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Insertion of tubes in an office setting and automated tube insertion devices were identified as high-priority quality improvement opportunities during the update process for the 2013 clinical practice guideline on tympanostomy tubes from the American Academy of Otolaryngology-Head and Neck Surgery. The guideline update group, however, decided to avoid any recommendations on these topics, based on limited research evidence, and instead selected a subset of group members to author this state of the art review, with the goal of facilitating informed decisions in clinical practice.PubMed through September 2021, Google search of device manufacturer websites, and SmartTots research website for articles on anesthesia neurotoxicity.A state of the art review format emphasizing evidence from the past 5 years, with manual cross-checks of reference lists of identified articles for additional relevant studies.The existing literature is too sparse to make recommendations about procedure setting and optimal technique or assess long-term outcomes. The role of automated devices is uncertain, given the increased equipment cost and limited information on characteristics of the proprietary preloaded tubes, including intubation duration and rates of otorrhea, obstruction, medialization, granulation tissue, and persistent perforation.Whether to undertake in-office tube insertion in awake children should be based on clinician experience, clinician ability to interact with and reassure caregivers, shared decisions with caregivers, and judgment regarding the level of cooperation (or lack thereof) to be expected from a given child. Clinicians should remain alert to new research and expect increasing queries from patients and families.

Paradoxical vocal fold motion (PVFM) is not well-characterized in infants. Sex- and race/ethnicity-based differences have been described in older children with PVFM. This study's objectives are to characterize demographic and clinical characteristics of infants diagnosed with PVFM and investigate sex- and race-specific differences in presentation.We retrospectively reviewed infants ≤1 year of age diagnosed with PVFM at our institution from 2009 to 2019. Patient demographics, symptoms, and findings on flexible laryngoscopy are described. Sex- and race/ethnicity-based differences were assessed using Fisher's exact test analyses.We identified 22 infants who were diagnosed with PVFM. The average age (range) at diagnosis was 5.7 (0.25-12.0) months, and 45.5% were male. The majority (54.6%) of patients identified as non-Hispanic White. Common comorbidities included GERD (45.5%) and chronic rhinitis (13.6%). Stridor was the only presenting symptom in the majority of patients (95.4%). The most common episode triggers were crying (45.5%), feeding (27.3%), and gastric reflux (9.1%). On flexible laryngoscopy, PVFM was observed in 95.5% of patients. A third of patients (31.8%) were misdiagnosed as having reactive airway disease or laryngomalacia prior to evaluation by otolaryngology. No sex- and race/ethnicity-based differences in presentation were identified.We present the largest case series of PVFM in infants. We found sparse clinical signs/symptoms other than stridor and a high incidence of misdiagnosis, which supports the importance of objective flexible laryngoscopy for the evaluation of stridor in this age group. Previously reported sex- and race/ethnicity-based differences in presentation of PVFM were not observed in this cohort of infants.

This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 "Clinical Practice Guideline: Nosebleed (Epistaxis)." This guideline uses research to advise doctors and other health care providers on the diagnosis, treatment, and prevention of nosebleeds. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.

This executive summary of the guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The summary and guideline are intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals.The purpose of this executive summary is to provide a succinct overview for clinicians of the key action statements (recommendations), summary tables, and patient decision aids from the update of the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline: Tympanostomy Tubes in Children (Update)." The new guideline updates recommendations in the prior guideline from 2013 and provides clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. This summary is not intended to substitute for the full guideline, and clinicians are encouraged to read the full guideline before implementing the recommended actions.The guideline on which this summary is based was developed using methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action," which were followed explicitly. The guideline update group represented the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the termThe purpose of this clinical practice guideline update is to reassess and update recommendations in the prior guideline from 2013 and to provide clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. In planning the content of the updated guideline, the guideline update group (GUG) affirmed and included all the original key action statements (KASs), based on external review and GUG assessment of the original recommendations. The guideline update was supplemented with new research evidence and expanded profiles that addressed quality improvement and implementation issues. The group also discussed and prioritized the need for new recommendations based on gaps in the initial guideline or new evidence that would warrant and support KASs. The GUG further sought to bring greater coherence to the guideline recommendations by displaying relationships in a new flowchart to facilitate clinical decision making. Last, knowledge gaps were identified to guide future research.In developing this update, the methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action" were followed explicitly. The GUG was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.The GUG made

Objectives Postoperative hemorrhage is a serious complication of tonsillectomy, with secondary bleeding rates affecting up to 0.8% to 3% of patients. Although these bleeds are anecdotally perceived as occurring more frequently at night, the occurrence of hemorrhage relative to the time of day has not been investigated. We measured the frequency of post-tonsillectomy hemorrhage onset relative to the time of day. Methods We reviewed electronic medical records of all patients who experienced postprocedural hemorrhage (International Classification of Disease, Ninth Edition [ICD-9] 998.11, ICD-10 J95.830 at two hospitals within a tertiary academic health system in a 10-year period). Patient demographics, time of bleed onset, emergency room [ED] arrival time, and management (operating room vs. observation) were abstracted. Patients without a recorded bleeding time were excluded. Time of bleed onset was categorized as morning (6:01 am-12 pm), afternoon (12:01 pm-6 pm), evening (6:01 pm-12 am), or overnight (12:01 am-6 am). Chi-square goodness of fit test was used to assess the distribution of hemorrhage timing (P ≤ 0.05). Results A total of 7,396 patients underwent tonsillectomy May 2008 through May 2018, among whom 121 (2%) post-tonsillectomy hemorrhage patients were identified. Among the 104 patients with ED arrival times, 29 (28%) arrived in the morning; 15 (14%) arrived in the afternoon; 40 (38%) arrived in the evening; and 20 (19%) arrived overnight (P = 0.003). Sixty patients (mean age 17.1 years, standard deviation 16.6) had a recorded timing of bleed onset. Bleed onset occurred most commonly overnight (24, 40%), followed by evening (21, 35%), afternoon (11, 18%), and morning (4, 7%) (P = 0.0007). Conclusion In this cohort, post-tonsillectomy hemorrhage occurred most frequently between midnight and 6 am. Our findings confirm anecdotal experience and provide data in setting caregiver expectations. Level of evidence 4 Laryngoscope, 130:1823-1827, 2020.

