicate that adenotonsillectomy was not independently associated with an increased risk of undesirable weight gain in children with mild oSDB. However, one-third of the children gained undesirable weight during the study, which suggests that there is an opportunity to address healthy weight management during the evaluation and treatment of children with mild oSDB., Trial Registration: ClinicalTrials.gov Identifier: NCT02562040.

Objective: The Food and Drug Administration recently approved upper airway stimulation (UAS) for children with Down Syndrome and persistent obstructive sleep apnea who meet certain inclusion and exclusion criteria. Although there is a robust experience with this therapy in the adult population, established protocols used in adults are not directly transferrable to a complex pediatric population. This review aims to combine the protocols from several institutions for patient selection and postimplantation optimization, including a protocol for Drug-Induced Sleep Endoscopy in children with Down Syndrome, preactivation threshold measurements, device titration, and follow-up sleep studies., Study Design: Expert panel development of best Practice algorithm., Setting: Multi-institutional investigator review., Methods: An expert panel was assembled of pediatric otolaryngologists with extensive experience in hypoglossal nerve stimulation in children with Down Syndrome. Thirty statements were created during an initial drafting session. A modified Delphi method was used assess consensus among the panel., Results: After 2 rounds of Delphi surveys, 29 statements met criteria for consensus. One statement did not meet consensus. The statements were grouped into several categories to facilitate presentation., Conclusions: A standardized approach to UAS for children with Down Syndrome must take into account the unique challenges inherent to treating a complex pediatric population with a high rate of sensory processing disorders. This expert panel has met consensus on several statements that will guide clinicians as this novel therapy is adopted., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Rationale: Neighborhood disadvantage (ND) has been associated with sleep-disordered breathing (SDB) in children. However, the association between ND and SDB symptom burden and quality of life (QOL) has not yet been studied. Objectives: To evaluate associations between ND with SDB symptom burden and QOL. Methods: Cross-sectional analyses were performed on 453 children, ages 3-12.9 years, with mild SDB (habitual snoring and apnea-hypopnea index < 3/h) enrolled in the PATS (Pediatric Adenotonsillectomy Trial for Snoring) multicenter study. The primary exposure, neighborhood disadvantage, was characterized by the Child Opportunity Index (COI) (range, 0-100), in which lower values (specifically COI ⩽ 40) signify less advantageous neighborhoods. The primary outcomes were QOL assessed by the obstructive sleep apnea (OSA)-18 questionnaire (range, 18-126) and SDB symptom burden assessed by the Pediatric Sleep Questionnaire-Sleep-related Breathing Disorder (PSQ-SRBD) scale (range, 0-1). The primary model was adjusted for age, sex, race, ethnicity, maternal education, recruitment site, and season. In addition, we explored the role of body mass index (BMI) percentile, environmental tobacco smoke (ETS), and asthma in these associations. Results: The sample included 453 children (16% Hispanic, 26% Black or African American, 52% White, and 6% other). COI mean (standard deviation [SD]) was 50.3 (29.4), and 37% ( n  = 169) of participants lived in disadvantaged neighborhoods. Poor SDB-related QOL (OSA-18 ⩾ 60) and high symptom burden (PSQ-SRBD ⩾ 0.33) were found in 30% ( n  = 134) and 75% ( n  = 341) of participants, respectively. In adjusted models, a COI increase by 1 SD (i.e., more advantageous neighborhood) was associated with an improvement in OSA-18 score by 2.5 points (95% confidence interval [CI], -4.34 to -0.62) and in PSQ-SRBD score by 0.03 points (95% CI, -0.05 to -0.01). These associations remained significant after adjusting for BMI percentile, ETS, or asthma; however, associations between COI and SDB-related QOL attenuated by 23% and 10% after adjusting for ETS or asthma, respectively. Conclusions: Neighborhood disadvantage was associated with poorer SDB-related QOL and greater SDB symptoms. Associations were partially attenuated after considering the effects of ETS or asthma. The findings support efforts to reduce ETS and neighborhood-level asthma-related risk factors and identify other neighborhood-level factors that contribute to SDB symptom burden as strategies to address sleep-health disparities.Clinical trial registered with www.clinicaltrials.gov (NCT02562040).

Importance: Exposure to secondhand smoke has been associated with numerous health problems in children, including obstructive sleep apnea. Secondhand smoke exposure may be a risk factor for increased pediatric sleep apnea severity., Objectives: To assess the association of secondhand smoke exposure (SHSe), quantified by urinary cotinine levels, with severity of obstructive sleep apnea (OSA) in children., Design, Setting, and Participants: This was a prospective cohort trial including pediatric patients from 3 to 16 years of age with sleep-disordered breathing who underwent a polysomnogram at a tertiary-level children's hospital in the US in either March 2014 to October 2016 or March 2020 to March 2021. Urine specimens were analyzed for cotinine, an important metabolite of nicotine. Each child's caregiver completed a validated SHSe questionnaire. Data were analyzed from February to June 2023., Exposure: OSA and secondhand smoke., Main Outcome and Measures: SHSe and severity of pediatric OSA, quantified by urinary cotinine levels and obstructive apnea hypopnea index (AHI) scores. Secondary outcomes were association of urinary cotinine levels with nadir oxygen saturation, sleep-related quality of life measured by the OSA-18 questionnaire, and caregiver-reported smoking habits (collected through a questionnaire)., Results: The study included 116 patients with a median (IQR) age of 6 (5-9) years, among whom 51 (45%) had obesity. The median (IQR) AHI was 3.0 (1.2-8.0), with 28 children (30.0%) having severe disease (AHI >10). Thirty-four children (29.0%) were found to have a positive result for urine cotinine screening, with a mean (SD) level of 11.7 (9.4) ng/mL. The percentage of children with SHSe was less than anticipated. There was no association identified between urinary cotinine levels and either AHI (ρ = -0.04; 95% CI, -0.22 to 0.15) or nadir oxygen saturation (ρ = -0.07; 95% CI, -0.26 to 0.11). Furthermore, SHSe was not associated with the presence of severe OSA (odds ratio, 0.70; 95% CI, 0.26 to 1.90). Children whose caregivers reported indoor SHSe were more likely to have a detectable urinary cotinine level (odds ratio, 20.3; 95% CI, 6.67 to 61.8)., Conclusions and Relevance: This cohort study did not identify any clinically meaningful association between SHSe, quantified by urinary cotinine level, and pediatric OSA severity. Future research with a larger number of children with SHSe is needed to confirm these findings and determine whether SHSe affects OSA treatment outcomes in children.

