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Objective: To describe the impact of timing of tympanostomy tube insertion on the number of tubes received and complications in children with routine tube placement.Design: Retrospective case series.Setting: Tertiary care children’s hospital.Participants: Records from a consecutive sample of 401 children with cleft palate were reviewed. Sixty-five patients with isolated cleft palate and 82 patients with cleft lip and palate had follow-up until 5 years of age and were included.Interventions: Tympanostomy tubes.Main Outcome Measure(s): Number of tubes received and tube-related complications. The hypothesis was formulated prior to data collection.Results: Males comprised 55.8% of included patients, and tubes were placed in 98.6% of patients at a median age of 6.5 months. Effusion was documented at first tube placement for 96.5% of patients. Most (67.4%) patients required replacement of tubes, and 10.6% required long-term tubes. Complications included otorrhea (71.0%), myringosclerosis (35.2%), granulation (22.8%), perforation (17.9%), retained tubes (5.5%), and cholesteatoma (1.4%). Cleft lip and palate (P< .001) and otorrhea (P= .023) were associated with tube placement before palatoplasty. Patients with tube placement before palatoplasty (P= .033), genetic disorders (P= .007), failed newborn hearing screen (P= .012), otorrhea (P< .001), and granulation (P< .001) received more tubes.Conclusions: Nearly universal effusion in patients with cleft palate supports the need for routine tube placement. The potential for otorrhea and requiring more tubes should be weighed against the risks associated with prolonged effusion when considering tube placement before palatoplasty.

Objectives: To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes.Design: Retrospective cohort study.Setting: Tertiary care children’s hospital.Participants: Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained.Main Outcome Measure: Number of tubes.Results: Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P= .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P= .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years).Conclusion: Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population.

OBJECTIVE To determine polysomnographic (PSG) variables that may potentially predict adverse respiratory events after pediatric adenotonsillectomy. DESIGN Retrospective, case-control study. SETTING Free-standing academic tertiary-care pediatric hospital. PATIENTS The study included 1131 patients undergoing adenotonsillectomy by 2 attending surgeons. There were no exclusion criteria. MAIN OUTCOME MEASURES Variables from preoperative PSGs were analyzed to determine predictors of postoperative respiratory complications. Logistic regression analysis was performed. RESULTS A total of 151 patients (13.4%) underwent preoperative PSG. Twenty-three of these patients (15.2%) had adverse respiratory events. The primary adverse event was desaturation requiring supplemental oxygen therapy, with 1 case of postobstructive pulmonary edema. Patients with adverse events had a significantly higher apnea-hypopnea index) (31.8 vs 14.1; P = .001), higher hypopnea index (22.6 vs 8.9; P = .004), higher body mass index (z score, 1.43 vs 0.70; P = .02), and lower nadir oxygen saturation (72% vs 84%; P &lt;.001). Patients with adverse events had a prolonged hospital course (odds ratio, 32.1; 95% confidence interval, 7.8-131.4). There were no differences in age or other PSG variables. There were no intubations or mortalities. CONCLUSIONS Polysomnography may be used to predict which patients are at higher risk for adverse respiratory events after adenotonsillectomy. Such knowledge is valuable for planning optimal postoperative management and intraoperative anesthesia. Predictors of increased respiratory complications include apnea-hypopnea index, hypopnea index, body mass index, and nadir oxygen saturation.Arch Otolaryngol Head Neck Surg. 2011;137(1):15-18--

OBJECTIVE To review national trends in the management of pediatric airway foreign bodies (A-FBs) and esophageal foreign bodies (E-FBs) that obstruct the airway. DESIGN Retrospective review using a national pediatric data set (Kids' Inpatient Database). SETTING Pediatric patients admitted across the United States during 2003. PATIENTS The Kids' Inpatient Database 2003 samples 2 984 129 pediatric discharges from 3438 hospitals in 36 states. MAIN OUTCOME MEASURES The Kids' Inpatient Database 2003 was analyzed for A-FBs and E-FBs (International Classification of Diseases, Ninth Revision, Clinical Modification codes E911 and E912) in patients 20 years or younger, and weighted data are presented to facilitate national estimates. RESULTS A total of 2771 patients (59% male) were admitted for an A-FB or an E-FB that was obstructing the airway. The mean (SE) age of the patients was 3.5 (0.17) years; 55% were younger than 2 years. The foreign bodies were classified as food (42%; mean age, 2.5 years) or other (58%; mean age, 4.3 years). The average length of stay was 6.4 days (median [SE], 1.5 [0.6] days), and the average number of procedures was 2.4 (median [SE], 1.3 [0.1] procedures). Seventy-one percent of the patients were treated at teaching hospitals. The mean (SD) total charges were $34 652 ($3543), with regional variation (P &lt; .001). Children's hospitals (28%) had higher mean total charges than nonchildren's hospitals (P = .03); 3.4% of admissions died in the hospital (mean [SE] age, 4.6 [0.9] years), with an average length of stay of 11.7 (SE, 2.7) days and an average of 6.2 (SE, 0.7) procedures. Bronchoscopy (52%), esophagoscopy (28%), and tracheotomy (1.7%) were the primary procedures performed. The rates of positive FB findings for bronchoscopy and esophagoscopy were 37% and 46%, respectively. CONCLUSIONS Pediatric A-FBs and E-FBs that obstruct the airway occur infrequently. Most of the patients are referred to teaching institutions. Among patients who were admitted with a diagnosis of airway obstruction from an A-FB or an E-FB, the rates of positive findings at surgery were 37% and 46%, respectively. A surprisingly high mortality rate was noted. Alternative education measures should be considered to train physicians in the management of this infrequent, potentially lethal condition.Arch Otolaryngol Head Neck Surg. 2010;136(4):373-379--

