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Elexis Hollingsworth,1,2 Benjamin H Shields,2,* Christopher Rutter,2,3,* Lynn Fox,4 Kelly N Evans,5 Jay Paul Willging,6 Amelia F Drake2 1School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; 2Department of Otolaryngology/Head and Neck Surgery, UNC Hospitals, Craniofacial Center, University of North Carolina, Chapel Hill, NC, USA; 3University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA; 4Adams School of Dentistry, UNC Craniofacial Center, University of North Carolina, Chapel Hill, NC, USA; 5Division of Craniofacial Medicine, Seattle Children’s Hospital, Seattle, WA, USA; 6Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA*These authors contributed equally to this workCorrespondence: Elexis Hollingsworth, UVA Health, Department of Anesthesiology, 1215 Lee St. Box 800710, Charlottesville, VA, 22908‐0816, USA, Fax +1 434‐982‐0019, Email eh6cm@uvahealth.orgObjective: In the USA, the American Cleft Palate Association-Craniofacial Association (ACPA-CPF) specifies guidelines to ensure craniofacial teams function in a multidisciplinary fashion to provide care in a sequence that mirrors the patient’s needs. Among these guidelines is the expectation that teams hold regular multidisciplinary team meetings to discuss patient care. The purpose of this study was to identify factors that contribute to optimal team functioning during these meetings. The impact of the virtual format on meetings was also evaluated.Design: One-hour semi-structured interviews of craniofacial team members, queried on current and ideal team meetings, were conducted from December 2020 – January 2021. Interviews were recorded, transcribed, and coded to identify common themes until thematic saturation was achieved.Setting/Participants: Sixteen team members from three major American craniofacial centers were interviewed virtually.Results: Three major categories were identified as integral to successful meetings: (1) meeting content, (2) meeting processes, and (3) team dynamics. Within these categories are several factors that participants reported as important to optimize their multidisciplinary meetings: key content for discussions, integration of patient perspective, recognition of collaboration in determining proper sequence of treatments, an attentive discussion leader promoting equitable discussions, managing absences, and team diversity. Participants also identified benefits and pitfalls of hosting meetings in the virtual setting, including lack of engagement and awkward communication.Conclusion: Diverse groups of disciplines are expected to come together during craniofacial multidisciplinary meetings to formulate intricate care plans for complex patients. In this study, craniofacial team members have identified several key factors to optimize these meetings. The research group used these factors to propose a self-evaluation instrument for meeting quality improvement, provided in printable format. Further studies should evaluate how implementation of these factors affects meetings and ultimately guides patient care.Keywords: cleft lip-palate, multidisciplinary, interdisciplinary, teamwork, self-evaluation, virtual

Background: The purpose of this study was to evaluate the incidence of vocal cord (VC) and swallowing dysfunction in infants after the Norwood operation and to examine the relationship between laryngopharyngeal dysfunction and postoperative outcomes., Methods: We conducted a retrospective review of 63 infants who underwent routine postoperative fiberoptic endoscopic evaluation of swallowing function and vocal cords after a Norwood operation at our institution during a recent 6-year period (2003-2009)., Results: The overall incidence of VC dysfunction after the Norwood operation was 58.7%. After a modification of the aortic arch dissection technique in 2007, the incidence of VC dysfunction decreased significantly from 79.5% in 2003 through 2006 to 25% in 2007 through 2009 (p<0.001). The incidence of swallowing dysfunction also decreased from 23.1% in 2003 through 2006 to 4.2% in 2007 through 2009 (p=0.07). Swallowing dysfunction was more common in patients with VC dysfunction (21.6%) as compared with patients without VC dysfunction (7.7%; p=0.18). Patients with VC dysfunction were more often discharged home on tube-only feeding regimens compared with infants without VC dysfunction (46% versus 26.9%). In infants with both VC and swallowing dysfunction, 75% were discharged exclusively to have tube feeding. Median hospital length of stay tended to be longer in infants with swallowing dysfunction (31 days) than in infants without swallowing dysfunction (23 days; p=0.16)., Conclusions: Vocal cord and swallowing dysfunction are common in infants after the Norwood operation and may increase the need for tube feeding regimens. Modification of surgical techniques for dissection and mobilization of the aorta can significantly reduce the incidence of these adverse outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Behavior in response to distressful events during outpatient pediatric surgery can contribute to postoperative maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, and attention seeking. Currently available perioperative behavioral assessment tools have limited utility in guiding interventions to ameliorate maladaptive behaviors because they cannot be used in real time, are only intended to be used during 1 phase of the experience (e.g., perioperative), or provide only a static assessment of the child (e.g., level of anxiety). A simple, reliable, real-time tool is needed to appropriately identify children and parents whose behaviors in response to distressful events at any point in the perioperative continuum could benefit from timely behavioral intervention. Our specific aims were to (1) refine the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to improve its reliability in identifying perioperative behaviors and (2) validate the refined PACBIS against several established instruments., Methods: The PACBIS was used to assess the perioperative behaviors of 89 children aged 3 to 12 years presenting for adenotonsillectomy and their parents. Assessments using the PACBIS were made during perioperative events likely to prove distressing to children and/or parents (perioperative measurement of blood pressure, induction of anesthesia, and removal of the IV catheter before discharge). Static measurements of perioperative anxiety and behavioral compliance during anesthetic induction were made using the modified Yale Preoperative Anxiety Scale and the Induction Compliance Checklist (ICC). Each event was videotaped for later scoring using the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) and Observational Scale of Behavioral Distress (OSBD). Interrater reliability using linear weighted kappa (kappa(w)) and multiple validations using Spearman correlation coefficients were analyzed., Results: The PACBIS demonstrated good to excellent interrater reliability, with kappa(w) ranging from 0.62 to 0.94. The Child Coping and Child Distress subscores of the PACBIS demonstrated strong concurrent correlations with the modified Yale Preoperative Anxiety Scale, ICC, CAMPIS-SF, and OSBD. The Parent Positive subscore of the PACBIS correlated strongly with the CAMPIS-SF and OSBD, whereas the Parent Negative subscore showed significant correlation with the ICC. The PACBIS has strong construct and predictive validities., Conclusions: The PACBIS is a simple, easy to use, real-time instrument to evaluate perioperative behaviors of both children and parents. It has good to excellent interrater reliability and strong concurrent validity against currently accepted scales. The PACBIS offers a means to identify maladaptive child or parental behaviors in real time, making it possible to intervene to modify such behaviors in a timely fashion.