Importance: It is unknown whether children with primary snoring and children with mild obstructive sleep apnea (OSA) represent populations with substantially different clinical characteristics. Nonetheless, an obstructive apnea-hypopnea index (AHI) of 1 or greater is often used to define OSA and plan for adenotonsillectomy (AT)., Objective: To assess whether a combination of clinical characteristics differentiates children with primary snoring from children with mild OSA., Design, Setting, and Participants: Baseline data from the Pediatric Adenotonsillectomy Trial for Snoring (PATS) study, a multicenter, single-blind, randomized clinical trial conducted at 6 academic sleep centers from June 2016 to January 2021, were analyzed. Children aged 3.0 to 12.9 years with polysomnography-diagnosed (AHI <3) mild obstructive sleep-disordered breathing who were considered candidates for AT were included. Data analysis was performed from July 2022 to October 2023., Main Outcomes and Measures: Logistic regression models were fitted to identify which demographic, clinical, and caregiver reports distinguished children with primary snoring (AHI <1; 311 patients [67.8%]) from children with mild OSA (AHI 1-3; 148 patients [32.2%])., Results: A total of 459 children were included. The median (IQR) age was 6.0 (4.0-7.5) years, 230 (50.1%) were female, and 88 (19.2%) had obesity. A total of 121 (26.4%) were Black, 75 (16.4%) were Hispanic, 236 (51.5%) were White, and 26 (5.7%) were other race and ethnicity. Black race (odds ratio [OR], 2.08; 95% CI, 1.32-3.30), obesity (OR, 1.80; 95% CI, 1.12-2.91), and high urinary cotinine levels (>5 µg/L) (OR, 1.88; 95% CI, 1.15-3.06) were associated with greater odds of mild OSA rather than primary snoring. Other demographic characteristics, clinical examination findings, and questionnaire reports did not distinguish between primary snoring and mild OSA. A weighted combination of the statistically significant clinical predictors had limited ability to differentiate children with mild OSA from children with primary snoring., Conclusions and Relevance: In this analysis of baseline data from the PATS randomized clinical trial, primary snoring and mild OSA were difficult to distinguish without polysomnography. Mild OSA vs snoring alone did not identify a clinical group of children who may stand to benefit from AT for obstructive sleep-disordered breathing., Trial Registration: ClinicalTrials.gov Identifier: NCT02562040.

Importance: The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown., Objectives: To evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB., Design, Setting, and Participants: Randomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months., Intervention: Participants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228)., Main Outcomes and Measures: The 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes., Results: Of the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: -3.1 for adenotonsillectomy vs -1.9 for watchful waiting; difference, -0.96 [95% CI, -2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, -0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, -9.02 [97% CI, -15.49 to -2.54] and -6.52 [97% CI, -11.59 to -1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, -11.2% [97% CI, -17.5% to -4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy., Conclusions: In children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up., Trial Registration: ClinicalTrials.gov Identifier: NCT02562040.

Study Objectives: Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors., Methods: 298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures., Results: Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function ( P = .002). Longer nocturnal sleep ( P = .02) and less sleep fragmentation ( P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old., Conclusions: Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity., Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040., Citation: Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med . 2023;19(9):1595-1603., (© 2023 American Academy of Sleep Medicine.)

Objectives: To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea., Methods: The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus., Results: A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids., Conclusion: This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients., Competing Interests: Declaration of competing interest All authors declare no conflict of interest or financial interest in relation to this manuscript., (Copyright © 2023. Published by Elsevier B.V.)