Rapid response teams have become necessary components of patient care within the hospital community, including for airway management. Pediatric patients with an increased risk of having a difficult airway emergency can often be predicted on the basis of clinical scenarios and medical history. This predictability has led to the creation of airway consultation services designed to develop airway management plans for patients experiencing respiratory distress and who are at risk for having a difficult airway requiring advanced airway management. In addition, evolving technology has facilitated airway management outside of the operating suite. Training and continuing education on the use of these tools for airway management is imperative for clinicians responding to airway emergencies. We describe the comprehensive multidisciplinary, multicomponent Pediatric Difficult Airway Program we created that addresses each component identified above: the Pediatric Difficult Airway Response Team (PDART), the Pediatric Difficult Airway Consult Service, and the pediatric educational airway program. Approximately 41% of our PDART emergency calls occurred in the evening hours, requiring a specialized team ready to respond throughout the day and night. A multitude of devices were used during the calls, obviating the need for formal education and hands-on experience with these devices. Lastly, we observed that the majority of PDART calls occurred in patients who either were previously designated as having a difficult airway and/or had anatomic variations that suggest challenges during airway management. By instituting the Pediatric Difficult Airway Consult Service, we have decreased emergent Difficult Airway Response Team calls with the ultimate goal of first-attempt intubation success.

Objectives/hypothesis Adenotonsillectomy is first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely. Study design Retrospective chart review. Methods We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank-sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea-hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest X-rays (CXRs). Results Mean age was 5.9 (±3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (±23.8) and 80.7% (±9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7-8.5) or CXR (OR, 3.0; 95% CI, 1.4-6.8) compared to OAHI 10-59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1-320.1) and CXR (OR, 4.1; 95% CI, 1.2-14.4). Conclusions Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre-adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre-adenotonsillectomy evaluation and reduce cost. Level of evidence 4 Laryngoscope, 131:2361-2368, 2021.

Objective: Effective delivery of discharge instructions and access to postoperative care play a critical role in outcomes after pediatric surgery. Previous studies in the pediatric emergency department suggest that caregivers with language barriers have less comprehension of discharge instructions despite use of interpretation services. However, the impact of language barriers during discharge on surgical outcomes in a pediatric surgical setting has not been studied. This study examined the effect of parental language during discharge on number and mode of healthcare contact following pediatric adenotonsillectomy. Methods: A retrospective cohort study was conducted on children who underwent adenotonsillectomy at a tertiary care pediatric academic medical center from July 1, 2016 to June 1, 2018. Data were collected on consecutive patients with non-English-speaking caregivers and a systematic sampling of patients with English-speaking caregiver. Surgery-related complications and healthcare contacts within 90 days after discharge were collected. Two-tailed t tests, χ2 tests, and logistic regression were performed to assess the association between parental primary language and incidence of healthcare contact after surgery. Results: A total of 136 patients were included: 85 English-speaking and 51 non-English-speaking. The groups were comparable in age, sex, and comorbidities. The non-English group had more patients with public insurance (86% vs. 56%; P Conclusion: Language barriers at discharge following pediatric otolaryngology surgery is associated with a meaningful difference in how patients utilized medical care. Interventions to improve comprehension and access may help reduce preventable emergency department visits and healthcare costs.

Objective The objective of this retrospective review was to determine the utility of polysomnography (PSG) in influencing the decision to decannulate pediatric patients with brain and spinal cord injuries in an inpatient rehabilitation hospital setting. Methods Between 2010 and 2016, data were collected on pediatric patients with brain and/or spinal cord injuries who had PSG performed with the goal of decannulation. Patients underwent a decannulation protocol involving toleration of continuous tracheostomy capping and bedside tracheoscopy by otolaryngology. Decision to decannulate was determined with input from multiple disciplines. Associations were examined between decannulation success and findings on PSG as well as demographic factors, injury characteristics, otolaryngology findings, and timeline from initial injury to selected events. Results A total of 46 patients underwent PSG, after which 38 (83%) were deemed appropriate and eight (17%) were deemed inappropriate for decannulation. Individuals who were deemed ready for decannulation had significantly lower obstructive apnea hypopnea indexes (AHI) (1.7 vs 5.4 events/h, P = 0.03), respiratory disturbance indexes (RDI) (2.4 vs 7.6 events/h, P = 0.006), and peak end tidal carbon dioxide (CO2 ) levels (50.0 vs 58.7 torr, P = 0.009) on PSG compared to those who were not decannulated. There were no complications following decannulation prior to discharge. Conclusion PSG provided important additional information as part of a multidisciplinary team assessment of clinical readiness for decannulation in pediatric patients with brain and spinal cord injuries who underwent a decannulation protocol. Obstructive AHI, RDI, and peak end tidal CO2 level were associated with successful decannulation prior to discharge from inpatient rehabilitation.

Objectives (1) Describe trends in the diagnosis of ankyloglossia and the use of lingual frenotomy and (2) analyze patient- and hospital-level factors as compared with the total pediatric discharge population. Study Design National database analysis. Methods We reviewed available data from 1997 to 2012 using the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. All weighted pediatric discharges with ankyloglossia, newborn feeding difficulty, or lingual frenotomy were analyzed for variables of sex, payer, zip code median income, hospital ownership, location/teaching status, bed size, region, and children's hospital status. Chi-square analysis with 95% CIs and odds ratio were used to identify differences between the study group and the total database discharge population. Results Diagnosis of ankyloglossia increased each year of publication (every third year)-with 3934, 5430, 7785, 11,397, 19,459, and 32,837 children, respectively, from 1997 to 2012-with the largest increase in the last 6 years. Similarly, frenotomy increased with 1279, 1633, 2538, 3988, 6900, and 12,406 procedures. Compared with the total discharge population, children with ankyloglossia or frenotomy were more often male (63.6% ankyloglossia, 65.3% frenotomy vs 51.2%), privately insured (60.1%, 62.1% vs 43.6%), from a higher median-income zip code (78.1%, 78.2% vs 68.6%), and in Midwest region (29.3%, 32.3% vs 21.7%). Conclusion These pilot data show increases in diagnoses of ankyloglossia and use of frenotomy. There is a preponderance of children who are male, privately insured, or Midwest residents being diagnosed and treated for ankyloglossia. This broad variation may reflect local practice patterns or imply cultural and socioeconomic bias.

Objective Parental role in decision-making has implications for quality of care. We describe roles of parent participation in decision-making for tonsillectomy. Methods Parents reported preferred role in decision-making before consultations for tonsillectomy and the role they experienced after their consult. Parents completed questionnaires, including items evaluating clinician/parent communication. Clinicians rated perception of parents’ preferred role in decision-making. Congruence between parent and clinician responses was evaluated via kappa analysis. Logistic regression identified associations between decision-making roles and socioemotional and communication factors. Results Consults between 63 parents and 8 otolaryngologists were analyzed.There was inadequate agreement between clinician and parent ratings of preferred roles (37%, p = 0.6, 95% CI [-0.09, 0.001]). Parents perceived greater involvement when clinicians discussed reasons to have (OR = 4.3, p = 0.03) or not have (OR = 4.1, p = 0.005) surgery. Parents perceived less involvement when clinicians used jargon (OR = 0.1, p = 0.03), and when parents trusted clinicians (OR = 0.4, p = 0.049), or experienced greater decisional conflict (OR = 0.9, p = 0.03). Conclusions Parents and clinicians perceived parental preference for decision-making involvement differently during consultations for tonsillectomy. Clinician information-sharing, jargon use, and parent trust in clinician predicted extent of perceived engagement. Practice implications Findings may enhance understanding of strategies to effectively communicate and engage parents in shared decision-making for pediatric surgical care.

