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Objectives Dysphonia and stridor are not infrequent in the pediatric population. Awake nasolaryngoscopy (ANL) is the primary diagnostic procedure used to evaluate a child with stridor and/or dysphonia. The major limitation of this technique is poor cooperation in children, resulting in inadequate visualization of the larynx. Ultrasound is a widely used noninvasive imaging modality that has yet to be applied to the laryngeal examination. Our goal was to investigate the feasibility and diagnostic potential of laryngeal ultrasound (LUS) in cases of pediatric stridor and/or dysphonia. Methods Prospective blinded cohort study of infants and children 0–16 years of age referred for ANL due to voice disorders and/or stridor. Prior knowledge of the etiology was considered an exclusion criterion. Results LUS concurred with the ANL in the diagnosis of abnormal vs normal larynx in 28/32 children that were recruited. LUS had a sensitivity and specificity of 87% (95% CI: 69%–96%) and 100% (95% CI: 16%–100%) respectively, for diagnosing overall laryngeal disorders in comparison to ANL. LUS also had an area under the receiver operating characteristic (ROC) curve (AUC) of 0.93, (P = 0.04, 95% CI: 0.84–1). Conclusion LUS may be applied as an adjuvant diagnostic tool for ruling in laryngeal pathologies in children including dysphonia and stridor. As further experience is acquired the value of LUS in diagnosis will be better understood.

Background Direct laryngoscopy and rigid bronchoscopy are currently performed using 2-dimensional endoscopic systems. Our objective was to determine whether a 3-dimensional endoscopic system can enhance visualization of the surgical field in pediatric direct laryngoscopy and rigid bronchoscopy. Methods A prospective cohort study was conducted. Thirty three children who underwent direct laryngoscopies in a tertiary referral children's hospital were enrolled. Direct laryngoscopy was performed using both 2- and 3-dimensional endoscopic systems, after which the surgeons scored the quality of the images obtained with each system on a scale from 1 (low) to 5 (high). Comparison of the scores obtained with the 2 endoscopic systems was performed. Results The 33 study children (mean age 2.3 years, M:F ratio 1:1.6) underwent 47 direct laryngoscopies. The mean score for visualization of the glottis was 4.8 for the three-dimensional system compared to 4.0 for the two-dimensional system (P = .025), 4.7 vs. 3.8, respectively, (P = .019) for the subglottis, and 4.6 vs. 3.9, respectively (P = .031) for visualization of the proximal trachea. The mean score for visualization of the distal trachea was 3.0 vs. 3.7, respectively (P = .020). In a child with recurrent type 3 laryngotracheal cleft a residual tracheo-esophageal fistula could not be detected using the 2D system, but was immediately detected using the 3D system. Conclusions Visualization of the glottis, subglottis and proximal trachea during direct laryngoscopy using a 3-dimensional endoscopic system was rated by the surgeons as being superior to the conventional 2-dimensional technique. Further outcome studies that will demonstrate the clinical advantage of the 3D technology are highly required. Level of evidence: 2b.

Informed consent is an important part of the surgical process. Based on our clinical experience, we hypothesized that parents providing consent for their children's tonsillectomy do not comprehend all the information that is given to them by the operating surgeon at the time of a conventional consent process.Parents whose children were scheduled for tonsillectomy with or without adenoidectomy and/or tympanostomy tubes insertion were enrolled. Within one hour after the consent process, they were asked to complete a questionnaire designed to collect demographic data and to evaluate how much of the information that was given to them was actually understood.Ninety-seven parents were enrolled between October 2011 and March 2013. The average percentage of correct answers (score) for the 16 multiple-choice questions was 76.3%. The average scores were 84.8% for the native Hebrew-speaking parents and 71.9% for the parents whose first language was other than Hebrew (p 0.01). The average scores were 83.3% for the parents who are healthcare system workers and 74.4% for those parents whose profession is not related to medicine (p 0.05). Fifty parents (51.5%) responded incorrectly to at least one of two questions that we defined as essential: "What would you do if your child starts to bleed from the mouth" and "What kind of food is recommended for your child during the first week after the surgery".The current conventional method of obtaining informed consent for tonsillectomy is inadequate, as reflected by the low level of parental comprehension of essential information. Further studies which will evaluate methods for improving the consent process are highly warranted.