Objective: To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged., Methods: An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey., Results: After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care., Conclusion: The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: Caregivers frequently report poor quality of life (QOL) in children with sleep-disordered breathing (SDB). Our objective is to assess the correlation between caregiver- and child-reported QOL in children with mild SDB and identify factors associated with differences between caregiver and child report., Study Design: Analysis of baseline data from a multi-institutional randomized trial SETTING: Pediatric Adenotonsillectomy Trial for Snoring, where children with mild SDB (obstructive apnea-hypopnea index <3) were randomized to observation or adenotonsillectomy., Methods: The Pediatric Quality of Life Inventory (PedsQL) assessed baseline global QOL in participating children 5 to 12 years old and their caregivers. Caregiver and child scores were compared. Multivariable regression assessed whether clinical factors were associated with differences between caregiver and child report., Results: PedsQL scores were available for 309 families (mean child age, 7.0 years). The mean caregiver-reported PedsQL score was higher at 75.2 (indicating better QOL) than the mean child-reported score of 67.9 (P < .001). The agreement between caregiver and child total PedsQL scores was poor, with intraclass correlation coefficients of 0.03 (95% CI, -0.09 to 0.15) for children 5 to 7 years old and 0.21 (95% CI, 0.03-0.38) for children 8 to 12 years old. Higher child age and health literacy were associated with closer agreement between caregiver and child report., Conclusion: Caregiver- and child-reported global QOL in children with SDB was weakly correlated, more so for young children. In pediatric SDB, child-perceived QOL may be poorer than that reported by caregivers. Further research is needed to assess whether similar trends exist for disease-specific QOL metrics., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Study Objectives: (1) To assess adenotonsillectomy (AT) outcomes in adolescents with obesity and with obstructive sleep apnea (OSA); (2) To identify clinical factors predicting OSA in adolescents following AT., Methods: Adolescents 12 to 18 years old with obesity who underwent AT for OSA were included. Subjects had pre-AT and post-AT polysomnogram. Nonobese adolescents with OSA that underwent AT were included as a comparison., Results: Seventy adolescents with obesity with a mean age of 14.2 years and a mean body mass index of 38.0 kg/m 2 were included. Patients in the nonobese group (n = 32) were similar demographically to the obese group, with the exception of body mass index. The majority of adolescents with obesity (74%) had severe OSA (apnea-hypopnea index [AHI] ≥ 10 events/h) with a mean baseline AHI of 33.9 events/h (standard deviation 28.5). The obese and control groups experienced clinically meaningful improvements in AHI following AT, with median change scores of 18.3 (95% confidence interval -29.2, -11.2, P < .001) and 14.6 (95% confidence interval -25.5, -8.5, P < .001), respectively. In the adolescents with obesity, 48% had an AHI < 5 events/h on postoperative PSG. However, adolescents with obesity were 7 times more likely (odds ratio = 7.1, 95% confidence interval [2.24, 22.48], P = .001) to have moderate or severe persistent OSA (AHI > 5 events/h) after AT compared with patients who were not obese. The need for post-AT positive airway pressure therapy was significantly higher in adolescents with obesity, with 37.1% of participants requiring this therapy (odds ratio = 8.3, 95% confidence interval 1.8, 37.6, P < .001)., Conclusions: AT results in improvement in polysomnogram parameters in adolescents with obesity and OSA. However, patients with obesity are at high risk for persistent OSA. Future research should include prospective trials to compare outcomes between AT and positive airway pressure therapy for adolescents with obesity., Citation: Kearney TC, Vazifedan T, Baldassari CM. Adenotonsillectomy outcomes in obese adolescents with obstructive sleep apnea. J Clin Sleep Med . 2022;18(12):2855-2860., (© 2022 American Academy of Sleep Medicine.)

Importance: Children with apnea-predominant obstructive sleep apnea (OSA) are hypothesized to have a more severe form of the disease. However, research is lacking as to whether there is a significant difference in outcomes between children with apnea-predominant vs hypopnea-predominant OSA., Objective: To assess the association between baseline apnea-predominant or hypopnea-predominant OSA on polysomnography and quality of life (QOL) outcomes in children with obstructive sleep apnea managed by watchful waiting with supportive care (WWSC) or adenotonsillectomy (AT)., Design, Setting, and Participants: This case-control study is a secondary analysis of a randomized clinical trial, the Childhood Adenotonsillectomy Trial, which was conducted at multiple tertiary children's hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to WWSC or AT and underwent polysomnography and completed validated QOL and symptom assessments at baseline and 7 months. The current data analysis was performed from October 2020 to February 2022., Main Outcomes and Measures: Apnea-predominant OSA was defined as an apnea hypopnea index (AHI) greater than 2 with more than 50% of the obstructive events being apneas. Patients were considered to have hypopnea-predominant OSA if they had an AHI greater than 2 and more than 50% of the obstructive events were hypopneas., Results: A total of 386 children (185 boys [48%]; mean [SD] age, 6.56 [1.4] years) were analyzed. The mean (SD) obstructive AHI for patients was 6.98 (5.62), with 198 patients (51%) having mild disease. Thirty-seven children (10%) had apnea-predominant OSA at baseline. Black children were at increased risk for apnea-predominant OSA vs White children (odds ratio [OR], 13.40; 95% CI, 5.70-33.90). Children with apnea predominance were more likely to have severe OSA (AHI >10) compared with children with hypopnea predominance (OR, 2.30; 95% CI, 1.03-5.03); baseline Pediatric Sleep Questionnaire and OSA-18 QOL scores were similar between the 2 groups. Among children undergoing AT, those with baseline apnea predominance were more likely to have a Pediatric Sleep Questionnaire score greater than 0.33 at follow-up (OR, 3.30; 95% CI, 1.01-10.80). Rates of OSA resolution and improvements in QOL scores following AT or WWSC were similar between the apnea-predominant and hypopnea-predominant groups., Conclusions and Relevance: In children with OSA, apnea-predominant disease is uncommon. Apnea predominance was not associated with symptom resolution and cure rates in children undergoing AT or WWSC for OSA. Further research is needed to assess how apnea predominance affects AT outcomes in children with more severe disease.

Study Objectives: Obstructive sleep apnea is associated with neurobehavioral dysfunction, but the relationship between disease severity as measured by the apnea-hypopnea index and neurobehavioral morbidity is unclear. The objective of our study is to compare the neurobehavioral morbidity of mild sleep-disordered breathing versus obstructive sleep apnea., Methods: Children 3-12 years old recruited for mild sleep-disordered breathing (snoring with obstructive apnea-hypopnea index < 3) into the Pediatric Adenotonsillectomy Trial for Snoring were compared to children 5-9 years old recruited for obstructive sleep apnea (obstructive apnea-hypopnea 2-30) into the Childhood Adenotonsillectomy Trial. Baseline demographic, polysomnographic, and neurobehavioral outcomes were compared using univariable and multivariable analysis., Results: The sample included 453 participants with obstructive sleep apnea (median obstructive apnea-hypopnea index 5.7) and 459 participants with mild sleep-disordered breathing (median obstructive apnea-hypopnea index 0.5). By polysomnography, participants with obstructive sleep apnea had poorer sleep efficiency and more arousals. Children with mild sleep-disordered breathing had more abnormal executive function scores (adjusted odds ratio 1.96, 95% CI 1.30-2.94) compared to children with obstructive sleep apnea. There were also elevated Conners scores for inattention (adjusted odds ratio 3.16, CI 1.98-5.02) and hyperactivity (adjusted odds ratio 2.82, CI 1.83-4.34) in children recruited for mild sleep-disordered breathing., Conclusions: Abnormal executive function, inattention, and hyperactivity were more common in symptomatic children recruited into a trial for mild sleep-disordered breathing compared to children recruited into a trial for obstructive sleep apnea. Young, snoring children with only minimally elevated apnea-hypopnea levels may still be at risk for deficits in executive function and attention., Trial Registration: Pediatric Adenotonsillectomy for Snoring (PATS), NCT02562040; Childhood Adenotonsillectomy Trial (CHAT), NCT00560859., (Published by Oxford University Press on behalf of Sleep Research Society (SRS) 2022.)

