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Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal.Blinded modified Delphi consensus process.Tertiary care center.A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items.The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus.It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated.5. Laryngoscope, 131:1168-1174, 2021.

Objectives/hypothesis Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. Study design Blinded modified Delphi consensus process. Setting Tertiary care center. Methods A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. Results The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. Conclusions It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. Level of evidence 5. Laryngoscope, 131:1168-1174, 2021.

Tracheal-bronchus is an aberrant bronchus arising from the lateral tracheal wall, superior to the carina. A "False-carina" can be classified as a sub-type. This clinical entity will be defined and the clinical presentation, diagnosis and management of five patients with variations of the anatomical definition of a False-carina, identified at our institution, will be reviewed. Congenital bronchial abnormalities, including False-carina, have important implications in the overall management of the airway. Management can range from expectant in asymptomatic patients to surgical intervention in cases of recurrent respiratory infections. Awareness and understanding of this clinical entity allows for timely investigation, diagnosis and appropriate intervention.

Objectives To develop (1) a practical and comprehensive algorithm of instruments and techniques available to treat neonates with tracheobronchial foreign bodies, based on the patient's subglottic diameter and (2) primary and secondary prevention strategies for neonatal tracheobronchial foreign bodies. Methods (1) Analysis of the case of a severely premature infant who presented with the incidental radiological finding of a 2 cm suction catheter tip, which, over a two week period, had migrated between her main bronchi; the foreign body was removed with a previously unreported combination of instruments: a 3 French (F) flexible urological forceps through the side port of a 2.5 mm rigid bronchoscope. (2) In vitro testing of typical foreign bodies and readily available endoscopic instruments. Results We have developed a practical and comprehensive algorithm for the treatment of neonates with tracheobronchial foreign bodies, as well as primary and secondary prevention strategies. Conclusions The treatment algorithm and prevention strategies may reduce morbidity and mortality from neonatal tracheobronchial foreign bodies.

Summary Cystic fibrosis (CF) affects between 1 in 2000 and 1 in 4500 children of European descent [R.S. Mendelsohn, B.M. Cohen. Otorhinolaryngologic aspects of cystic fibrosis. Archives of Otolaryngology 79 March (1964) 312–17]. There have been few reported cases of fungal sinus infections in patients with CF [S.K. Wise, T.T. Kingdom, L. McKean, J.M. DelGaudio, G. Venkatraman. Presence of fungus in sinus cultures of cystic fibrosis patients. American Journal of Rhinology 19 January–February (1) (2005) 47–51]. We report a unique case of a young male with CF presenting with severe destructive sinonasal polyposis, which was refractory to all treatment until he was treated for a concomitant fungal bronchopulmonary infection.

Summary Objective : To report a case of a 17-month-old female presenting with a giant retropharyngeal abscess and to outline the minimally invasive technique that was used to drain it. Design : Case study. Results : A previously healthy 17-month-old female was found by contrast-enhanced computed tomography (CECT) to have a retropharyngeal abscess (RPA) which extended from the level of the nasopharynx to the level of the aortic arch. The RPA measured 4.5cm transversely, 2.7cm antero-posteriorly and 8.0cm cephalocaudally. After orotracheal intubation, transoral incision and drainage of the abscess was performed. Based on the CECT findings, the baby Yankauer suction was advanced 6cm beyond the oropharyngeal incision (within the retropharynx) to break the distal septae and completely drain the RPA with a minimally invasive technique. Discussion: Our case describes the management of the largest RPA in the medical literature. We present the first report of the use of a baby Yankauer suction advanced through the oropharyngeal incision to drain intrathoracic RPA loculations.

Summary We present two cases of foreign body aspiration that occurred during the 2004–2005 Christmas season. In one 8-month-old boy, the hardware from a Christmas tree ornament became a supraglottic foreign body. In another 10-month-old boy, a metallic sticker in the shape of a Christmas tree traveled from the glottis to the nasopharynx and back to the glottis. The winter holidays are a time when children may have less supervision and greater exposure to potential aerodigestive foreign bodies. It is especially important that parents are vigilant and that physicians are perceptive of the symptoms of foreign body aspiration, especially during the holiday season.