Introduction An accepted screening question for Obstructive Sleep Apnea (OSA) in children is “Does your child snore”. However, this has no correlation to severity. The purpose of this study is to evaluate a simple 2-item questionnaire that reflects the degree of parental concern to predict the severity of Obstructive Sleep Apnea (OSA) in children as measured by Polysomnography (PSG). Methods Prospective analysis of parental concern regarding their children referred for PSG due to suspected OSA. Parents of all study children completed the brief Parental Concern Scale (PCS) questionnaire that we devised and the validated Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder questionnaire (PSQ-SRBD). The PCS consisted of 1 question on the need for surgery and 1 question on concerns about the child's breathing. Both questionnaires were compared to PSG results. Results Ninety-five children (mean age 4.2 ± 2.5 years, 52% males, mean body mass index z score 0.45 ± 1.8) were recruited. Twenty-three children (24%) had moderate-severe OSA and were referred for adenotonsillectomy. Correlations were found between the need for surgery score and the apnea-hypopnea index (r = 0.22, P = .029), as well as the mean SpO2 levels (r = −0.24, P = .02). The likelihood for the diagnosis of moderate-severe OSA by PSG increased as parental ranking for the need for surgery increased (P = .003). The need for surgery score was the only predictor for moderate-severe OSA (P = .039). Conclusion Querying parents on their perception of their child's need for surgery is a practical, and easy-to-use tool that can help the clinician in prioritizing referral to PSG.

Objective Evaluate the inter-observer correlation of sleep endoscopy findings in children with persistent obstructive sleep apnea (OSA) with awake office fiber-optic endoscopy. Method Design: retrospective case series; blinded review. Setting: tertiary care children's hospital. Patients: Children with persistent obstructive sleep apnea. Interventions: Both awake and drug induced sleep endoscopy were performed. Endoscopy video recordings were mixed at random on a DVD. Two pediatric otolaryngologists and two pediatric pulmonologists independently scored each recording using an upper airway endoscopy scoring survey. Main outcome measures: reviewers scored the following parameters: each structure's contribution (nose, nasopharynx, lateral pharyngeal walls, tongue base, supraglottis) to the obstruction, the main site in which the obstruction occurs, the severity of OSA (mild, moderate, severe), the level of confidence of endoscopy findings (poor, fair, good). Results When reviewing sleep endoscopy recordings for the upper airway obstruction site, the highest correlation among the four observers was found for the nasopharynx and the supraglottis (Kappa score: 0.6 and 0.5, respectively). Compared to awake endoscopy, sleep endoscopy demonstrated more cases of airway obstruction caused by collapse of lateral pharyngeal walls and base of tongue (McNemar test for symmetry, P value Conclusions Sleep endoscopy is a consistently reliable tool for identifying the site of obstruction in children with persistent OSA. Though anesthetic induced sleep is not a perfect model for real sleep, the technique demonstrably guides further therapy better than awake endoscopy.

Complications from a prolonged nasogastric tube intubation, though seldom reported, are well described. Herein we describe the first two reported cases of velopharyngeal insufficiency secondary to velopharyngeal scarring and immobility from repetitive nasogastric tube insertions and prolonged use. Differing only in location, the proposed pathophysiologic mechanism of injury is identical to that of the nasogastric tube syndrome, a rare and serious, well described entity consisting of bilateral vocal fold paralysis due to pressure-induced ulceration of the posterior cricoarytenoid musculature.

To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy.A retrospective chart review.Tertiary-care, university affiliated children's hospital.One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002.All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call.Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions.Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR.These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

Rationale Fiberoptic flexible laryngoscopy (FFL) is the diagnostic procedure of choice in patients with laryngomalacia. Two techniques can be applied, either when the infant is awake or using anesthesia/sedation. The choice of technique may effect the diagnosis. Study objectives To compare the two techniques for diagnosing laryngomalacia. Patients and interventions A total of 42 infants who underwent awake fiberoptic laryngoscopy for congenital stridor, in whom either laryngomalacia was diagnosed or no cause for stridor was found, underwent a repeat laryngoscopy using anesthesia/sedation. The 84 video recordings of the supraglottic portions were copied onto a videotape along with 25 recordings of normal upper airways without stridor and 31 duplicate cases with stridor. A total of 140 recordings was mixed at random on a videotape. Sound was not included. Measurements Three investigators (Y.S., J.B.A., and A.D.) independently scored each recording using a laryngomalacia scoring system (scoring range, 0 to 8). Results A threshold score of 2 was the optimal cutoff point for discriminating laryngomalacia from normal condition. The awake technique (WT) missed three cases of laryngomalacia and overdiagnosed one healthy control subject. The anesthesia technique was superior with a sensitivity of 100%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 100% compared with 93%, 92%, 97%, and 79%, respectively, for the WT. Conclusions The diagnosis of laryngomalacia with FFL is more accurate using anesthesia/sedation. The WT may be appropriate for screening or for patients with mild cases having a characteristic presentation.