Objective: To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep., Methods: Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized., Results: The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research., Conclusion: Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

Importance: Children with obstructive sleep apnea (OSA) are at increased risk for nocturnal enuresis (NE). However, randomized clinical trials assessing NE outcomes in children randomized to adenotonsillectomy (AT) vs watchful waiting are lacking., Objective: To assess the outcomes of AT vs watchful waiting in children with nonsevere OSA who experience NE., Design, Setting, and Participants: Secondary analysis of data from a multicenter randomized clinical trial conducted at tertiary children's hospitals was performed. Participants included 453 children aged 5.0 to 9.9 years with nonsevere OSA who were randomized to either watchful waiting or AT as part of the multicenter Childhood Adenotonsillectomy Trial. Caregivers completed the Pediatric Sleep Questionnaire, which includes a binary item on bed-wetting, at baseline and 7-month follow-up. The trial was conducted between October 2007 and June 2012. Evaluation in this secondary analysis involving NE occurred from October 2019 to March 2021., Interventions: Adenotonsillectomy vs watchful waiting in children with NE., Main Outcomes and Measures: Prevalence of NE as defined by parental response to the Pediatric Sleep Questionnaire bed-wetting item at baseline and 7-month follow-up., Results: Of the 453 children enrolled, 393 were included in analysis; of these, 201 were girls (51.1%). Mean (SD) age at baseline was 6.54 (1.40) years. At baseline, the number of children with NE was similar (2.6%; 95% CI, -0.12% to 0.07%) between the AT (59 [30.7%]) and watchful-waiting (67 [33.3%]) groups. The odds of NE in the watchful-waiting group were approximately 2 times higher than the AT group after 7 months (odds ratio, 2.0; 95% CI, 1.3 to 3.1). Following AT, there was a decrease (-11.0%; 95% CI, -16.3% to -5.7%) in the number of children with NE (n = 38). The prevalence of NE did not change significantly (-0.5%; 95% CI, -5.4% to 6.4%) in the watchful-waiting group (n = 66) at follow-up. Although NE was less frequent in girls (adjusted odds ratio, 0.53; 95% CI, 0.33-0.85), other clinical factors, such as age, race and ethnicity, obesity, and apnea-hypopnea index, were not associated with improvement of NE., Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, AT for the treatment of pediatric OSA appears to result in improvement in NE. Further research is needed to assess whether AT is associated with long-term benefits for NE compared with watchful waiting., Trial Registration: ClinicalTrials.gov Identifier: NCT00560859.

Objectives: (1) To assess outcomes in children undergoing adenoidectomy for the treatment of mild obstructive sleep apnea (OSA). (2) To identify clinical factors that predict which children will have persistent obstruction following adenoidectomy., Study Design: Case series with chart review over a 10-year period., Setting: Tertiary children's hospital., Subjects and Methods: Children between 2 and 17 years old undergoing adenoidectomy for treatment of mild OSA (obstructive apnea-hypopnea index [AHI] between 1 and 5 on polysomnogram) were included. The need for additional medical or surgical intervention following adenoidectomy was recorded. When available, postoperative polysomnogram data were reviewed., Results: In total, 134 children with a mean age of 5.4 years were included. Fifty-three percent (n = 71) were female and 57% (n = 76) were black. The mean (SD) baseline AHI was 2.2 (1.09). Caregivers reported a moderate impact of sleep disturbance on quality of life with a mean (SD) preoperative total OSA-18 score of 64.1 (19.28). Postadenoidectomy outcomes were reported for 105 patients (78%) with a mean follow-up time of 6 months. Sixty-nine percent (n = 72) of children had resolution of obstructive symptoms. While 31% (n = 33) of children required additional intervention following adenoidectomy, only 6.8% (n = 9) underwent a subsequent tonsillectomy. Demographic factors such as age and baseline AHI did not predict which children required additional treatment following adenoidectomy., Conclusion: Adenoidectomy may be an effective treatment for mild OSA. A randomized trial comparing outcomes for adenoidectomy and adenotonsillectomy is needed to determine the ideal surgical treatment for nonsevere OSA in children.