Objectives To review clinical presentations and management strategies for children with plastic bronchitis. Methods Retrospective chart review. Results Seven patients required rigid bronchoscopy to remove bronchial casts over a 17-year study period. Mean age at presentation was 60 months. Mean follow-up was 53 months. Co-morbidities included: congenital heart disease (n = 3), chronic pulmonary disorders (n = 2) and sickle cell disease (n = 1). 4 patients required multiple bronchoscopies for recurrent casts. Adjunctive topical therapies were administered in all 7 patients, without complication. Rigid bronchoscopy for cast removal was performed in 2 patients who were on extra-corporal membrane oxygenation (ECMO), using special precautions to safeguard the ECMO catheters. Conclusions Bronchial casts in children may present acutely or sub-acutely. Recurrent casts are unusual; however, in combination with severe cardiac disease may lead to mortality. Adjunctive topical therapies are still under investigation. Special safeguards for ECMO catheters are imperative. This case series complements and adds to the International Plastic Bronchitis Registry.

Summary Objective: To report two cases in which toddlers drank a caustic liquid which their parents had been using to prepare free-base and crack cocaine. Design: Case series. Results: Two toddlers presented with first- and second-degree burns of the oral cavity, pharynx and esophagus from caustic ingestion. The first had drunk ammonia from an unmarked clear plastic container the morning after “a party at a friend's house”. The second had drunk potassium hydroxide from a clear plastic container which was labelled “pH UP” and had a small “Danger” sign. Both children were treated with intravenous hydration, steroids, antibiotics and analgesics. Fortunately, neither child suffered long-term physical sequelae. When questioned, the parents of both children admitted to using these alkalis to prepare free-base and crack cocaine. Appropriate steps were taken by social services to protect these children from further neglect. Discussion: Despite federal legislation and public education, pediatric caustic ingestion remains a significant problem. These cases suggest that, in certain cases of pediatric caustic ingestion, caregivers should be questioned regarding possible drug abuse. Larger warning labels and further public education might help prevent many cases of pediatric caustic ingestion.

Purpose : To illustrate the challenge and approach to diagnosing a laryngeal foreign body (FB) in a child with pre-existing laryngeal pathology. Methods : Case report. The diagnosis of laryngeal FB was initially missed in a 21-month old-infant. Two weeks later, the child experienced worsening in symptoms. Results : Flexible laryngoscopy revealed the presence of a plastic object in the subglottis, which was then removed under general anesthesia. Conclusions : For children with pre-existing laryngeal pathology, a sudden unexplained worsening of laryngeal symptoms, particularly dysphonia and biphasic stridor, should prompt the clinician to consider the possibility of a thin, sharp laryngeal FB.

Importance Because tonsillar enlargement can have substantial ill health effects in children, reliable monitoring and documentation of tonsil size is necessary in clinical settings. Tonsil grading scales potentially allow clinicians to precisely record and communicate changes in tonsil size, but their reliability in a clinical setting has not been studied. Objective To assess the interobserver and intraobserver reliability of the Brodsky and Friedman tonsil size grading scales and a novel 3-grade scale. Design, Setting, and Participants Cross-sectional study between June 2012 and August 2013 at a tertiary pediatric otolaryngology outpatient clinic at British Columbia Children's Hospital. We recruited 116 children, aged 3 to 14 years, with no major craniofacial abnormalities. For each child, 2 separate tonsil assessments (with at least a 5-minute interval in between) were conducted by 4 independent observers: 2 staff pediatric otolaryngologists, 1 otolaryngology trainee (fellow or resident), and 1 medical student. Each observer assessed and graded tonsil sizes using 3 different scales. Main Outcomes and Measures Interobserver and intraobserver reliabilities were assessed by deriving the intraclass correlation coefficients (ICCs) and Pearson correlation coefficients, respectively. To discount for any asymmetric scores, all data analysis was conducted on the left tonsil measurement only. Results Mean interobserver reliability was highest for the Brodsky grading scale (ICC, 0.721; Cronbach α, 0.911), followed by the Friedman grading scale (ICC, 0.647; Cronbach α, 0.879) and the 3-grade scale (ICC, 0.599; Cronbach α, 0.857). The mean intraobserver reliabilities for the Brodsky, Friedman, and modified 3-grade scales were 0.954, 0.932, and 0.927, respectively. Conclusions and Relevance The Brodsky grading scale offered the highest interobserver and intraobserver reliability when compared with the Friedman and novel 3-grade scales. The results of this study would support the uniform use of the Brodsky scale for future clinical and research work.