Importance The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child’s consultation is not known. Objective To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent–clinician communication. Design, Setting, and Participants Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist. Main Outcomes and Measures The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient’s treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents). Results A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as “Other.” Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34). Conclusions and Relevance In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Introduction Despite recent concerns about potential overuse of tympanostomy tube (TT) placement to treat otitis media in children, utilization of this common procedure in the U.S. has been shown to be relatively less common among minority children. It is not known if the indications for TT differ by child race/ethnicity and/or socioeconomic status (SES). Our objective is to analyze the association of patient- and neighborhood-level demographics and SES with clinical indications for TT. Methods We conducted a retrospective chart review of children who underwent TT at single urban academic tertiary pediatric care center in a 6-month period (8/2013-3/2014). Children with congenital anomalies or syndromic diagnoses were excluded (50/137 children, 36.5%). Children were grouped by primary TT indication, recurrent acute otitis media (RAOM) or chronic otitis media with effusion (OME). Group characteristics were compared using t-tests and chi-square analyses, and logistic regression was performed to assess the association between demographics and TT indication. Results 87 children were included in this analysis (mean age = 2.8 years, 1–6 years). The most common indication for TT was RAOM (53%), and these children had a mean of 6 AOM episodes/year. Indications for TT varied significantly by the patient's neighborhood SES (median neighborhood income $70,969.09-RAOM vs $58, 844.95-OME, p-value = 0.009). Those undergoing TT for RAOM were less likely to live in a high-poverty neighborhood (OR = 0.36,p-value = 0.02), whereas children who underwent TT for OME were more likely to live in a high-poverty neighborhood. There was no significant difference in indication by race/ethnicity or insurance type. Conclusions In this population, TT indications differed by SES. Among children receiving tubes, those from high poverty areas were more likely than those from low poverty neighborhoods to receive tubes for the indication of OME as opposed to RAOM. This finding suggests that concerns for appropriate use of TT in the setting of RAOM may be specific to a more affluent population. Future prospective patient-centered research will evaluate cultural and economic influences for families pursuing TT placement, as well as factors considered by physicians who make surgical recommendations.

Identify incidence and factors associated with respiratory complications after type 1 cleft repair.Retrospective chart review of patients who underwent cleft repair over a 5-year period performed by a single surgeon. Primary endpoint was respiratory complications (oxygen desaturation90%). Fisher's exact test was used to identify differences between repair types (endoscopic carbon dioxide laser-assisted repair and injection laryngoplasty). Logistic regression was used to identify predictors of respiratory events.Fifty-five patients were included. Thirty-four (62%) patients underwent endoscopic carbon dioxide laser-assisted repair and 21 (38%) underwent injection laryngoplasty. Average hospital stay for each group was 1.6 days (SD = 3.1) and 0.6 days (SD = 0.9), respectively. Desaturations occurred in three patients (9%) in the laser-assisted repair group and one patient (4%) in the injection group. All occurred within 3 h after surgery and resolved with supplemental oxygen, oral airway placement, and/or mask ventilation. Two affected patients had comorbid diagnosis of asthma (one had poor medication compliance), and one had a history of developmental delay and hypotonia. In the injection group, desaturations occurred in one patient with a history of tracheal stenosis and double aortic arch. No correlation existed between repair type and desaturation (p = 0.57). No variables were significant predictors of events.In this cohort, respiratory events after type 1 laryngeal cleft repair occurred early in the postoperative period, in children with cardiac and pulmonary comorbidities. This suggests postoperative admission may only be necessary for a select group of patients undergoing type 1 cleft repair. However, further research is needed to determine criteria for same-day discharge.

Importance Tonsillectomy is common in children, but little is known about parental preferences and values concerning this surgical procedure. Twitter offers an opportunity to evaluate parental understanding and experience of tonsillectomy care. Objective To identify parental perspectives about tonsillectomy in children that may not be apparent in a routine clinical encounter. Design, Setting, and Participants In this qualitative study, social media platform Twitter was searched for posts (tweets) published between January 1, 2008, and December 31, 2017, by US-based parents about their child’s tonsillectomy. Modified grounded theory was applied to develop a coding taxonomy to classify the tweets. Tweets were assessed for thematic synthesis and classification, and descriptive statistics were obtained for each theme. Main Outcomes and Measures Themes of parental experiences and perspectives about their child’s tonsillectomy. Results Of the 5801 total tweets retrieved, 782 (13.5%) satisfied the inclusion criteria. Tweets were categorized under 2 overarching themes: procedural concerns (549 tweets [70.2%]) and attitudes or experiences (498 [63.7%]). Common tweets under procedural concerns mentioned surgical indication for tonsillectomy (55 tweets [7.0%]); eg, “strep–I think it’s tonsil removing time…”) and recovery (227 tweets [29.0%]), including child’s attitude (89 tweets [11.4%]; eg, “so hard to get my daughter to eat”) and parental experience (87 tweets [11.1%]; eg, “tonsillectomy recovery sucks for the parent as much as the kid!”). Common tweets regarding attitudes or experiences included the tenor of overall care (225 tweets [28.6%]; eg, “Tonsillectomy is a bear”) and fears or apprehensions (209 tweets [26.6%]). Conclusions and Relevance These social media findings may be used to guide clinicians in educating and counseling parents as well as further engaging parents and children in shared decision making for tonsillectomy.

Objective To evaluate follow-up and timing of sleep-disordered breathing diagnosis and treatment in urban children referred from primary care. Study Design Retrospective longitudinal cohort analysis. Setting Tertiary health system. Subjects and Methods Pediatric outpatients with sleep-disordered breathing, referred from primary care for subspecialty appointment or polysomnography in 2014, followed for 2 years. Timing of polysomnography or subspecialty appointments, loss to follow-up, and sleep-disordered breathing severity were main outcomes. Chi-square and t-test identified differences in children referred for polysomnography, surgery, and loss to follow-up. Logistic regression identified predictors of loss to follow-up. Days to polysomnography or surgery were evaluated using the Kaplan-Meier estimator, with Cox regression comparing estimates by polysomnography receipt and disease severity. Results Of 216 children, 188 (87%) had public insurance. Half (109 [50%]) were lost to follow-up after primary care referral. More children were lost to follow-up when referred for polysomnography (50 [76%]) compared with subspecialty evaluation (35 [32%]; P < .001). Children referred to both polysomnography and subspecialty were more likely to be lost to follow-up (odds ratio = 2.73, 95% confidence interval = 1.29-5.78; P = .009). For children who obtained polysomnography, an asymmetric distribution of obstructive sleep apnea severity was not observed ( P = .152). Median time to polysomnography and surgery was 75 and 226 days, respectively. Obstructive sleep apnea severity did not influence time to surgery ( P = .410). Conclusion In this urban population, half of the children referred for sleep-disordered breathing evaluation are lost to follow-up from primary care. Obstructive sleep apnea severity did not predict follow-up or timeliness of treatment. These findings suggest social determinants may pose barriers to care in addition to the clinical burden of sleep-disordered breathing.