Objectives: Research has shown improvement in apnea-hypopnea index in children with mild obstructive sleep apnea treated with anti-inflammatory medications. Data on quality of life outcomes in children receiving these medications is lacking. We aim to assess quality of life in children with mild obstructive sleep apnea treated with montelukast and fluticasone., Methods: Children between 3 and 16 years old with mild sleep apnea (apnea-hypopnea index > 1 and ≤ 5) presenting to a pediatric otolaryngology clinic were recruited prospectively and treated with 4 months of montelukast and fluticasone. Subjects' caregivers completed the OSA-18, a validated quality of life survey, at baseline and 4 months. Children with ongoing obstruction at follow-up underwent adenotonsillectomy., Results: Thirty-one patients were included. Mean (SD) age was 6.8 (3.9) years. Most subjects (54.8%) were black and 48% were obese. Mean (SD) apnea-hypopnea index of the subjects was 2.8 (1.0). The mean (SD) baseline OSA-18 score was 60.2 (18.5), indicating a moderate impact of sleep disturbance on quality of life. Following treatment, there was significant improvement (p < 0.005) in mean OSA-18 score. Four children discontinued montelukast due to behavioral side effects. Seven children (22%) underwent adenotonsillectomy after failing medical therapy. Demographic factors such as obesity [OR 0.63 (0.11, 3.49)] and apnea hypopnea index [OR 1.38 (0.59, 3.66)] failed to predict which children would respond to anti-inflammatory medications., Conclusions: Children with mild obstructive sleep apnea treated with montelukast and fluticasone experience significant improvements in quality of life. Further research is needed to determine optimal duration of therapy., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives (1) To assess for changes in cerebral blood flow velocity in children with sickle cell disease and obstructive sleep apnea (OSA) following adenotonsillectomy. (2) To determine if clinical factors such as OSA severity affect cerebral blood flow velocity values. Study Design Case series with chart review over 10 years. Settings Two tertiary children's hospitals. Subjects and Methods Children aged 2 to 18 years with a history of sickle cell disease and OSA, as defined by an apnea hypopnea index (AHI) >1 on polysomnography, were eligible for inclusion. Transcranial Doppler ultrasonography was used to assess cerebral blood flow velocity before and after adenotonsillectomy. Results Fifteen patients met inclusion criteria; 73% (n = 11) were female. The mean preoperative AHI was 8.9 (range, 1.2-22.2). Six (40%) patients had severe OSA (AHI >10). Following adenotonsillectomy, there was a significant reduction in mean (95% CI) cerebral blood flow velocities of the left terminal internal cerebral artery, 91.2 (79.4-103.1) to 75.7 (61.7-89.8; P = .018), and the right middle cerebral artery, 134.3 (119.2-149.3) to 116.5 (106.5-126.5; P = .003). There was not a significant correlation between baseline AHI and change in cerebral blood flow velocities. Conclusion Adenotonsillectomy may result in a reduction in some cerebral blood flow velocities. Further research is needed to determine if changes in cerebral velocities as assessed by transcranial Doppler ultrasonography translate into a reduced risk of stroke for children with sickle cell disease and OSA.

Objective Due to limitations of polysomnography (PSG), novel ways to evaluate pediatric obstructive sleep apnea (OSA) are needed. Urinary leukotriene E4 (LTE4), an inflammatory marker, has been identified as a potential biomarker for pediatric OSA. The objective of the study was to assess whether urinary LTE4 levels correlate with OSA severity, as determined by obstructive apnea-hypopnea index (AHI) and nadir oxygen saturation. Study Design Prospective trial. Setting Tertiary care children's hospital. Subjects and Methods Children (age, 3-16 years) with sleep-disordered breathing (SDB) who were referred for PSG were included. Urine samples were obtained the morning following PSG, and urinary LTE4 levels were quantified with enzyme-linked immunoassay kits. Results A total of 113 children were enrolled, and the mean age was 7.3 years. Thirty-nine percent (n = 44) were obese, and the majority were white (53%, n = 58). Seventy-eight percent (n = 88) were diagnosed with OSA (AHI >1), with 27% (n = 30) having severe disease (AHI >10). The mean urinary LTE4 level was 91.3 ng/mM. Urinary LTE4 levels did not correlate with AHI ( P = .77) or nadir oxygen saturation ( P = .64). There was a significant difference in urinary LTE4 levels between patients with mild SDB and those with moderate to severe OSA ( P = .03). Conclusion Urinary LTE4 levels do not correlate with AHI in children with SDB. Compared with children with severe OSA, children with mild SDB have higher urinary LTE4 levels. Further research is needed determine whether urinary LTE4 is a satisfactory biomarker for pediatric OSA.

Objective To systematically review the scoring systems used to report findings during drug-induced sleep endoscopy (DISE) for adults and children with obstructive sleep apnea. Data Sources PubMed, CINAHL, EBM Reviews, Embase, and Scopus databases. Review Methods This is a systematic review of all indexed years of publications referring to scoring of DISE for children and adults with obstructive sleep apnea. The type of DISE scoring system utilized was the primary outcome. PRISMA guidelines were followed to carry out this review; articles were independently reviewed by 2 investigators. All pediatric and adult studies that utilized ≥1 DISE grading systems were included. Results Of 492 identified abstracts, 44 articles (combined population, N = 5784) were ultimately included; 6 reported on children, 35 on adults, and 1 on children and adults. Twenty-one reporting methods were used in these studies, with the most common being the VOTE system (velum, oropharynx, tongue base, and epiglottis; 38.6%) and the Pringle and Croft classification (15.9%). The sites of obstruction most commonly included in a scoring system were the tongue base (62%), lateral pharynx/oropharynx (57%), palate (57%), epiglottis/supraglottis (38%), and hypopharynx (38%). Less commonly included sites were the larynx (29%), velum (23%), nose (23%), tongue (14%), adenoids (10%), and nasopharynx (10%). Conclusion There is no consensus regarding which scoring system should be utilized to report findings during DISE. The VOTE system and the Pringle and Croft classification were the most frequent scoring systems reported for patients undergoing DISE. Standardization of the reporting of DISE findings would improve comparability among studies.

Objective: To identify improvements in daytime sleepiness following adenotonsillectomy in children with non-severe obstructive sleep apnea and narcolepsy., Study Design: Case series with chart review over 15 years., Setting: Tertiary Children's Hospital., Subjects and Methods: Children between 6 and 17 years of age with narcolepsy that underwent adenotonsillectomy for non-severe obstructive sleep apnea (OSA) were included. Narcolepsy was diagnosed based on clinical assessment and the Multiple Sleep Latency Test (MSLT) results. A standardized instrument, the pediatric Epworth Sleepiness Scale (ESS), was used to assess daytime sleepiness before and after adenotonsillectomy., Results: Nine children with a mean age of 12.1 years were included. The majority of the subjects (78%, n = 7) were African American and six children (66.7%) were obese. Four children (44%) were treated with wake promoting agents during the study. The mean preoperative apnea hypopnea index on polysomnography was 4.89 (SD 1.86), while the mean sleep latency on MSLT was 6.32 min (SD 3.14). The mean preoperative ESS was 16.10 and the postoperative ESS was 10.80 (SD 3.96). There was significant improvement (p = 0.02) in the ESS following adenotonsillectomy with seven children (78%) reporting diminished daytime sleepiness., Conclusions: Children with non-severe OSA and narcolepsy experience significant improvement in daytime sleepiness following adenotonsillectomy. Future studies are needed to determine the incidence and clinical significance of non-severe OSA in children with narcolepsy., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Controversy exists surrounding how to best define and assess quality in the health care setting. Clinical practice guidelines (CPGs) have been developed to improve the quality of medical care by highlighting key clinical recommendations based on recent evidence. However, data linking CPGs to improvements in outcomes in otolaryngology are lacking. Numerous barriers contribute to difficulties in translating CPGs to improvements in quality. Future initiatives are needed to improve CPG adherence and define the impact of CPG recommendations on the quality of otolaryngologic care provided to our patients.