Summary We report our experience, not previously reported in the literature, with a young male Jehovah Witness who aspirated a metal button backing into his right bronchus intermedius. While in the operating room, a size 5, 30 cm Storz rigid ventilating bronchoscope with a 0 degrees rod lens telescope was passed through the larynx to visualize the bronchus intermedius. Then, using the “duckbill” telescopic alligator forceps, the sharp edges of the foreign body were grasped and removed. The patient recovered well and was discharged home hours after without any complications.

Congenital midline cervical cleft (CMCC) is a rare developmental defect of the anterior neck normally characterized by an atrophic mucosal plaque with a cranial nipple-like skin tag, a short caudal sinus, and may be attached to a subcutaneous fibrous cord of variable length. Clinically, patients present at an early age with, white females being the most commonly affected population. In addition to aesthetic concerns, CMCC can prevent full extension of the neck, result in micrognathia and torticollis, predispose patients to infection, and can coexist with other clefting defects or cysts. Fewer than 50 cases have been published in the English-language literature. Herein, we report a case of CMCC that also presented with a mild contracture of the right sternohyoid muscle. The embryopathogenesis, histopathology, diagnosis, and treatment of this rare condition are also discussed.

Objective:We present an extremely rare case of severe intracranial hypertension secondary to sigmoid sinus compression by a group A streptococcal epidural abscess.Method:Case report and review of the world literature.Results:A five-year-old boy was treated for acute otitis media and group A streptococcal bacteraemia, but subsequently developed severe intracranial hypertension. Computed tomography revealed that, although the sigmoid sinuses were not thrombosed, the patient had a dominant right sigmoid sinus that was almost completely compressed by a small epidural abscess. After surgical decompression of the epidural abscess, with aggressive debridement of the granulation tissue from the sigmoid sinus wall, the patient awoke from general anaesthesia with complete resolution of his symptoms and signs of intracranial hypertension. He suffered no sequelae over the subsequent six months' follow up.Conclusion:This is the first reported case of intracranial hypertension due to an epidural abscess causing sigmoid sinus compression without thrombosis. This case illustrates the fact that, even in the absence of thrombosis of the sigmoid sinus, a small epidural abscess may require urgent surgical treatment.

Summary Objective To review the demographics, pathophysiology and management of aspiration of sharp, metallic foreign bodies; to review prevention strategies. Design Case series and review of the related literature (1932–2006). Setting Tertiary care pediatric hospital. Patients All patients presenting to BC Children's Hospital with aspiration of sharp, metallic foreign bodies since 1998. Results The seven patients ranged in age from 11 to 15 years (mean 13 years). The two boys had been playing with other boys at the time of aspiration. One aspirated a thumbtack and one aspirated a homemade blowdart (which traveled from his carina to his subglottis with coughing). Three of the five girls had been holding thumbtacks or a darting pin between their lips while putting up posters or sewing. The other two girls, who aspirated thumbtacks, refused to provide a history. One was treated successfully 6 days after the aspiration. The other girl withheld the history for over a year, presented with hemoptysis and eventually required thoractomy and right main bronchotomy to remove the tack. All of the other patients were diagnosed and successfully treated by rigid bronchoscopy within 24 h. (Two patients initially had a failed attempt at foreign body removal by flexible bronchoscopy at another hospital.) This is the second largest series of aspiration of sharp, metallic foreign bodies since at least 1966. Adolescents are still aspirating sharp, metallic foreign bodies because of the same behaviors described by Jackson and Jackson in 1932. Education about choking hazards is needed for this age group. Conclusions Aspiration of a sharp, metallic foreign body is a serious injury which is best treated by rigid bronchoscopy. These injuries potentially could be prevented through education.

