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Objective: To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers., Design: Multicenter blinded R (inter) and R (intra) study., Setting: Eight academic tertiary care centers., Participants: Sixteen otolaryngologists from 8 centers., Main Outcome Measures: Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated., Results: The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size., Conclusions: In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Objectives: (1) To determine the prevalence of Internet medical information searches by parents prior to their child's surgical procedure, and (2) to evaluate whether Internet-based health information influences parents' medical decisions on behalf of their children., Design: A questionnaire designed to gather information regarding preoperative use of the Internet by parents of children who were scheduled to undergo outpatient otolaryngology procedures. Parents were asked to respond to questions regarding Internet searches for information specific to their child's diagnosis and anticipated surgical procedure., Setting: Tertiary care pediatric hospital., Results: Internet access was available to 83% of respondents. Of those parents with Internet access, 48% searched the Internet for information regarding their child's diagnosis and surgical procedure. Of those who searched the Internet, 93% said they found information that was both understandable and helpful. More important, 84% of parents using the Internet said the information influenced or somewhat influenced the medical decisions they made on behalf of their child. Only 43% of parents discussed the information they found on the Internet with their child's surgeon., Conclusions: Approximately 50% of the parents in our study with Internet access used it to find medical information prior to their child's surgery. Parents who used the Internet found the information helpful and influential, although physicians remain the most important source of information that guides a parent or patient in their medical decision making. Ideally, surgeons would direct parents or patients to a few trusted Internet sites and be prepared to discuss this information.

Background: Children with complete tracheal rings are often challenging to manage. Most children will present early with a severely compromised airway and will require tracheal reconstruction., Objective: To show that a small number of minimally symptomatic patients with complete tracheal rings experience airway growth over time and do not require tracheoplasty., Design: A retrospective medical chart review over a 10-year period., Setting: A tertiary care pediatric hospital., Patients: Children (N = 10) with a diagnosis of complete tracheal rings, confirmed on bronchoscopy, who were observed for a minimum of 1 year prior to determining the need for tracheoplasty., Main Outcome Measures: Patient symptoms, bronchoscopic findings, airway size, and the progression of these over time. Other congenital anomalies, the reason for initial diagnosis, and the need for tracheoplasty were documented., Results: The 10 patients in our series fell into the following 3 categories: 5 patients were minimally symptomatic or asymptomatic, showed bronchoscopic evidence of progressive airway growth, and did not require tracheoplasty; 2 patients had worsening symptoms of exercise intolerance, showed minimal airway growth, and ultimately required tracheoplasty; and 3 patients are still being clinically observed and may eventually require tracheoplasty. Periods of observation have varied from 1 year to over 12 years., Conclusions: Not all patients with complete tracheal rings require tracheoplasty. Some have satisfactory airway growth and do not require airway reconstruction. A period of observation to monitor airway growth and clinical symptoms is safe and may spare some patients from undergoing unwarranted airway reconstruction.

Objectives: To refine the classic definition of, and provide a working definition for, congenital high airway obstruction syndrome (CHAOS) and to discuss the various aspects of long-term airway reconstruction, including the range of laryngeal anomalies and the various techniques for reconstruction., Design: Retrospective chart review., Patients: Four children (age range, 2-8 years) with CHAOS who presented to a single tertiary care children's hospital for pediatric airway reconstruction between 1995 and 2000., Conclusions: To date, CHAOS remains poorly described in the otolaryngologic literature. We propose the following working definition for pediatric cases of CHAOS: any neonate who needs a surgical airway within 1 hour of birth owing to high upper airway (ie, glottic, subglottic, or upper tracheal) obstruction and who cannot be tracheally intubated other than through a persistent tracheoesophageal fistula. Therefore, CHAOS has 3 possible presentations: (1) complete laryngeal atresia without an esophageal fistula, (2) complete laryngeal atresia with a tracheoesophageal fistula, and (3) near-complete high upper airway obstruction. Management of the airway, particularly in regard to long-term reconstruction, in children with CHAOS is complex and challenging.