Objectives: (1) To identify tracheostomy complications in institutionalized children with chronic tracheostomy. (2) To determine factors that predispose to development of tracheostomy complications in institutionalized children with chronic tracheostomy., Study Design: Case series with chart review over 10 years., Setting: Tertiary children's hospital., Subjects and Methods: Children were included if they underwent tracheostomy before 21 years of age and resided at a pediatric nursing facility. Most children were ventilator dependent and had severe comorbid medical conditions, including developmental delay and cerebral palsy. The number of tracheostomy complications and unplanned hospital admissions were recorded. Interventions for tracheostomy complications were also reviewed., Results: Thirty-two institutionalized children with chronic tracheostomy were included. The mean age at time of tracheostomy was 5.4 years, with a mean duration of institutionalization of 9.1 years. Twenty-seven children (84%) experienced tracheostomy complications. The total number of complications was 79. The most common tracheostomy complications identified were peristomal granulation (n = 13) and suprastomal granulation (n = 12). Age at time of tracheostomy, duration of institutionalization, and ventilator dependence did not predict the likelihood of developing a complication. Of 32 patients, 20 were evaluated in the emergency room during the study, and there were 48 unplanned admissions for tracheostomy-related complications during the study. Forty-five urgent direct laryngoscopy and bronchoscopy procedures were performed in a total of 20 children with tracheostomy complications., Conclusions: Tracheostomy complications are common in institutionalized children with chronic tracheostomy and are challenging to manage. Further research is necessary to determine novel ways to reduce tracheostomy complications in this population., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objectives: (1) To determine the prevalence of central nervous system (CNS) pathology identified on head magnetic resonance imaging (MRI) scans in children with central sleep apnea (CSA); (2) to assess the yield of MRI in evaluation of CSA; and (3) to identify factors that predict CNS pathology in children with CSA., Study Design: Case series with chart review., Setting: Tertiary children's hospital., Subjects and Methods: A chart review was conducted over 12 years. Patients 6 months to 18 years of age who underwent head MRI for evaluation of CSA were included. CSA was diagnosed on polysomnogram as central apnea index >1., Results: Forty children were included in the CSA group. Twenty-two patients were male, and the mean age was 60 ± 41.5 months. The mean central apnea index was 3.8 ± 1.9, while the mean obstructive apnea hypopnea index was 3.4 (interquartile range, 0.7-3.8). Eighteen percent (7 of 40) of children with CSA had evidence of CNS pathology on MRI, with the most common finding (n = 3) being arachnoid cyst. Children with CSA who had gastroesophageal reflux disease or abnormal neurologic examinations were more likely to have CNS pathology. Other factors, such as prematurity, did not improve the yield of MRI in children with CSA., Conclusions: While routine evaluation of children with elevated central apnea index by MRI is not indicated, providers should consider neuroimaging in children with CSA and abnormal neurologic examination findings or gastroesophageal reflux disease. Further research is necessary to identify other tests with improved diagnostic yield for evaluation of pediatric CSA., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Non-accidental trauma is a sad but commonly described mechanism of injury in the pediatric literature. However, the otolaryngologist infrequently encounters the initial presentation of non-accidental trauma despite the fact that a significant percentage of injuries take place in the head and neck. This case report seeks to discuss otolaryngologic presentations of non-accidental trauma in the pediatric population as well as to discuss management strategies. The case of a 3 month old female with a hypopharyngeal injury and esophageal perforation is presented and discussed., (Published by Elsevier Ireland Ltd.)

Background: Children with micrognathia commonly present with upper airway symptoms and are at risk for developing obstructive sleep apnea (OSA). Prone positioning is widely used as first-line management for micrognathic children with obstructive symptoms. The aim of the present study was to document the effect of positioning on oxygenation and upper airway obstruction as measured by polysomnography (PSG)., Methods: Three children with micrognathia from two institutions underwent PSG in both the prone and supine position., Results: Patient ages were 1 week, 3 months, and 7 months. Supine obstructive apnea-hypopnea indices (oAHI) were severe for all 3 children, with a mean of 21.9 events/hour (range 16.8 to 26.3). In the prone position, the oAHI significantly improved in 2 of 3 children, with a mean of 5.1 events/hour (range 0.3 to 10.3). The frequency of central apnea events increased in 1 child following supine positioning. Nadir oxygen saturation improved in 2 of 3 children and remained within normal limits in the third., Conclusions: This is the first report of the effect of positioning on changes in PSG indices of micrognathic children. Improvement in obstructive PSG indices occurred with prone positioning, though OSA persisted in 2 of 3 children. The effect of positioning on central apnea was unclear. In light of these findings, we recommend that routine PSG be considered in micrognathic children undergoing prone positioning for definitive therapy of upper airway obstruction., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: (1) To determine the prevalence of cardiac disease in children with electrocardiogram (ECG) abnormalities on polysomnogram (PSG). (2) To assess whether factors such as family history of heart disease and severity of sleep apnea are associated with cardiac disease., Study Design: Case series with chart review from 2002 to 2012., Setting: Tertiary children's hospital., Subjects and Methods: Children between 1 and 16 years of age with ECG abnormalities on PSG who were referred to cardiology for evaluation were included. Children with a known history of cardiac disease were excluded., Results: Sixty-one children had ECG abnormalities on PSG and were subsequently referred to cardiology. The mean age was 6.5 years (SD, 4.5), and 64% (n = 39) of subjects were African American. The mean obstructive apnea hypopnea index (AHI) was 8.8 (SD, 13.3), and 26% of the children had severe obstructive sleep apnea (AHI >10). The most common ECG abnormality (n = 52) recorded on PSG was premature ventricular contractions. Thirty percent (n = 18) of children had marked arrhythmias noted on their PSG ECG. Most children referred to cardiology underwent echocardiogram (45/61) and 24-hour arrhythmia monitoring (42/61). Five children (8%) had cardiac pathology, including atrial and ventricular ectopy, tuberous sclerosis, mitral regurgitation, and aortic insufficiency. Factors such as family history of heart disease (P = .40) and severe OSA (P = .74) were not associated with cardiac pathology., Conclusion: Cardiac pathology in children with abnormal ECGs on PSG is common. Cardiology referral in such patients should be considered. Further research is needed to determine the appropriate cardiac workup.

