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OBJECTIVE Complaints of dysphonia and dysphagia frequently require rigid or flexible laryngoscopy in the office to aid in diagnosis. For young children, flexible laryngoscopy can be uncomfortable and often requires multiple adults to restrain the child. Rigid laryngoscopy does not result in crying but does require patient cooperation; thus, it is used primarily in adults. This project describes our experience using rigid laryngoscopy in a pediatric cohort. METHODS This was a retrospective chart review of patients at a pediatric voice clinic who underwent laryngoscopy from December 2011 through March 2017. Data analysis is via Student t test and descriptive analysis. RESULTS Three hundred and eleven patients were identified with 423 unique laryngoscopy exams. Of those, 212 of the exams were flexible and 210 were rigid. One patient did not tolerate either rigid or flexible exam. There was a statistically significant difference in age between children diagnosed via rigid mean 10.92 years (range 2.39-19.14 years) versus flexible mean 6.51 years (range 0.41-19.29 years), P ≤ 0.01. Of the 44 children under 3 years of age, flexible laryngoscopy was used almost exclusively, with 43 of 44 (97.7%) flexible scope exams. Rigid laryngoscopy was performed on 24 of 115 (20.9%) children aged 3 to 5 years, 26 of 40 (65%) aged 6 years, and 159 of 223 (71.3%) aged 7 and older. CONCLUSION Transoral 70o rigid laryngoscopy can be used in select children as young as 3 years of age. This modality allows for improved visualization of lesions with greater comfort for patients. Laryngoscope, 129:1657-1659, 2019.

Objective:Fibrovascular polyps of the hypopharynx and esophagus are rare, with few case reports in the literature. In this article, we present our institutional experience with a focus on airway and surgical management.Study Design:Case series.Setting:Tertiary academic institution.Methods:A retrospective review was conducted of 4 patients that presented to a tertiary medical center with fibrovascular polyps between 1990 and 2012. Patient demographics, clinical presentation, diagnostic studies, and surgical approaches were reviewed. A review of the published literature was also performed.Results:The average age at presentation was 72 years (range, 59-85 years). Among the 4 patients, 2 presented with airway compromise requiring tracheotomy. All patients had removal of the polyp shortly after presentation; 2 underwent transcervical approaches with lateral pharyngotomy/esophagotomy, and the other 2 had endoscopic removal. The polyps arose from the hypopharynx in 3 patients and upper esophagus in 1. Three patients had complete resolution of their symptoms and remained disease free. One patient had recurrence of the polyp 2 years later and is currently being observed.Conclusion:Fibrovascular polyps are rare tumors of the hypopharynx/esophagus that present in older adults. Although benign, they can cause life-threatening airway compromise that may necessitate tracheotomy. We present 4 cases of fibrovascular polyps and discuss our evolving surgical management, including endoscopic removal.

Gastroesophageal reflux disease (GERD) is a common problem that has been linked to multiple extraesophageal manifestations relevant to the otolaryngologist. Finding evidence for a causal relationship between reflux and manifestations of otolaryngologic disease is often difficult, however, due in part to the non-specific nature of extraesophageal symptoms and the lack of pathognomonic endoscopic or laryngoscopic signs. This poses an even greater challenge in pediatrics given the inherent unreliability when obtaining subjectively reported data from younger aged children. Numerous studies have drawn a correlation between GERD and specific extraesophageal symptoms such as otitis media, sinusitis, chronic cough, and various laryngeal findings; however, determining a clear causative relationship has proven to be much more difficult. Further studies must be done to elucidate the true pathophysiologic mechanisms behind these disease processes. Diagnosis of GERD is challenging and is typically over-diagnosed among otolaryngologists based on laryngoscopic findings. This method has been proven to be both inconsistent and non-specific when evaluating for the presence of GERD. Impedance monitoring is supplanting pH probes as the new gold standard; the clinical utility of impedance testing among patients with extraesophageal symptoms remains unclear however and there are practical limitations in performing these studies in children. The accuracy of diagnostic tests (laryngoscopy, endoscopy, and pH- or pH-impedance monitoring) for patients with suspected extraesophageal manifestations of gastroesophageal reflux disease remains suboptimal at this time. Management options for GERD include lifestyle changes, pharmacologic therapy, and surgical intervention. H2 blockers and proton pump inhibitors are effective treatment options in children but must be used judiciously given their potential side-effect profiles. Surgical options remain for those cases which are refractory to medical management. Multidisciplinary approaches and close collaboration between otolaryngologists and gastroenterologists is recommended to ensure application of best practice guidelines and for continued improvements in this area.