Summary Objective: Adenotonsillar hypertrophy (ATH) is the leading cause for obstructive sleep apnea syndrome (OSAS) in children. The peak age for adenoid and tonsillar hypertrophy and related OSAS is 3/6 years. It has been suggested that OSAS due to ATH is extremely rare in infants. The purpose of the present study was to delineate OSAS due to ATH in infants. Methods: Twenty-nine consecutive infants B/18 months of age who underwent polysomnography (PSG) and were diagnosed with OSAS due to ATH were studied. A pediatric sleep questionnaire was completed by parents of all infants. Information regarding demographic variables, referring physician specialty, assessment of infant’s development and recurrence of symptoms post treatment was collected. Pre and post surgery body weight and developmental assessment by parents were evaluated. Results: The mean age of adenotonsillectomy was 12.39 /3.9 months with the mean duration of symptoms ranging 6.29 /3.0 months. 24% of the infants were born preterm. Snoring was the most common finding and appeared in all infants. Other symptoms were sleep apnea (72%), frequent movements during sleep (69%), mouth breathing (62%) and recurrent awakenings (38%). During the preoperative period, mean body weight decreased from the 67th9 /25 percentile to the 42nd9 / 32 percentile (P B/0.00001). 14/29 (48%) of the infants dropped two or more major percentiles before treatment. A significant weight gain to the 59th9 /31 percentile was observed post surgery (P B/0.0001). 5/29 (17%) infants were considered by their parents as having a developmental delay preoperatively, which resolved in 3/5 (60%) post treatment. Clinical symptoms resolved or improved significantly after surgery. Recurrence of symptoms was documented in 6/23 (26%) of infants. Conclusions: Infantile OSAS due to hypertrophic adenoids and tonsils does occur in infants. Unique characteristics for this age group include: male predominance, high incidence of preterm infants, failure to gain weight and high recurrence rate after surgery. Otolaryngologists and pediatricians should be aware to the existence of the ‘‘early OSAS’’ in small infants.

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascularized, locally aggressive benign tumor, occurring almost exclusively in young men. The tumor is assumed to originate in the sphenopalatine foramen area. Tumor invasion to the nasal cavity, paranasal sinuses, orbit, pterygomaxillary fossa, infratemporal fossa, cheek, cavernous sinus, and anterior or middle cranial fossa may occur. Blood supply to the tumor most commonly arises from the internal maxillary artery. A variety of surgical techniques to the facial skeleton and the skull base are now well established; this is mainly the result of improved preoperative imaging assessment, technical advances in tumor resection and reconstruction, improved postoperative care, and the cooperation of multidisciplinary teams. In children and adolescents with JNA, we have used the combined midfacial degloving/transmaxillary approach and the facial translocation technique. The preoperative evaluation, surgical technique, advantages, and limitations of these approaches will be detailed.

Choanal atresia (CA) is a congenital anomaly, with an incidence of 1:5,000–8,000 births. It occurs more frequently in girls than boys and is more often unilateral than bilateral. The presenting symptoms vary from mild airway obstruction in unilateral disease to acute respiratory distress in bilateral atresia. The diagnosis is based on endoscopy and computed tomography scan. In this report, we review the variety of surgical procedures that have been proposed for CA repair, including transnasal puncture, transnasal drillout, transseptal, transpalatal, and endoscopic transnasal technique. Special attention is given to endoscopic technique with powered instrumentation, which is the technique routinely used in our institution. During the past 2 years we performed 10 endoscopic CA repairs, including 1 revision. One case was navigation-assisted. We have used endoscopic equipment in all cases, including revisions, with an initial success rate of 80%. The described approach is chracterized by low morbidity and an immediate alleviation of the child's nasal obstruction, with a prompt return to normal diet and breathing. We believe that endoscopic technique is the best approach available today, and it should be used in primary repair as well as in revisions.

Tongue base collapse is a problematic component of obstructive sleep apnea from a surgical point of view. Current surgical technique requires invasive surgery with related morbidity. Presented in this article is initial experience with a new minimally invasive technique that achieves stabilization of the tongue base. This technique uses a soft tissue to bone anchor inserted intra-orally into the mandible with an attached Prolene (Ethicon Endo-Surgery, Inc, Cincinnati, OH) 1-0 suture that is passed through the tongue. After incorporation of the suture in the tongue musculature rigidity is added to the airway. This procedure can be performed alone or as part of a comprehensive multilevel approach in obstructive sleep apnea surgery.

A 2-year-old boy presented with varices and a neck mass. Imaging studies revealed internal jugular vein aneurysm. Gradual increasing of the mass, potential thrombus formation and cosmetical considerations were indications for surgery. At surgery aneurysms of both the external and internal jugular veins were found and resected.