Objective: To determine the impact of adenotonsillectomy vs observation on quality of life (QOL) in children with mild obstructive sleep apnea (OSA)., Study Design: Prospective, nonrandomized trial., Setting: Tertiary children's hospital., Subjects and Methods: Sixty-four children (ages 3-16 years) with mild OSA (apnea hypopnea index between 1 and 5 on polysomnogram) completed the study. Caregivers chose between management options of adenotonsillectomy and observation and completed validated QOL instruments (OSA-18 and Children's Health Questionnaire) at baseline, early, and late follow-ups. The primary outcome measure was QOL., Results: Thirty patients chose adenotonsillectomy, while 34 were observed. Total OSA-18 scores at baseline were significantly poorer (P = .01) in the surgery group (72.3) compared with the observation group (58.5). Four months following surgery, OSA-18 scores improved by 39.1 points over baseline (P = .0001), while there was no change for the observation group (P = .69). After 8 months, OSA-18 scores remained improved in the surgery group, and observation group scores improved by 13.4 points over baseline (P = .005). While OSA-18 scores at the late follow-up visit were poorer in the observation group, the difference was not statistically significant (P = .05). Six observation patients opted for adenotonsillectomy during the study., Conclusion: Quality of life significantly improves in children with mild OSA after adenotonsillectomy. In children with mild OSA who are observed, QOL improvements at early follow-up are less pronounced, but significant improvements in QOL are evident after 8 months. QOL instruments may be useful tools to help providers determine which children with mild OSA may benefit from early intervention.

Objective: Patients commonly refer to Internet health-related information. To date, no quantitative comparison of the accuracy and readability of common diagnoses in Pediatric Otolaryngology exist., Study Aims: (1) identify the three most frequently referenced Internet sources; (2) compare the content accuracy and (3) ascertain user-friendliness of each site; (4) inform practitioners and patients of the quality of available information., Methods: Twenty-four diagnoses in pediatric otolaryngology were entered in Google and the top five URLs for each were ranked. Articles were accessed for each topic in the three most frequently referenced sites. Standard rubrics were developed to include proprietary scores for content, errors, navigability, and validated metrics of readability., Results: Wikipedia, eMedicine, and NLM/NIH MedlinePlus were the most referenced sources. For content accuracy, eMedicine scored highest (84%; p<0.05) over MedlinePlus (49%) and Wikipedia (46%). The highest incidence of errors and omissions per article was found in Wikipedia (0.98±0.19), twice more than eMedicine (0.42±0.19; p<0.05). Errors were similar between MedlinePlus and both eMedicine and Wikipedia. On ratings for user interface, which incorporated Flesch-Kinkaid Reading Level and Flesch Reading Ease, MedlinePlus was the most user-friendly (4.3±0.29). This was nearly twice that of eMedicine (2.4±0.26) and slightly greater than Wikipedia (3.7±0.3). All differences were significant (p<0.05). There were 7 topics for which articles were not available on MedlinePlus., Conclusions: Knowledge of the quality of available information on the Internet improves pediatric otolaryngologists' ability to counsel parents. The top web search results for pediatric otolaryngology diagnoses are Wikipedia, MedlinePlus, and eMedicine. Online information varies in quality, with a 46-84% concordance with current textbooks. eMedicine has the most accurate, comprehensive content and fewest errors, but is more challenging to read and navigate. Both Wikipedia and MedlinePlus have lower content accuracy and more errors, however MedlinePlus is simplest of all to read, at a 9th Grade level., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To determine if there are changes in the central apnea index (CAI) when pediatric patients undergo adenotonsillectomy for obstructive sleep apnea (OSA)., Study Design: Case series with chart review., Setting: Two tertiary children's hospitals., Subjects and Methods: Children between 1 and 16 years of age who underwent adenotonsillectomy for OSA and had both preoperative and postoperative full-night polysomnography (PSG) with CAI greater than 1 on preoperative PSG were eligible for inclusion. Central apnea was defined as the absence of both inspiratory effort and chest wall movement lasting longer than 20 seconds. Criteria for diagnosis of central sleep apnea (CSA) was CAI greater than 1., Results: A total of 101 children with OSA had preoperative and postoperative PSG. Fifteen of these patients had a preoperative CAI greater than 1. The mean age was 67.7 months (SD, 62.7 months). The CAI ranged from 1.1 to 11.1. The mean preoperative CAI was 3.9 (SD, 2.9), while the mean postoperative CAI was 1.9 (SD, 4.8). There was significant improvement (P = .008) of the CAI following adenotonsillectomy. Ninety percent of subjects with mild CSA (CAI between 1 and 5) had postoperative resolution of their disease. There was also significant improvement (P = .004) in the obstructive apnea hypopnea index (AHI), with the mean preoperative AHI of 22.8 (SD, 19.8) decreasing to an AHI of 5.5 (SD, 6.5) postoperatively., Conclusions: Children with OSA and mild CSA on preoperative PSG showed significant improvement in CAI following adenotonsillectomy. Future studies are needed to determine the clinical significance of CSA in children with OSA and to identify treatment strategies.