Invasive aspergillosis is a severe, devastating fungal infection that is seen in patients with hematologic malignancies and profound neutropenia. Despite aggressive treatment, the outcome is poor without neutrophil recovery. The authors describe two children with acute myelogenous leukemia (AML) with extensive invasive aspergillosis who were successfully treated both for their infection and the underlying malignancy. These patients were treated aggressively for their infections and simultaneously were able to complete treatment of their AML. Currently both patients are alive without evidence of fungal infection or AML. Patients with hematologic malignancies can survive severe, invasive aspergillosis during prolonged periods of neutropenia with a combination of antifungal and growth factor therapies, donor granulocyte infusions, and surgical debridement.

Postsurgical follow-up of children with tympanostomy tubes is becoming a contentious issue in this era of managed care. Primary care providers believe themselves to be capable of evaluating these children. Otolaryngologists, on the other hand, have more specialized equipment available to them (suction apparatus, otomicroscopes, audiology devices, etc) for treating suppurative infections and monitoring the tympanic membrane for structural changes. In addition, the otolaryngologist is placed in an uncomfortable legal and ethical position if access to the patient with a tube-related complication is denied by the primary care provider. Attempts to develop an American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) policy statement have been hampered by a lack of data on the incidence and severity of tube-related complications and the role that otolaryngologists can play in reducing these sequelae. A survey designed by the AAO-HNS Pediatric Otolaryngology Committee was distributed to 1000 board-certified otolaryngologists and all members of the American Society of Pediatric Otolaryngologists and the American Academy of Pediatrics-Otolaryngology Section regarding current practice patterns and practitioners' experiences with tympanostomy tube complications. Specific information regarding complications that could have been avoided with earlier otolaryngology referral was also obtained. The results of the survey and its implications for AAO-HNS policy are presented.

OBJECTIVES:The goal was to determine the incidence and types of airway abnormalities in patients with Arnold-Chiari malformation (ACM).METHODS:The study was a retrospective chart review of 24 patients with ACM who were evaluated and treated between November 1991 and August 1997.RESULTS:Eighteen (75%) and 6 (25%) of the 24 patients had types I and II ACM, respectively. Three (12.5% of 24 patients) of the type II ACM patients had vocal cord impairment: 1 bilateral paralysis, 1 bilateral paresis, and 1 unilateral paralysis. None of the type I ACM patients had vocal cord impairment. Tracheotomy was necessary in 3 of the 24 patients and all in patients with type II ACM. Central sleep apnea was found in 5 of 6 type II ACM patients, but not in any of the type I ACM patients.CONCLUSIONS:Vocal cord impairment and sleep apnea were found in 12.5% and 21%, respectively, of this ACM Population. When type II ACM patients were considered separately, the incidences of vocal cord impairment and sleep apnea were 50% and 83%, respectively. Type II ACM patients tend to have a higher incidence of airway abnormalities and other neurologic dysfunctions. Flexible fiberoptic laryngoscopy is recommended in the airway evaluation of ACM patients. Early recognition, diagnosis, and management of these abnormalities may be lifesaving.

Voice disorders are frequently seen in the pediatric population. They can have significant impact on the patient. Voice disorders may result from aberrations in the speech mechanism. The salient features of four common voice disorders and their clinical relevance are discussed.