Importance The relief of pain after tonsillectomy in children remains challenging and even controversial. While the need for pain control after this surgery is understood, recent debate has centered around the risks of opioids in children with obstructive sleep apnea syndrome (OSAS) and the possible increases in posttonsillectomy hemorrhage with the use of alternative nonsteroidal anti-inflammatory drugs (NSAIDs). Observations We discuss the multiple facets of posttonsillectomy pain control in children. A variety of pharmacologic and nonpharmacologic interventions used before, during, and after surgery are reviewed, presenting the evidence for efficacy and possible adverse effects. We also review the various surgical techniques used in tonsillectomy with a focus on reducing postoperative pain. Conclusions and Relevance Clinicians should understand effective methods of analgesia after tonsillectomy in children, and know the potential consequences of each option. Caution should be employed when using opioids, particularly in young children with severe OSAS. Although large studies of NSAID use have shown effective pain management without an increase in posttonsillectomy bleeding frequency, the potential for more severe bleeding events has been debated. Cold dissection techniques lead to less pain, but hot techniques remain popular, with less intraoperative blood loss and shorter operative time. Partial (intracapsular) tonsillectomy seems to reduce pain as well.

Although chronic rhinosinusitis (CRS) is common in children, the influence of race and socioeconomic status (SES) on the diagnosis/treatment of CRS has not been evaluated. We describe the epidemiology of children with CRS in a pediatric otolaryngology clinic and evaluate demographic differences when compared to a group of children referred for a general pediatric otolaryngology evaluation.Historical cohort study.Tertiary academic care center.All new/consult patients (March 1, 2008-July 1, 2011) in a tertiary pediatric otolaryngology clinic with primary diagnosis of CRS were compared to a control group that consisted of all new/consult patients seen in the same clinic over 3 months. Records were evaluated for variables including age, sex, race, and insurance. Characteristics were compared between groups using Mann-Whitney and Fisher's exact tests.One hundred and seventy-four children with CRS were compared to 430 controls. When compared to the general pediatric otolaryngology population, children with CRS were older (8.2 ± 4.4 years vs 5.9 ± 4.8 years; P.0001) and more commonly male (63% vs 52%; P = .018). When compared to controls, children with CRS were more likely to be white (CRS 77% white, 10% black, 13% other vs control 47% white, 33% black, 20% other; P.0001, risk ratio [RR] = 2.7; 95% confidence interval [CI], 2.0-3.7). Likewise, children with CRS were less commonly insured with medical assistance (CRS 14% vs control 44%; P.0001; RR = 0.3; 95% CI, 0.21-0.45).When compared to the general population of children seen in this academic urban pediatric otolaryngology setting, children with CRS were more likely to be white and privately insured. This study is the first to evaluate race and SES in relationship to pediatric CRS. Future research should employ nationally representative data to assess the true demographic variation in children with CRS.

Objectives/Hypothesis To evaluate the accuracy of three-dimensional (3D) airway reconstructions obtained using quantitative endoscopy (QE). We developed this novel technique to reconstruct precise 3D representations of airway geometries from endoscopic video streams. This method, based on machine vision methodologies, uses a post-processing step of the standard videos obtained during routine laryngoscopy and bronchoscopy. We hypothesize that this method is precise and will generate assessment of airway size and shape similar to those obtained using computed tomography (CT). Study Design This study was approved by the institutional review board (IRB). We analyzed video sequences from pediatric patients receiving rigid bronchoscopy. Methods We generated 3D scaled airway models of the subglottis, trachea, and carina using QE. These models were compared to 3D airway models generated from CT. We used the CT data as the gold standard measure of airway size, and used a mixed linear model to estimate the average error in cross-sectional area and effective diameter for QE. Results The average error in cross sectional area (area sliced perpendicular to the long axis of the airway) was 7.7 mm2 (variance 33.447 mm4). The average error in effective diameter was 0.38775 mm (variance 2.45 mm2), approximately 9% error. Conclusion Our pilot study suggests that QE can be used to generate precise 3D reconstructions of airways. This technique is atraumatic, does not require ionizing radiation, and integrates easily into standard airway assessment protocols. We conjecture that this technology will be useful for staging airway disease and assessing surgical outcomes. Level of Evidence N/A. Laryngoscope, 123:2880–2887, 2013

We describe the management of posterior trachea tears after blunt neck trauma in two children. The first, a 5 year-old boy who fell off his scooter, causing a 1.0cm tear in the membranous cervical trachea, was managed conservatively with 5 days of intubation. The second, a 12 year-old girl who fell on her bicycle, causing a 4.0cm tear in the membranous thoracic trachea, was repaired with thoracoscopic techniques. The presumed mechanism may be expansion of the U-shaped cartilage with tear of the membranous trachea. The size, location, and severity of symptoms dictate the decision about primary repair versus conservative management.

Importance Parental decision making about adenotonsillectomy (AT) for obstructive sleep-disordered breathing (oSDB) is associated with decisional conflict that may be alleviated with improved knowledge about symptoms and treatments. Objective To develop a measure of parental knowledge about oSDB and AT. Design, Setting, and Participants A sequential design was used for scale development. A prototype measure containing 9 oSDB and AT themes and 85 items was administered in survey format via an online platform. Participants included 19 clinician experts (otolaryngologists and pediatricians) and 13 laymen (parents of children who snore or do not snore, and other adults). Quantitative and qualitative responses were used to modify the measure and create the knowledge scale. Content validity of the scale was established through expert feedback and evaluation. Criterion validity was established with t test comparisons of experts with laymen. Reliability of the responses was assessed with Cronbach α testing. Main Outcomes and Measures An 85-item prototype measure and 39-item modified measure were evaluated for consensus/approval and psychometric integrity. Results Of 45 potential participants, 32 individuals (71%) responded to the prototype scale. Respondents included 19 clinician experts (59%) (otolaryngologists and pediatricians) and 13 laymen (41%) (parents of children who snore [n = 8] or do not snore [n = 2] and other adults [n = 3]); demographic data were not collected. Content analysis and qualitative feedback were largely rated positively: 27 respondents (84%) stated that the measure was a good evaluation of knowledge, 30 respondents (94%) commented that the items were clear, and 31 individuals (97%) approved of its organization, although there were several suggestions for rewording and/or addition of response options. Experts identified themes most important for assessing oSDB (symptoms) and AT (experiences: risks and benefits) knowledge. These qualitative comments were used to modify the scale, and items were eliminated if more than 2 were reported as misleading or less than 85% of clinicians provided correct responses. Five themes (oSDB symptoms, treatment options, AT risks, anesthesia, and AT benefits) and 39 items composed the final scale. Experts scored higher than laymen on the oSDB and AT Knowledge Scale for Parents overall (17 [94%] vs 12 [67%]; Cohen d = 1.96; 95% CI, 1.05-2.86) and within all themes, including experiences of children with oSDB (19 [88%] vs 13 [62%]; Cohen d = 1.53; 95% CI, 0.71-2.32), treatment options (19 [97%] vs 12 [68%]; Cohen d = 1.74; 95% CI, 0.88-2.57), AT risks (17 [97%] vs 12 [59%]; Cohen d = 1.94; 95% CI, 1.03-2.83), anesthesia (17 [97%] vs 12 [79%]; Cohen d = 1.09; 95% CI, 0.29-1.88), and AT benefits (17 [95%] vs 12 [67%]; Cohen d = 1.28; 95% CI, 0.46-2.09), demonstrating criterion validity. All responses demonstrated high reliability (Cronbach α = 0.94). Conclusions and Relevance The oSDB and AT Knowledge Scale for Parents is psychometrically sound for use in the assessment of parental knowledge.