Objectives: To determine the incidence and demographic profile of children who develop complications from deep neck space abscess., Study Design: Case series., Setting: Tertiary children's hospital., Subjects and Methods: One hundred thirty-eight patients admitted for deep neck space abscesses between 1998 and 2008. Inclusion criteria were age younger than 18 years and computed tomography scan demonstrating an abscess in the retropharyngeal, parapharyngeal, or peritonsillar spaces. Children were diagnosed with abscess if purulence was encountered on operative incision and drainage., Results: In the first 5 years of the study, 45 children met the inclusion criteria, whereas in the latter 5 years, 93 children were treated for abscesses. There were no differences between these cohorts in terms of age (P = .70), gender (P = .08), abscess site (P = .23), or rate of surgical intervention (P = .83). The total major complication rate was 9.4% (n = 13) with mediastinitis being the most frequent (n = 9) complication. The number of complications between the first (n = 3) and second (n = 10) groups was not significantly different (P = .55). The factors that predisposed patients to develop complications were younger age at presentation and retropharyngeal abscess location. Children with complications were more likely to have Staphylococcus aureus identified as the causative organism (P = .007). Only 1 of 4 children with methicillin-resistant S aureus had a complicated clinical course., Conclusions: Deep neck space abscesses continue to cause significant morbidity in children. Factors that predict complications include young age, retropharyngeal location, and S aureus. Providers must maintain a high index of suspicion to promptly diagnose and treat these complications.

Objective: To compare the use of flexible laryngeal mask airway (LMA) and endotracheal tube (ETT) in pediatric adenotonsillectomy., Design: Prospective randomized trial., Setting: Tertiary care hospital., Patients: One hundred thirty-one children (aged 2-12 years). Exclusion criteria were body mass index (calculated as the weight in kilograms divided by the height in meters squared) greater than 35 and craniofacial anomalies. Obstructive sleep apnea was the most common indication for surgery., Intervention: Children undergoing adenotonsillectomy were randomized to use of an LMA or ETT. A standardized anesthesia protocol was used., Main Outcome Measures: Primary outcome measure was laryngospasm. Secondary measures included anesthesia, operative, and recovery times., Results: Sixty children were randomized to the LMA group and 71 to the ETT group. There was no difference between groups with regard to age (P = .76), ethnicity (P = .75), body mass index (P = .99), or American Society of Anesthesiologists grade (P = .46). Incidence of postoperative laryngospasm between LMA (12.5%) and ETT (9.6%) was similar (P = .77). In 10 patients, the LMA was changed to ETT intraoperatively owing to tube kinking or difficulty with visualization. Mean (SD) surgical times for LMA and ETT groups were 33.35 (13.39) and 37.76 (18.26) minutes, respectively (P = .15). Time from surgery end to extubation was significantly shorter in patients who used LMA (P = .01) by 4.06 minutes. There were no differences (P = .49) in postanesthesia care unit recovery times., Conclusions: An LMA is an efficient alternative to ETT in pediatric adenotonsillectomy. When comparing LMA and ETT, there is no difference in rates of laryngospasm. Time to extubation is significantly shorter in patients using LMA. Before adopting the routine use of LMA in pediatric adenotonsillectomy, further study is needed to address visualization and kinking issues associated with this device.

Objectives: The objectives of the present study were (1) to assess receptive language scores in children after cochlear implantation and compare them with scores in normal hearing children and children with hearing loss that use hearing aids and (2) to determine how demographic factors, such as age of implantation, impact language outcomes., Study Design: Case series., Subjects/methods: Receptive language scores in children with profound prelingual hearing loss who received cochlear implants between 1996 and 2004 were analyzed., Results: Standardized language assessments were available for 36 children. The average age at implantation was 33 months. The mean language scores for implanted children were within 1 standard deviation of scores of normal hearing individuals. Children with cochlear implants had significantly higher subtest scores (P < 0.05) than children with hearing aids. Children with additional disabilities had significantly (P < 0.05) poorer language performance., Conclusions: Pediatric cochlear implant recipients acquire receptive language skills that approach those of their hearing peers and exceed those of children with hearing aids.

Objective: 1) To assess the quality of life (QOL) in children with obstructive sleep apnea (OSA) compared with QOL of children with chronic medical conditions, and 2) To determine QOL in children with OSA after adenotonsillectomy in short- and long-term follow-up. DATA SOURCES/REVIEW METHODS: A literature review on QOL in pediatric OSA using the PubMed database., Results: The literature search yielded 10 articles that satisfied inclusion and exclusion criteria. In three studies, the Child Health Questionnaire (CHQ) survey was used to compare 193 patients who had OSA with 93 children who had juvenile rheumatoid arthritis (JRA) and with 815 healthy children. Of 12 CHQ subscale scores for children with OSA, 8 scores were significantly lower (indicating a poorer QOL) than controls. Children with OSA scored 19.23 points lower than healthy children in the subscale of parental impact-emotional. Children with OSA had QOL scores that were similar to those of children with JRA. In seven publications, 369 children with OSA undergoing adenotonsillectomy were studied by using the OSA-18 QOL instrument. The total OSA-18 score and each of the domain scores showed significant improvement (P < 0.0001) after adenotonsillectomy. At long-term follow-up, QOL scores remained significantly improved., Conclusions: Pediatric OSA has a significant impact on QOL. QOL in pediatric OSA is similar to that of children with JRA. Large improvements in QOL occur after adenotonsillectomy, and these findings are maintained in the long-term. The literature lacks control studies on QOL in pediatric OSA.