Adenotonsillectomies are commonly performed for various indications. In this paper, the evaluation of patients for adenotonsillectomy, including history taking; physical examination; preoperative laboratory testing; and such adjunctive measures as nasopharyngoscopy, sleep fluoroscopy, and polysomnography are discussed. The techniques of adenoidectomy and tonsillectomy and the complications associated with different surgical techniques are reviewed. The indications for inpatient and outpatient adenotonsillectomy and the need for postoperative monitoring are discussed. Finally, surgical complications are mentioned in order to enable physicians to perform prompt diagnosis and management.

OBJECTIVES: To determine the necessity of rigid endoscopy in the diagnosis and management of laryngomalacia and its associated synchronous airway lesions (SALs), to analyze the incidence of SALs associated with laryngomalacia and their significance, and to determine the need for epiglottoplasty in management of laryngomalacia. DESIGN: Retrospective medical chart review. SETTING: Tertiary care children's hospital. PATIENTS: Two hundred thirty-three patients with a primary diagnosis of laryngomalacia on flexible fiberoptic laryngoscopy treated at the Children's National Medical Center, Washington, DC, from January 1, 1984, to June 30, 1994. INTERVENTIONS: Evaluation and treatment of laryngomalacia and associated SAL by flexible fiberoptic laryngoscopy, radiographic studies, rigid endoscopy, and other surgical procedures. MAIN OUTCOME MEASURES: Resolution of airway symptoms from laryngomalacia and associated SAL. RESULTS: Ninety patients (38.6%) underwent rigid endoscopy, and 12 patients (5.2%) required epiglottoplasty. Synchronous airway lesions were discovered in 44 patients (18.9%). Eleven patients (4.7%) had SALs that were considered clinically significant; nine (3.9%) of these required surgical intervention. CONCLUSIONS: Rigid endoscopy in evaluation of an infant with laryngomalacia is rarely necessary. Clinically significant SALs requiring surgical intervention are uncommon. Surgical intervention for laryngomalacia also is rarely necessary.(Arch Otolaryngol Head Neck Surg. 1996;122:302-306)

OBJECTIVES: To determine the need for preoperative evaluation for gastroesophageal reflux disease (GERD) in all children undergoing laryngotracheal reconstruction (LTR) and to assess the effect of GERD on the outcome of LTR. DESIGN: Prospective, single-blind, observational study. SETTING: Tertiary care children's hospital. PATIENTS: Seventy-four pediatric patients with laryngotracheal stenosis who underwent LTR at the Children's National Medical Center, Washington, DC, from October 1, 1986, through August 31, 1994. INTERVENTION: Evaluation for and treatment of GERD, LTR, endoscopy, and removal of granulation tissue. MAIN OUTCOME MEASURES: Successful decannulation and number of endoscopies required to remove laryngeal and tracheal granulation tissue. RESULTS: Seventy-four patients underwent 82 LTRs. The senior surgeon was blinded to the status of GERD evaluation and treatment. Four groups were identified: 37 patients (40 LTRs) with no preoperative evaluation for GERD; 10 patients (11 LTRs) with normal findings on preoperative evaluation for GERD; seven patients (nine LTRs) with abnormal findings on preoperative evaluation for GERD but who failed to receive appropriate treatment; and 20 patients (22 LTRs) with abnormal findings on preoperative evaluation for GERD who received appropriate therapy. Severity and extent of stenosis as determined by multicentricity of stenosis, type of repair, and duration of stent were similar in the four groups. The effect of GERD and its treatment on the outcome of LTR was measured by the number of endoscopies necessary for removal of granulation tissue following reconstruction and successful decannulation. Statistical analyses indicate that (1) all children do not require preoperative evaluation for GERD; (2) neither the presence of GERD nor its treatment are major factors in determining the outcome of LTR. CONCLUSION: Preoperative evaluation for GERD and its treatment do not favorably affect the outcome of LTR.(Arch Otolaryngol Head Neck Surg. 1996;122:297-300)