Background Noninflammatory masses of the salivary gland region in children are extremely rare. Therefore, very few published individual and institution-based experiences exist. Design Retrospective chart review from 1990 through 1997. Setting University-based children's hospital. Design Patients 18 years of age or younger with a tumor in the salivary gland region. Masses of infectious origin were excluded. Hemangiomas and lymphangiomas were tallied for relative incidences only. Results Three hundred twenty-four consecutive cases of salivary gland masses were found: 192 hemangiomas (59.2%), 89 lymphangiomas (27.5%), and 43 (13.3%) solid masses. No significant difference was found between the age at presentation of the patients with benign solid tumors and the patients with malignant solid tumors (mean + SEM age, 7.2 + 0.7 years). Sixty-one percent of the masses were found in the parotid region; 18% were localized to the submandibular gland region; and the remaining 21% were located in a minor salivary gland site. The most common benign perisalivary masses were pilomatrixomas (20.9%), followed by pleomorphic adenomas (11.6%). The most common malignant masses were mucoepidermoid carcinomas (9.3%), followed by rhabdomyosarcomas (7.0%). Treatment was individualized to the disease. Twenty-two patients had adequate data for follow-up analysis (mean + SEM follow-up, 30.0 + 8.4 months). Four patients (18.2%) experienced recurrent or residual disease and were alive with disease at last follow-up, and 100% of our population demonstrated disease-specific survival at last follow-up. Conclusions Vascular lesions outnumber solid tumors of the salivary gland region. The most common salivary tumors were pleomorphic adenomas, followed by mucoepidermoid carcinomas. Although certain solid salivary masses may demonstrate locally aggressive behavior, the overall prognosis is favorable.

A retrospective chart review was performed to quantify the postoperative complications and outcomes of 82 consecutive cases of laryngotracheal reconstruction (LTR) and cricotracheal resection (CTR) performed at a pediatric tertiary care hospital over the last 9 years. Six cases of respiratory syncytial virus (RSV) bronchiolitis and 8 cases of cervical pseudomonal wound abscess (PWA) were identified in a total of 12 patients. All of these infections occurred after single-stage LTR or CTR. Both RSV bronchiolitis and PWA were associated with significantly more unexpected days of intubation and admission to the intensive care unit, as well as higher rates of failure of LTR. Ossification of the cricoid cartilage, grade IV subglottic stenosis, and untreated gastroesophageal reflux disease (GERD) were also associated with restenosis. Trisomy 21 did not significantly influence the success rate of pediatric LTR. Both RSV bronchiolitis and PWA are potentially preventable complications of pediatric LTR and CTR. We propose strategies to prevent these infections. We also advocate the treatment of GERD during the healing phase of LTR.