Objective: To explore the effect of mitomycin treatment on the pediatric airway following laryngotracheal reconstruction., Design: Randomized, double-blind, placebo-controlled trial., Patients: Children aged 2 to 17 years with subglottic or upper tracheal stenosis undergoing laryngotracheal reconstruction at a single, tertiary care, children's hospital., Intervention: At the time of extubation or stent removal, the children underwent bronchoscopy and 0.4 mg/mL (2 mL of a 0.2-mg/mL solution of either mitomycin or an equal volume of isotonic sodium chloride was directly applied to the subglottic region for a single application of 2 minutes. These children then underwent interval endoscopy at 2 weeks, 6 weeks, and 3 months postoperatively for assessment of their airways., Results: Granulation tissue was graded on a scale of 0 (none) to 4 (near-total or total occlusion). Videotapes of endoscopies were independently observed and graded by 3 pediatric otolaryngology fellows with a subsequent interobserver agreement of 91.6%. The results were then dichotomized to represent a single cohort in which further surgical intervention would be required and another separate cohort in which further surgery would not be required. At the 1-year mark, interim analysis was performed by a Data Safety and Monitoring Committee. At this time, 13 children had been randomized to the mitomycin-treated arm of the study and 11 children to the placebo-treated arm. A 2-tailed Fisher exact test revealed a value of 1.00. The Data Monitoring and Safety Committee advised that the trial should be stopped because the distributions between the 2 populations were almost identical., Conclusion: We cannot reject the null hypothesis that a single topical dose of mitomycin exerts an equal benefit as does isotonic sodium chloride when applied to the pediatric airway after laryngotracheal reconstruction.

Objectives: To report on our incidence of posttonsillectomy hemorrhage and to define what constituted posttonsillectomy bleeding., Design: Retrospective study., Setting: Tertiary care children's hospital and a local satellite facility., Patients: A series of 1438 consecutive patients who had undergone either tonsillectomy or adenotonsillectomy between January 1, 1999, and December 31, 1999., Intervention: During this period, parents were instructed to return with their children for clinical evaluation if any blood was seen in the postoperative period., Main Outcome Measures: Postoperative day of evaluation, age, sex, location of bleeding, management strategy, length of hospital admission, and any bleeding disorders were noted for each patient., Results: A total of 112 patients underwent evaluation 134 times. Of these patients, 96 required only 1 evaluation and 16 required more than 1 evaluation. All patients who had more than 1 evaluation required intervention. The total number of children requiring intervention for posttonsillectomy hemorrhage was 51 (3.5%) of the 1438 patients. Female patients were more likely than male patients to return for evaluation. Patients who were 12 years and older were the most likely and those 3 years and younger were the least likely to have posttonsillectomy hemorrhage. The most common time from surgery to initial evaluation for hemorrhage was 6 days., Conclusions: By reviewing our own criteria for defining and recording posttonsillectomy hemorrhage, we conclude that posttonsillectomy hemorrhage is defined differently in the literature. This supports the need for a standard definition to allow for direct comparisons.

Objectives: To review the treatment of pediatric patients with methicillin-resistant Staphylococcus aureus (MRSA)-positive cultures as a result of otorrhea after tympanostomy tube placement in terms of both medication and isolation strategies and to highlight an emerging problem faced by the clinician with reference to treatment options as well as to the treatment of these patients in an outpatient setting., Patients: Between December 1998 and January 2000, a total of 8 children between the ages of 1 and 11 years had MRSA-positive cultures as a result of otorrhea after tympanostomy tube placement., Main Outcome Measures: The Department of Infectious Diseases was notified, and a variety of topical antibiotic treatments were administered. Arch Otolaryngol Head Neck Surg. 2000;126:1440-1443

Objective: To determine whether DNA ploidy and the S-phase fraction are predictive of the clinical course in children with recurrent respiratory papillomatosis., Design: Masked compression of DNA analysis findings to the clinical course of the disease., Setting: Tertiary referral center., Patients: All pediatric patients treated for recurrent respiratory papillomatosis at our institution between 1989 and 1995 who had adequate follow-up and whose primary biopsy specimen was available for examination. Fifty-five patients met these criteria., Methods: Information was collected from the case notes on the patient's age at presentation, sex, sites of disease, duration of active disease, and frequency of operative interventions. Flow cytometric analysis was performed on the archival paraffin-embedded primary biopsy specimen obtained at the initial surgical excision, providing DNA content and percentages of S-phase cells. The investigators who performed the DNA analysis were masked to the clinical course., Results: The age of the patients at presentation ranged from 3 months to 16 years. Thirty patients had involvement in more than 1 anatomical site. The disease in 10 patients had spread to the distal tracheobronchial tree. The patients underwent a total of 1124 procedures, with a frequency range of 7 to 27 per year. All cell populations studied were diploid. The percentage of S-phase cells was significantly higher in the primary biopsy specimen from patients with disease characterized by more frequent recurrences, multiple sites, and distal extension (P<.05). In multiple regression analysis, the S-phase fraction was found to be an independent and powerful prognostic factor for aggressive disease., Conclusions: The S-phase fraction may be predictive of the clinical course in patients with juvenile respiratory papillomatosis. Prospective studies are needed to assess the diagnostic and clinical value of our primary results and to determine whether DNA analysis can assist in identifying patients at increased risk for an aggressive clinical course.