OBJECTIVES: To evaluate the following: the incidence of invasive Aspergillus sinusitis (AS); the value of surveillance nasal cultures and screening radiologic studies in predicting AS; the clinical criteria used to decide on surgical biopsy in patients suspected of having AS; the surgical and medical management of AS; and the outcome of AS in the peritransplantation period of children who underwent bone marrow transplantation. DESIGN: Retrospective medical chart review. SETTING: Tertiary care children's hospital. PATIENTS: Eighty pediatric patients who underwent bone marrow transplantation for a variety of refractory malignant neoplasms or lymphohematopoietic disorders at the Children's National Medical Center, Washington, DC, from April 1, 1988, to September 30, 1993. INTERVENTION: Diagnostic surgical biopsies, surgical débridement, and treatment with amphotericin B. MAIN OUTCOME MEASURE: Resolution of AS and discharge from the hospital. RESULTS: Seventy-two patients had screening sinus radiographs, 27 of which showed abnormalities. Aspergillus sinusitis developed in three of the patients with abnormal screening radiographs. Fifty-eight patients had screening nasal cultures. One culture was positive for Aspergillus, and histopathologically proved AS developed in this patient. Twelve diagnostic biopsies were done in nine patients. Three biopsy specimens showed histopathologic evidence of AS. The three patients with AS were successfully treated with aggressive surgical and medical therapy and were discharged from the hospital. CONCLUSION: The incidence of AS was 4% (3/80) in the patients who underwent bone marrow transplantation. Screening radiographs, while not a good predictor of AS, have a role in evaluation of patients undergoing bone marrow transplantation to define preexisting sinus disease. Screening nasal cultures do not reliably predict AS. When AS is suspected and diagnostic biopsy is considered, the seven clinical criteria outlined in this article should be used. Survival of immunocompromised patients with AS requires early diagnosis and aggressive surgical and medical therapy.(Arch Otolaryngol Head Neck Surg. 1995;121:1188-1192)

OBJECTIVES: To determine the relative frequency of retropharyngeal abscesses (RPAs) vs lateral pharyngeal abscesses (LPAs) and to analyze alternative approaches for surgical drainage. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Seventy pediatric patients who were evaluated, admitted, and treated for presumed deep neck abscesses (RPAs and LPAs) between January 1, 1986, and December 31, 1996. INTERVENTION: Intravenous antibiotic therapy and surgical drainage. MAIN OUTCOME MEASURE: Clinical resolution of the abscess. RESULTS: Fifty-eight patients were evaluated with computed tomographic scan. Thirteen of these patients did not have surgical intervention. Of 12 patients diagnosed as having an isolated RPA, all had intraoral surgical drainage and 9 had evidence of pus at surgery. Twenty-one patients had an isolated LPA. Sixteen of these underwent intraoral drainage and 5 underwent external drainage. Purulence was found at surgery in 14 and 2 patients, respectively. The remaining 12 patients had a combination of RPA and LPA. Eight patients underwent intraoral drainage, and 4 patients required both intraoral and external approaches. Purulence was found at surgery in 5 and 4 patients, respectively. Of the 12 patients who were not evaluated with computed tomographic scan, two thirds were treated prior to 1987. Six of these 12 patients underwent surgical drainage via an intraoral approach, and 4 of the 6 patients had pus. The remaining 6 improved without surgery. CONCLUSIONS: Most deep neck abscesses in children are located in the retropharyngeal or in the lateral pharyngeal space medial to the great vessels. Therefore, most can be managed successfully with intraoral rather than external drainage. External approaches are better reserved for those abscesses that are lateral to the great vessels or that involve multiple spaces. In this patient population, LPAs were more commonly seen than RPAs.Arch Otolaryngol Head Neck Surg. 1997;123:1271-1275

OBJECTIVE: To determine the indications for admission, requisite imaging studies, and urgent medical or surgical intervention. DESIGN: We retrospectively reviewed the charts of 26 children (age range, 5 months to 14 years) who were seen by the otolaryngology service in the emergency department at the Children's National Medical Center, Washington, DC, from 1985 to 1993 and who were diagnosed as having oropharyngeal trauma. We specifically looked for common findings in the history and physical examination on initial presentation to predict the necessary steps in evaluation and management. SETTING: Tertiary care pediatric referral center. RESULTS: Indications for admission were (1) concern about neurologic injury, (2) concern about vascular injury, (3) radiographic evidence of retropharyngeal free air or abscess, (4) pneumomediastinum, and (5) unreliable adult supervision at home. Six patients required surgery: 3 underwent retropharyngeal aspiration or incision and drainage procedures; 2 required neck explorations; and 1, who had an impaled foreign body in the parapharyngeal space, underwent surgical extraction. There were no vascular, neurologic, or other permanent injuries. CONCLUSIONS: Oropharyngeal trauma may result in palatal and posterior pharyngeal wall injury requiring closure of lacerations and management of retropharyngeal free air. Rarely does an injury lead to retropharyngeal abscess or significant pneumomediastinum. Lateral oropharyngeal injuries require increased concern about potential neurovascular impairment. However, neither the mechanism of injury nor the degree of injury correlates with the potential for neurovascular sequelae. Since neurovascular involvement may not become clinically apparent until days or weeks after the incident, admission for observation alone should be based on the distance from the patient's home to the hospital and on the level of reliable adult supervision. Indications for medical and surgical treatment of internal carotid artery thrombosis remain controversial.Arch Otolaryngol Head Neck Surg. 1997;123:1267-1270

Minor blunt cervical injuries in children are relatively common occurrences leading to serious sequelae in only rare circumstances, yet sufficient impact of even a seemingly minor event may lead to a significant posterior tracheal wall laceration, resulting in pneumomediastinum with or without pneumothorax. Three cases demonstrate how the mechanism of injury does not always match either the severity of initial presentation or the consequent necessary level of emergent management. Pneumomediastinum without pneumothorax often can be treated conservatively; however, the onset of massive pneumomediastinum and pneumothorax may necessitate both tracheotomy and tube thoracostomy as initial treatment.