Neck masses present as palpable lumps and bumps in children with acquired lesions more common than congenital ones. Assessment of the anatomical site of origin, signal, and contrast enhancement characteristics may help define the etiology of the lesions, eg, developmental, inflammatory, vascular, or neoplastic. The age of the patient along with detailed clinical history and physical exam findings are important element to narrow down the differential diagnosis. The correct final diagnosis is essential to guide treatment as well as the urgency of intervention. The objective of this review is to define the characteristic location, classic and differentiating imaging features of the most frequent congenital and acquired cervical lumps and bumps in the pediatric population.

This article reviews some of the otolaryngologic manifestations of skeletal dysplasias. Achondroplasia is discussed most comprehensively. Skeletal dysplasias are bone and cartilage disorders that disrupt the development of the long bones, craniofacial skeleton, and vertebral column, with the most notable characteristic being short stature. Children with skeletal dysplasias have various medical problems. These children often develop head and neck manifestations of their disorders. Hearing loss, middle ear disease, and respiratory difficulties are seen in these children. Otolaryngologists must be knowledgeable about these disorders to diagnose, treat, and appropriately refer children with skeletal dysplasias.

A hearing screening program was performed to determine the prevalence of hearing loss and abnormal tympanometry in individuals with short-stature skeletal dysplasias attending a national meeting. Behavioral audiometry, otoacoustic emission testing, and tympanometry were used to assess hearing. Failed hearing screen was defined as hearing ≥ 35 dB at one or more frequencies or by "fail" on otoacoustic emissions. One hundred ten of 112 subjects completed the screening. 58 (51.8%) were children. Seventy-three (65.2%) had achondroplasia, 34 (30.4%) had one of 11 other diagnoses, and 5(4.4%) were undiagnosed. 25.8% of children failed hearing screening in one or both ears, while 46.3% of adults failed in one or both ears. 55.1% of adults and 25.0% of children with achondroplasia failed screening. Abnormal hearing was also found in the some patients with spondyloepiphyseal dysplasia congenital (SEDC; 75%), diastrophic dysplasia (66%), and Morquio (66%). Hearing was normal in those with hypochondroplasia, pseudoachondroplasia, and microcephalic osteodysplastic primordial dwarfism. Tympanometry was abnormal in at least one ear in 53.3% of children and 38.5% of adults. Abnormal tympanometry in the absence of functioning tympanostomy tubes was associated with 9.5 greater odds of hearing loss in children and 2.8 greater odds of hearing loss in the total cohort. Only 3 (2.7%) respondents reported the use of hearing aids. Hearing loss and middle ear disease are common in both children and adults with skeletal dysplasia. Adults were more likely to fail hearing screening than children. Abnormal tympanometry is associated with hearing loss. Hearing screening with appropriate intervention is recommended for these patients.

The mainstay of treatment of children with recurrent respiratory papillomatosis has been CO2 laser laryngoscopy. Powered microdebriders allow precise removal of laryngeal lesions without thermal damage. The microdebrider may reduce costs by reducing operative time and limiting the need for expensive laser-related equipment. To compare the use of the microdebrider with that of the CO2 laser in children undergoing surgery for recurrent respiratory papillomatosis, we retrospectively reviewed the charts of 18 patients from 2 institutions covering a treatment period between December 1998 and October 2001. These patients were initially treated with the CO2 laser, but were switched to microdebrider resection during the review period. We recorded the number of procedures, the technique(s) of resection used, and the operative time for each procedure. We identified 18 patients, 11 male and 7 female, ages 18 months to 14 years. A total of 127 procedures were performed with the CO2 laser, and a total of 50 procedures were performed with the microdebrider. The mean number of procedures per patient was 10 (range, 2 to 17 procedures). The mean surgical time per procedure using the CO2 laser was 59.2 minutes (range, 8 to 130 minutes). The mean time per procedure with the microdebrider was 32 4 minutes (range, 12 to 47 minutes). This reduction in operative time was clinically and statistically significant (p = .0001, unpaired Student's t-test). We concluded that microdebrider resection of laryngeal papilloma in children allowed more rapid surgery with potentially reduced treatment costs. Other advantages of this technique include precise excision without thermal injury. Our report details useful refinements of technique with the microdebrider.

Acute otitis media (AOM) is a common disease of childhood. AOM is most appropriately diagnosed by careful otoscopy with an understanding of clinical signs and symptoms. The distinction between AOM and chronic otitis media with effusion should be emphasized. Treatment should include pain management, and initial antibiotic treatment should be given to those most likely to benefit, including young children, children with severe symptoms, and those with otorrhea and/or bilateral AOM. Tympanostomy tube placement may be helpful for those who experience frequent episodes of AOM or fail medical therapy. Recent practice guidelines may assist the clinician with such decisions.

Salivary gland stones (sialoliths) are a common cause of salivary gland enlargement, but such stones are uncommon in children. Low-flow vascular malformations of the head and neck region may develop phleboliths. Phleboliths within a venous malformation may be mistaken for a salivary stone given the similar calcified nature and location. We present two children who were referred to us for evaluation of submandibular gland sialoliths but were found to have venous malformations containing phleboliths. Multiple calcifications, calcifications 1 cm, within a soft tissue mass separate from the substance of the submandibular gland suggest a diagnosis, of phleboliths within a venous malformation as opposed to a sialolith.