Objective: To determine if second-look nasal endoscopy (SLE) improves clinical outcome after pediatric functional endoscopic sinus surgery (FESS)., Design: A retrospective review was performed for all patients who had undergone FESS between January 1993 and December 1994. The patients were divided into 2 groups: those who underwent SLE 2 to 3 weeks after FESS (n=94) and those who did not undergo SLE after FESS (n=53). Patients with a history of cystic fibrosis, bone marrow transplantation, or isolated sphenoidal sinus disease were excluded from the study., Setting: Pediatric tertiary care hospital., Patients: All patients had a diagnosis of chronic rhinosinusitis, had failed medical therapy, and had subsequently undergone FESS., Main Outcome Measures: The need for revision sinus surgery was used as the definition for poor clinical outcome, indicating that sinus disease recurred or was persistent. The number of patients requiring revision sinus surgery in each group was compared., Results: Revision surgery was performed in 20 of the 94 patients who underwent SLE after FESS. Revision surgery was performed in 10 of the 53 patients who did not undergo SLE after FESS. Six patients in the "no-second-look group" underwent follow-up nasal endoscopy at some time after the initial FESS. There was no significant difference in terms of clinical outcome between the 2 groups., Conclusions: The rate of revision sinus surgery was comparable in those patients who underwent SLE after FESS and those who did not. The usefulness and application of SLE need to be considered carefully.

Objective: Obtain normative data on the distance from the tonsillar fossa to the internal carotid artery in children, and relate this distance to age and weight parameters., Design: A prospective study of 100 children undergoing magnetic resonance imaging studies for pathology unrelated to the upper aerodigestive tract. The torus tubarius corresponds to the lateral extent of the tonsillar fossa and was used as the reference site for measurements. One hundred children (aged 7 days to 18 years; median, 6 years) were consecutively entered into the study. Exclusion criteria included any preexisting abnormalities of the upper aerodigestive tract. The study defined the distance from the tonsillar fossa to the internal carotid artery. Relationships of this distance were defined for both age and weight parameters., Results: With increasing age and weight, the distance between the tonsillar fossa and the internal carotid artery increases in a regular fashion to a value approaching 25 mm. Both relationships are exponential with asymptotes being achieved by 56 kg (correlation coefficient, 0.8616; R2 value, 0.7423) or 12 years of age (correlation coefficient, 0.8452; R2 value, 0.7143)., Conclusion: Age and weight parameters can be used to predict the distance from the tonsillar fossa to the internal carotid artery in children.

Child abuse is a common problem seen by practicing physicians. To further define the incidence and the type of head and neck injury in children referred for evaluation of child abuse, a 5-year retrospective study of 4340 patients was undertaken. Of these patients, 2950 (68%) were victims of sexual abuse, while 1390 (32%) were victims of physical abuse. Forty-nine percent of patients abused physically had evidence of injury to the head and neck region, while only 1% of the sexually abused children had injuries in the head and neck area. The age of the patients ranged from 1 day to 17 years, with a mean of 5.6 years. More than 150 of these children were under the age of 1 year; 180 patients were admitted. The average age of the admitted patients was 2.1 years. The alleged perpetrator, mechanism of injury, and location of injury were tabulated. There were 11 deaths in the series (1.6%). Child abuse has been defined in our institution as any injury inflicted on a child. Identification and reporting of suspected child abuse is required by law and essential for the well-being of the abused child. Recommendations are made concerning the evaluation of these children, their management, and the physician's legal responsibility to report suspected cases of child abuse.