Lingual hamartoma is a rare tongue mass, primarily diagnosed in childhood. In most cases in the literature, the masses were surgically removed without preoperative imaging. There are only 3 cases reported in the clinical literature that describe preoperative imaging findings. We report the clinical and imaging findings in an infant with lingual hamartoma and review the literature.

Chronic pulmonary aspiration (CPA) in children is an important cause of recurrent pneumonia, progressive lung injury, respiratory disability and death. It is sporadic, intermittent and variable, and often occurs in children with complicated underlying medical conditions and syndromes that produce symptoms indistinguishable from CPA. For most types of aspiration there is no gold-standard diagnostic test. The diagnosis of CPA is currently made clinically with some supporting diagnostic evaluations, but often not until significant lung injury has been sustained. Despite multiple diagnostic techniques, the diagnosis or exclusion of CPA in children is challenging. This is of particular concern given the outcome of unrecognised progressive lung injury and the invasiveness of definitive therapies. Although new techniques have been introduced since the 1990s and significant advances in the understanding of dysphagia and gastro-oesophageal reflux have been made, characterisation of the aspirating child remains elusive.

Obstructive sleep apnea (OSA) has been shown to be an independent risk factor for cardiovascular disease in adults. However, there are severe limitations in the extent to which the cardiovascular consequences of OSA are being studied in children. To investigate the echocardiographic changes in children with OSA, right and left ventricular (RV, LV) dimensions and LV mass index and geometry were measured in 28 children with OSA and 19 children with primary snoring (PS). The study showed that LV mass index and relative wall thickness were greater in the OSA group compared with those with PS (p = 0.012 and p < 0.0001, respectively). An apnea-hypopnea index of more than 10 per hour was significantly associated with RV dimension above the 95th percentile (odds ratios, 6.7; 95% confidence interval, 1.4-32) and LV mass index above the 95th percentile (odds ratios, 11.2; confidence interval, 1.9-64). Abnormality of LV geometry was present in 15% of children with PS compared with 39% of children with OSA. We conclude that OSA in children is associated with increased LV mass.

Ninety-six children received morphine 0.1 mg/kg (n = 47) or ketorolac 1 mg/kg (n = 49) intravenously (IV) in a prospective, randomized, double-blind fashion, after tonsillectomy. Recovery variables and complications were recorded while subjects were in the hospital and parent(s) were contacted 24 h and 14 days after surgery. There were no differences in demographics, surgical management, awakening time, oxygen requirements, or time to readiness for postanesthesia care unit (PACU) discharge or discharge home between the two groups. Ketorolac subjects had fewer emetic episodes than morphine subjects (median 1 vs 3; P = 0.006) and were less likely to have more than two episodes of emesis after PACU discharge (9/49 vs 22/47; P = 0.007). Ketorolac subjects had more major bleeding (bleeding requiring intervention; 5/49 vs 0/47, one-tailed P = 0.03) and more bleeding episodes (0.22 episodes/subject vs 0.04 episodes/subject, P < 0.05) in the first 24 h after surgery, but no greater overall incidence of bleeding than the morphine subjects. In children having tonsillectomy, ketorolac, compared to morphine, reduced the number of emetic episodes after PACU discharge, but did not hasten awakening, readiness for PACU discharge or discharge home, and increased the likelihood of major bleeding in the first 24 h after surgery.