UNLABELLED Rational determination of oral airway size in children must account for the oropharyngeal length. We used magnetic resonance imaging (MRI) to measure the distance from the teeth/gums to the prevertebral pharyngeal space and created algorithms to predict this distance based on age, weight, and gender. After institutional review board approval, we reviewed 200 MRI head scans of children 0-17 yr old. Patient information, including midline distance from teeth/gums to prevertebral space (L1) and distance along a perpendicular line from L1 to the epiglottis tip (L2), was recorded. Two groups (Group 1 (n = 100) training group, Group 2 (n = 100) validation group) were then randomly selected from this sample. Predictive models created using Group 1 were tested using Group 2 as the sample group. Oropharyngeal distance was related to age, weight, and gender. A prediction equation using all data was estimated to determine the final model: predicted L1 = 5.51 + 0.25 (age [years]) -0.01 (age2) + 0.02 (weight [kg]) + 0.12 (male). We report equations to predict the oropharyngeal distance based on age, weight, and gender in children. The oral airway size will be 1-2 cm longer than these measurements to position the tooth/lip guard outside the lip. Variability in the distance to the epiglottis must be considered when selecting proper oral airway size for any child. This information will provide the foundation for a more rational determination of the proper oral airway size for infants and children. IMPLICATIONS Age, weight, and gender can be used to predict the length of the oropharynx in children as determined by midline sagittal magnetic resonance image of the airway. Prediction of this length will lead to a more rational determination of proper oral airway size for infants and children and, potentially, more effective airway management.

Objective: Functional laryngeal dyskinesia (FLD) is characterized by signs and symptoms of airway obstruction without anatomic basis. Failure to recognize its features often leads to inappropriate diagnostic studies and therapies. A systematic approach is presented for the recognition and management of patients with this disorder. Design: A retrospective case series at a large, urban tertiary care academic hospital. Methods: Retrospective review of charts of adults and children diagnosed with FLD between 1979 and 1996. Presenting symptoms and signs of FLD were categorized and methods of diagnosis were recorded. Therapeutic interventions and resolution of FLD at follow-up were also analyzed. Results: Ten patients were identified with FLD, seven females and three males, with mean age of 25.9 years at diagnosis (range, 10–59 y). Patients were hospitalized a mean of three times (range, 1 to 6 admissions) before FLD was correctly diagnosed. Nine patients were receiving treatment for asthma prior to diagnosis. Flow volume loops most often showed a fixed extrathoracic inspiratory. Arterial blood gas and radiographic data were essentially normal. The most useful diagnostic test was fiberoptic laryngoscopy, which showed abnormal adduction of the vocal cords on inspiration in the nine patients in this series who underwent laryngoscopy. Conclusions: The authors' experience with FLD shows that its early recognition is associated with fewer interventions and their accompanying risks. A high degree of suspicion is required in these patients, who are often young and well educated. They present with stridor that may disappear while they are asleep or after distraction techniques. Laryngoscope, 108:1520–1523, 1998

Study Objective: To examine factors contributing to successful lightwand (lighted stylet) intubation of infants and children. Design: Prospective observational study. Setting: University hospital. Patients: 125 children under age 10 years presenting for elective surgery. Interventions: Prototype lightwands specifically designed for pediatric patients were used. Intubations were done by anesthesia residents with little or no prior lightwand experience. All attempts were recorded on videotape. In a subgroup of 14 patients, an endoscopic view of the lightwand was also recorded with a flexible nasopharyngoscope. Measurements and Main Results: 125 patients with a mean age of 3.0 years (±2.4 years SD; range: 3 weeks to 9 years) were enrolled. 83.2% were intubated using the lightwand, including 75.5% (34 of 45) of infants weighing less than 10 kg. Of the 21 failed intubations, 8 were due to an inappropriately large endotracheal tube, as recognized during direct laryngoscopy; 4 were due to other reasons discussed; and 9 (persistent vallecular or esophageal entry) could not be explained from videotape analysis. Factors contributing to successful intubation included: (1) use of a shoulder roll and slight head extension; (2) conscientious alignment of airway axes; (3) anterior jaw lift to elevate the epiglottis; and (4) gentle handling of the lightwand to avoid displacing soft tissue. Inability to advance the lightwand despite correct glow is caused by entrapment in the vallecula, hang up of the lightwand on the aryepiglottic folds, subglottic narrowing, or vocal cord closure. Conclusions: Lightwand intubation in children uses both tactile and visual cues regarding the location of the endotracheal tube tip. Attention to detail results in a high level of success among novice users of the pediatric lightwand. Endoscopic and external videotaping gave us a means of monitoring the progress of mechanical skills among novice users.

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tympanostomy Tubes in Children. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed address patient selection, surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes.

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type.The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

a) To determine the need for intensive monitoring on the first operative night of surgery in children undergoing adenotonsillectomy for mild obstructive sleep apnea; b) to examine the effect of narcotics on postoperative obstructive sleep apnea.Randomized, prospective study.University hospital.Children, ranging in age between 1 and 18 yrs, presented to the Pediatric Otolaryngology Clinic for adenotonsillectomy for mild obstructive sleep apnea defined as from one to 15 obstructive apnea events per hour on preoperative polysomnogram.Patients were assigned to receive either a narcotic- or a halothane-based anesthetic for adenotonsillectomy. A postoperative polysomnogram was performed in the pediatric intensive care unit on the first operative night.Eighteen patients were recruited, 15 of whom met inclusion criteria: nine patients received a halothane-based anesthetic and six patients received a fentanyl-based anesthetic. When the data were analyzed by pooling both groups, the differences between pre- and postoperative sleep studies demonstrated a reduction in the number of obstructive events and less severe oxygen desaturations on the operative night. Total sleep time between the two sleep studies decreased from 371 +/- 13 to 304 +/- 14 mins. The number of obstructive apnea events/hr decreased as well. The lowest oxygen saturation measured during rapid eye movement sleep was 78 +/- 5% preoperatively and 92 +/- 1% postoperatively.Our data suggest that children without underlying medical conditions, neuromotor diseases, or carniofacial abnormalities, 1 to 18 yrs of age, who suffer from mild obstructive sleep apnea, have improvements documented by polysomnography on the night of surgery following adenotonsillectomy and do not necessarily need to be monitored intensively. These findings were not significantly affected by the choice of intraoperative anesthetic.