Objectives:To determine whether there are any changes in the incidence and management of neonatal subglottic stenosis (SGS). Methods:A retrospective chart review of 416 infants who were admitted to the neonatal intensive care unit of the Children’s National Medical Center between July 1, 1995, and June 30, 1996, was carried out. The incidence of airway obstruction requiring anterior cricoid split or placement of tracheotomy tube was determined and compared with the incidence studied 10 years ago at the same institution. Results:One of 416 neonates required surgical intervention for airway obstruction caused by SGS, for an overall neonatal SGS incidence of 0.24%. When only the neonates who were intubated for 48 hours or longer were considered, the incidence of SGS was 0.49% (1/204). In neonates who were intubated for 48 hours or longer and survived, the incidence of SGS was 0.63% (1/160). This is in comparison with the incidences of 0.65% (3/462), 1.5% (3/195), and 1.9% (3/159), respectively, seen in a study done at the Children’s National Medical Center 10 years ago. Five infants in this current study required placement of a tracheotomy tube for reasons other than SGS. Two infants needed tracheotomy tube placement for micrognathia, and 3 others for central hypotonia, an omphalocele that required multiple surgical procedures, and choanal atresia with a serious heart anomaly, which was a manifestation of CHARGE association. None of these 5 infants had evidence of SGS at rigid endoscopy preceding the tracheotomy tube placement. Conclusion:The incidence and management of neonatal SGS remain unchanged during this study period when compared with those of 10 years ago. (Otolaryngol Head Neck Surg 2000;122:61-3.)

OBJECTIVE: To determine whether there is an ideal age at which to perform a laryngotracheal reconstruction (LTR) in the pediatric population. DESIGN: Prospective observational study. SETTING: Tertiary care children's hospital. PATIENTS: Forty-eight patients aged 48 months or younger with laryngotracheal stenosis who underwent 50 LTRs from October 1, 1986, to June 30, 1995. Patients were divided into 2 groups: group 1, aged 8 through 24 months (22 patients); group 2, aged 25 through 48 months (26 patients). INTERVENTION: Endoscopy and LTR. MAIN OUTCOME MEASURES: Successful decannulation. RESULTS: Statistical analysis showed that (1) patients in group 2 had more severe degree of laryngotracheal stenosis as determined by duration of stenting with no difference in multiple sites of stenosis or type of repair required to correct laryngotracheal stenosis and (2) patients in group 2 were more likely to have successful decannulation. CONCLUSION: Laryngotracheal reconstruction at a younger age (&lt;25 months) is important for a child's speech and language development as well as for eliminating the morbidity and mortality associated with a tracheotomy. However, LTR at a younger age is associated with a higher risk of failure despite lesser degree of pathology. Therefore, although we still recommend LTR at a younger age since it may be beneficial for a child's speech and language development and avoidance of tracheotomy complications, this recommendation may be at the price of LTR failure and requirement for revision procedures.Arch Otolaryngol Head Neck Surg. 1997;123:206-208

We apologize to Dr Cotton that his name is not mentioned in the body of the text because it was added to the letter to the editor after the response to Drs Bluestone and Healy was sent.We are pleased that Drs Bluestone and Healy, have chosen to comment on our recent article. Since these 2 eminent pediatrie otolaryngologists have vast experience in the treatment of children with stridor, their concerns must be taken seriously. We would like to address their concerns.The article by Gonzales et al1 mentioned by the authors in their letter was a retrospective analysis of 103 infants who presented to the Children's Hospital of Pittsburgh, Pa, with airway obstruction, stridor, or both. Laryngomalacia was found in 59 patients, other laryngeal abnormalities in 19, subglottic lesions in 23, and trachabnormalities in 20. The authors found multiple synchronous lesions in 17.5% of the patients. Thus, the authors concluded that complete upper and lower airway examination by rigid endoscopy is necessary in evaluating infants with airway obstruction.

Educational objectives: To become familiar with possible complications of sinusitis in children and to become comfortable with reasonable treatment options, both medical and surgical, including open and endoscopic surgical techniques for complications of pediatric sinusitis.