Background Cystic hygromas are characterized by a proliferation of small vessels and lymphatics with intervening fibrous tissue. Studies have shown malignant tumors and some benign neoplasms are dependent on angiogenesis, the induction of new capillaries from preexisting vessels. Growth and progression of these tumors are associated with a disturbance in the balance of angiogenic inducers and inhibitors. We have postulated that cells derived from cystic hygromas are angiogenic due to secretion of higher levels of angiogenic inducers that promote vascular proliferation. Design A large cystic mass was surgically removed and a portion of the sterile tumor was immediately placed in the medium. The tissue was minced, washed in phosphate-buffered saline, and grown to near confluence. Conditioned medium was collected under serum-free conditions after 48 hours. Secreted proteins were concentrated, quantitated, and analyzed in an in vitro endothelial cell migration assay and by Western blot. Antibody to factor VIII-related antigen was performed to confirm endothelial cell origin of the cultured cells. Main Outcome Measures In vitro angiogenic activity of secreted proteins in a capillary endothelial migration assay was tested by using blocking antibodies to angiogenic inducer, basic fibroblast growth factor, and angiogenic inhibitor, thrombospondin-1. Total protein levels of thrombospondin-1 were determined by Western blot. Results Cells isolated from cystic hygroma are angiogenic in vitro and this angiogenic activity is due to secretion of high levels of angiogenic inducer, basic fibroblast growth factor, and lower levels of naturally occurring angiogenic inhibitor, thrombospondin-1. Conclusions Cystic hygromas may represent another neoplasm dependent on angiogenesis. The angiogenic activity is due in part to elevated levels of potent angiogenic inducer, basic fibroblast growth factor. Anti-angiogenic therapy directed at the endothelial cell may help suppress the growth of cystic hygromas.

Importance To our knowledge, the present study is the first double-blind, randomized, placebo-controlled trial in children to compare nasal preparation sprays administered before flexible nasendoscopy with placebo. Objective To compare the degree of pain experienced by children undergoing flexible nasendoscopy after 1 of 3 intranasal sprays: placebo, decongestant with topical local anesthetic (TLA), or decongestant without TLA. Design, Setting, and Participants A randomized placebo-controlled trial with blinding of participants, caregivers, observers, and otolaryngologists was conducted in a tertiary pediatric otolaryngology ambulatory clinic. Participants included a consecutive sample of children aged 3 to 12 years requiring flexible nasendoscopy. Exclusion criteria included concomitant respiratory tract infection, known allergy to a trial agent, or previous flexible nasendoscopy. One hundred fifty-one children were assessed for eligibility; 24 eligible children refused participation and 69 were included and block-randomized. All completed the study, and there were no adverse events. Interventions Nasal spray administration of placebo (normal saline); xylometazoline hydrochloride, 0.05% (decongestant); or lidocaine hydrochloride, 1%, with xylometazoline hydrochloride, 0.05% (TLA with decongestant) was performed 10 minutes before flexible nasendoscopy. Main Outcomes and Measures Primary outcome measure was the child-reported Wong-Baker Faces Pain (WBFP) scale. Secondary outcomes included the caregiver-proxy WBFP scale; the Face, Legs, Activity, Cry, and Consolability (FLACC) scale; and the physician-reported Difficulty of Procedure Visual Analog Scale (DPVAS). Results Twenty-three children were recruited in each of the intervention arms. Baseline characteristics were comparable between groups. The mean child-rated WBFP scale scores were 2.4, 1.8, and 2.2 for the placebo, decongestant, and TLA with decongestant groups, respectively ( P = .45). Although the finding was statistically nonsignificant, decongestant had the lowest mean caregiver-proxy WBFP scale score, lowest observer-rated FLACC scale score, and highest physician-rated DPVAS score. Subgroup analysis did not demonstrate any correlation between the outcomes and age or sex. Conclusions and Relevance This study revealed no statistically significant difference in the discomfort experienced by children undergoing flexible nasendoscopy after placebo, decongestant, or TLA with decongestant. Decongestant was associated with the least discomfort (on child, caregiver, and observer-rated pain scale scores) and the lowest rating for difficulty of procedure. With these findings, the study suggests that there is no significant benefit of topical decongestant with or without TLA compared with placebo in reducing pain associated with pediatric flexible nasendoscopy. Trial Registration clinicaltrials.gov Identifier:NCT01351298