Although dysplasia of inner ear structures in Down syndrome has been reported in several histopathological studies, the imaging findings have not been widely studied. To evaluate the prevalence and clinical significance of inner ear anomalies detected on CT images in patients with Down syndrome. The temporal bone CT images of patients with Down syndrome were assessed for inner ear anomalies; clinical notes and audiograms were reviewed for hearing loss. Logistic regression models were employed to identify which CT findings were associated with sensorineural hearing loss (SNHL). Inner ear anomalies were observed in 74.5% (38/51) of patients. Malformed bone islands of lateral semicircular canal (LSCC), narrow internal auditory canals (IACs), cochlear nerve canal stenoses, semicircular canal dehiscence (SCCD), and enlarged vestibular aqueducts were detected in 52.5% (53/101), 24.5% (25/102), 21.4% (21/98), 8.8% (9/102) and 2% (2/101) of patients’ ears, respectively. IAC stenosis had the highest odds ratio (OR = 5.37, 95% CI: 1.0–28.9, P = 0.05) for SNHL. Inner ear anomalies occurred in 74.5% of our population, with malformed (

Objective To determine the prevalence of hearing loss and abnormal tympanometry in children with skeletal dysplasia. Design Clinical screening program. Setting National convention of the Little People of America. Patients Convenience sample of volunteers aged 18 years or younger with skeletal dysplasias. Interventions Hearing screening with behavioral testing and/or otoacoustic emissions, otoscopy, and tympanometry. Main Outcome Measures A failed hearing screen was defined as hearing 35 dB HL (hearing level) or greater at 1 or more tested frequencies or by a “fail” otoacoustic emissions response. Types B and C tympanograms were considered abnormal. Results A total of 58 children (aged ≤18 years) with skeletal dysplasia enrolled, and 56 completed hearing screening. Forty-one children had normal hearing (71%); 9 failed in 1 ear (16%); and 6 failed in both ears (10%). Forty-four children had achondroplasia, and 31 had normal hearing in both ears (71%); 8 failed hearing screening in 1 ear (18%), and 3 in both ears (7%). Tympanometry was performed in 45 children, with normal tympanograms found in 21 (47%), bilateral abnormal tympanograms in 15 (33%), and unilateral abnormal tympanograms in 9 (20%). Fourteen children with achondroplasia had normal tympanograms (42%); 11 had bilateral abnormal tympanograms (33%); and 8 had unilateral abnormal tympanograms (24%). For those children without functioning tympanostomy tubes, there was a 9.5 times greater odds of hearing loss if there was abnormal tympanometry (P = .03). Conclusions Hearing loss and middle-ear disease are both highly prevalent in children with skeletal dysplasias. Abnormal tympanometry is highly associated with the presence of hearing loss, as expected in children with eustachian tube dysfunction. Hearing screening with medical intervention is recommended for these children.

Objectives/Hypothesis: We sought to determine the effectiveness of powered intracapsular tonsillectomy and adenoidectomy (PITA) in the treatment of children with moderately severe obstructive sleep apnea and to measure changes in quality of life that occur with such treatment. Study Design: Prospective, nonrandomized clinical trial in an academic pediatric otolaryngology practice. Methods: Convenience sample of children ages 3 to 12 years diagnosed with obstructive sleep apnea of moderate severity, defined as an apnea-hypopnea index (AHI) between 5 and 20 on polysomnography. Children with recurrent streptococcal pharyngitis, chromosomal abnormalities, craniofacial abnormalities, neuromotor disease, sickle cell disease, obesity, or coagulopathy were excluded. PITA was performed by using the microdebrider. Polysomnography was performed before surgery and repeated 4 to 8 weeks after surgery. The Obstructive Sleep Apnea (OSA)-18 questionnaire was completed at surgery and at the time of postoperative polysomnography to assess quality of life changes. The main outcome measure was cure of obstructive sleep apnea, as defined by a postoperative AHI of 1 or less for complete cure and less than 5 for partial cure. Improvements in quality of life were assessed by changes in the OSA-18 questionnaire. Results: Nineteen children underwent PITA for moderate obstructive sleep apnea syndrome (OSAS), and 14 completed postoperative polysomnography. All 14 subjects who completed the study achieved at least partial cure. Thirteen of 14 (93%) subjects had a complete cure of OSAS after PITA. The median preoperative AHI was 7.9, and the median AHI after surgery was 0.1. The mean number of arousals per hour before surgery was 9.5, and this was reduced to a mean of 5.6 after surgery. Quality of life measures on OSA-18 also improved, with large improvements in total quality of life scores and in all five domains seen after surgery. Conclusions: PITA cures otherwise healthy children with obstructive sleep apnea of moderate severity, at least in the short-term, as documented by postoperative polysomnography. Improvements in quality of life measures, as documented by changes in OSA-18, were seen in all children as well.

Importance Although children with low socioeconomic status (SES) have increased risk for sleep-disordered breathing (SDB), their access to subspecialty care is often limited. Polysomnography (PSG) is the gold standard diagnostic test used to characterize SDB and diagnose obstructive sleep apnea; however, it is unknown whether SES impacts timeliness of obtaining PSG and surgical treatment with adenotonsillectomy (AT). Objective To evaluate the impact of SES on the timing of PSG, surgery with AT, and loss to follow-up for children with SDB. Design, Setting, and Participants Retrospective cohort analysis conducted in tertiary outpatient pediatric otolaryngology clinics among patients newly evaluated for SDB over a 3-month period who did not have prior PSG ordered and had a minimum of 1-year follow-up. Main Outcomes and Measures Public insurance (Medical Assistance [MA]) was used as a proxy for low SES. Demographics and disposition between groups were compared using t tests and χ 2 analysis. Logistic regression adjusting for disposition and insurance was used to predict loss to follow-up. Days to PSG and days to AT were evaluated using the Kaplan-Meier estimator, and the log-rank test was used to compare distribution of time to events between insurance groups. Results A total of 136 children (without PSG) were evaluated for SDB over the course of 3 months; 62 (45.6%) had MA. Polysomnography was recommended for 55 children (27 of 55 [49%] with MA vs 28 of 55 [50%] with private insurance; P > .99). After the initial visit, 24 of 55 children with PSG requested (44%) were completely lost to follow-up (9 of 27 [33%] with MA vs 15 of 28 [54%] private insurance; P = .34). Children with MA who obtained PSG experienced longer intervals between initial encounter and PSG (mean interval, 141.1 days) than privately insured children (mean interval, 49.9 days) ( P = .001). For those children who ultimately underwent AT surgery after obtaining PSG (n = 14), mean (SD) time to AT was longer for children with MA (222.3 [48.2] days vs 95.2 [66.1] days; P = .001). Conclusions and Relevance Children with public insurance experienced longer intervals from initial evaluation to PSG or surgery. Almost half of patients with PSG requested were lost to follow-up, regardless of SES. These findings suggest that PSG may be a deterrent for definitive care for all children, and particularly for children with public insurance or low SES. This study emphasizes the need to understand factors contributing to disparities surrounding delay in care with PSG and surgery for children with SDB.

Objective: To review the results of a simple technique of closure of persistent tracheocutaneous fistula (TCF) in children. Design: Retrospective case series. Setting: Tertiary pediatric otolaryngology referral center. Patients: Children (age, Interventions: Surgical closure of persistent TCF using multilayered closure of de-epithelialized local tissue. Tracheal dissection was not performed. A thermal hemostatic scalpel was used in some cases to assist in de-epithelialization and provide hemostasis without electrocautery near the airway. Main Outcome Measures: Success of closure and number and types of complications. Results: Nine procedures were performed in 8 children. Seven (88%) of 8 primary procedures were successful, but early recurrent TCF developed in 1 patient. Revision surgery using an identical surgical technique, but maintaining endotracheal intubation for 48 hours, was successful in this patient. No complications occurred. Conclusions: This procedure is a simple, reliable method for closure of TCF in children. Arch Otolaryngol Head Neck Surg. 1997;123:1066-1068.

The diagnosis of obstructive sleep apnea in children requires clinical suspicion supplemented with the use of specific diagnostic tests. Polysomnography remains the key to diagnosis, and helps to assess the need for treatment, the risk for perioperative respiratory compromise, and the likelihood of persistent OSAS after treatment. Adenotonsillectomy is the mainstay of treatment, although children with complex medical conditions that affect upper airway anatomy and tone may require additional treatment.

To summarize the radiologic findings in our series of immunocompetent children with NTMA and to review the clinical and laboratory findings, as well as the treatment and clinical courses, in these patients. We reviewed the computed tomographic (CT) studies, as well as the clinical courses of eleven patients with laboratory-confirmed diagnosis of NTMA, and recorded the anatomic locations of the affected lymph nodes. In 10 of 11 patients, there were peripherally enhancing, centrally cystic nodes. In 7 of the patients, there was (usually mild) inflammation of the regional fat and overlying skin thickening. Adenopathy in the parotid and submandibular regions was most common. In 4 of the patients, there was more than one nodal group involved. In a child who presents with enlarging neck masses and with radiologically demonstrated centrally cystic nodal masses exhibiting relatively little mass effect or inflammatory change in the surrounding fat, the diagnosis of NTMA should be entertained.

Objective To describe the clinical manifestations of latex allergy in otolaryngology patients. Design Descriptive case series. Setting Tertiary academic otolaryngology practice. Patients Otolaryngology patients with documented allergic reactions to latex during surgery and confirmatory laboratory test results for latex allergy. Main Outcome Measures Clinical description of latex reactions; identification of risk factors for latex allergy. Results We describe 3 patients, 2 children and 1 young adult, with severe latex allergy manifested by intraoperative cardiorespiratory changes and confirmed by positive latex-specific IgE test results. A 9-year-old boy with a tracheotomy and a history of multiple procedures for laryngeal stenosis developed a rash and unexplained bronchospasm during an open laryngeal procedure. Surgery was aborted, and subsequent surgery was performed uneventfully 4 weeks later using a latex-safe environment. A 13-year-old boy with recurrent respiratory papillomatosis and a ventriculoperitoneal shunt had sudden unexplained arterial oxygen desaturation and a rash during laser endoscopy. He was then treated successfully using latex-safe protocols. A 23-year-old man with a parotid malignancy developed unexplained hypotension and ventilatory difficulties in the operating room during preparation for surgery. He responded to medical treatment for anaphylaxis. Conclusion The otolaryngologist should share in the increased awareness of latex allergy. Our patients who have had multiple surgical procedures or who are exposed to latex on a long-term basis may be at increased risk. Latex allergy should be considered when unexplained cardiorespiratory compromise occurs during surgery.

The differential diagnosis of dysphagia in children is widespread. Dysphagia is defined here as any process that produces difficulty with active transport of food and liquid from mouth to stomach. This article divides diagnostic pediatric dysphagia into categories including congenital, infectious/inflammatory, systemic, neoplastic, traumatic, and miscellaneous causes (Table 1).

Objective: To determine the usefulness and safety of the laryngeal mask airway (LMA) as an adjunct to pediatric flexible fiberoptic bronchoscopy (FOB). Design: A case-series retrospective study. Setting: Pediatric otolaryngology tertiary referral center, outpatient and inpatient operating suites. Patients: Retrospective review of charts of children who had FOB performed with the use of LMA by the pediatric otolaryngology service. The patients were ages 3 months to 18 years with respiratory symptoms requiring FOB for diagnosis. Interventions: Use of LMA to support airway during FOB with spontaneous ventilation with the patients under general anesthesia. Main Outcome Measures: Ability to perform airway evaluation with FOB and LMA; number and type of complications. Results: Seventeen patients, ages 3 months to 18 years (median age, 39 months) underwent FOB with use of LMA. In 2 patients use of LMA failed—1 from airway obstruction with LMA in place, which required intubation, and another who could not have LMA appropriately placed. Fifteen patients underwent uncomplicated FOB through the LMA. None of these 15 patients required unplanned endotracheal intubation. Two patients with mandibular hypoplasia required LMA use for airway evaluation when the glottis could not be visualized at direct laryngoscopy. Conclusions: The LMA is a safe and effective adjunct to pediatric FOB. Laryngeal mask airway use for FOB allows evaluation of the airway during spontaneous ventilation without an endotracheal tube or a face mask. Larger fiberoptic scopes can be used through the LMA compared with pediatric FOB performed through the nose or through an endotracheal tube. Arch Otolaryngol Head Neck Surg. 1996;122:1364-1367

The effects of functional endoscopic sinus surgery (FESS) on sinus and midfacial development remain unclear. The authors report five children who, at a median age of 30 months, underwent FESS for refractory sinusitis. Three of the children had cystic fibrosis, and two had asthma. Preoperative computed tomographic (CT) scanning showed symmetric maxillary sinus development with varying degrees of mucosal disease. At a mean of 42 months after surgery, CT scans were obtained to evaluate recurrent symptoms in the five children. The scans showed unilateral maxillary hypoplasia in four children and bilateral maxillary sinus hypoplasia in one child. No child had clinically apparent facial asymmetry or midfacial hypoplasia. The authors also discuss the factors involved in maxillary sinus pneumatization, the possible effects of sinus surgery on sinus development, and the clinical implications of "acquired" maxillary sinus hypoplasia.

Suppurative parotid infections and atypical mycobacterial cervical adenitis are often seen in children. A six-year-old immunocompetent girl presented with a fluctuant parotid mass initially thought to be a bacterial parotid abscess. However, acid-fast organisms were identified by stain and culture of material from needle aspirates. Definitive treatment included superficial parotidectomy and limited cervical node excision. Childhood mycobacterial infections of the head and neck will be detailed, with particular attention to infections affecting the parotid region.

Fifteen children with nontuberculous mycobacterial adenitis of the head and neck underwent surgical treatment between July 1991 and July 1994. Fine-needle aspiration for biopsy and culture allowed early diagnosis in nine children. Positive cultures grew Mycobacterium avium-intracellulare complex in 12 children and M. chelonei in one child. Total excision was performed in 10 cases with combinations of lymphadenectomy and salivary gland excision. Curettage was used to successfully treat five children. One patient required local flap coverage for primary wound repair. Two patients required more than one surgical procedure. Our approach to early diagnosis and surgical treatment of cervicofacial nontuberculous mycobacterial adenitis is presented.