Objectives/hypothesis Vocal fold motion impairment (VFMI) is a known sequela of cardiovascular surgery. The gold standard for the evaluation of vocal fold movement is flexible nasolaryngoscopy (FNL). Although safe, FNL does cause measurable physiologic changes. Noxious stimuli in cardiovascular intensive care unit (CVICU) neonates may cause imbalance between the pulmonary and systemic circulations and potentially circulatory collapse. The goals of this project were to determine the accuracy of laryngeal ultrasound (LUS) compared to FNL to identify VFMI in CVICU neonates and compare their physiologic impact. Study type Case control. Design Prospective case-control study. Methods Forty-six consecutive infants from the CVICU were recruited, 23 with VFMI and 23 without based on FNL findings. They then underwent LUS, which was subsequently reviewed by two pediatric radiologists blinded to the FNL results. Physiologic parameters were recorded before and after the procedures. Data analysis was performed with Cohen's kappa and Wilcoxon signed-rank test. Results Agreement between LUS and FNL was substantial (κ = 0.78). Laryngeal ultrasound had a sensitivity of 0.84 and specificity of 0.95 for identifying VFMI. In terms of physiologic impact, LUS caused statistically significantly less change in diastolic blood pressure (P = 0.01), pulse (P = 0.001), and O2 saturation (P = 0.004) compared to FNL. Arytenoid rotation could be seen clearly, and the vocal fold-arytenoid angle in abduction was most predictive of symmetry and movement (P = 0.17). However, it was difficult to determine vocal fold closure patterns with LUS. Conclusion Laryngeal ultrasound is a comparable to FNL for evaluating vocal fold mobility with less physiologic impact. Level of evidence 3b. Laryngoscope, 127:167-172, 2017.

Objective To determine the long-term prognosis of children with vocal fold mobility impairment (VFMI) after cardiac surgery, with respect to time to normal feeding and incidence of admissions for pneumonia and feeding difficulties. Methods A retrospective chart review was conducted of all neonates who had otolaryngology exam after cardiac surgery at a tertiary children's hospital from May 2007 to May 2008. Charts were reviewed for demographics, type of cardiac surgery, vocal fold mobility, diet at time of discharge and at last follow-up, time to full oral feeding, and hospital admissions. Results There were a total of 94 patients included in the study, 17 of whom had VFMI. While significantly more patients with VFMI required modified diet at discharge, 48% compared to 19% of patients with normal vocal fold mobility; there was no statistically significant difference in time to regular diet on long-term follow-up, 0.8 years (VFMI) compared to 0.4 years (normal vocal fold mobility). Of the 25 patients with modified diet or gastrostomy tube at discharge, 52% returned to full feeds within a year. There was no difference in hospitalizations for pneumonia in patients with or without VFMI. However in patients with VFMI, 35% required readmission for feeding difficulty or poor weight gain compared to only 5% in the infants with normal vocal fold mobility. Conclusion After neonatal cardiac surgery, there do not appear to be long-term effects of VFMI with regards to readmission for pneumonia. However, there is an increased risk for hospitalization with respect to feeding difficulties in those neonates with VFMI. The overall prognosis for time to oral feeding is good.

Tracheobronchopathia osteochondroplastica (TBOC) is a rare disease of the trachea and bronchi characterized by submucosal nodules of osseous and cartilaginous tissue. In this series, we present three cases highlighting the varied clinical presentations of this rare disease process, which ranged from a rough voice to a chronic cough to lobar pneumonia. The disorder may mimic other lesions. We review the clinical presentations, pathophysiology, lab tests, imaging, diagnosis, and management of TBOC patients. Laryngoscope, 126:2006-2009, 2016.

Objectives/Hypothesis Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes. Study Design Medical record abstraction. Methods Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up. Results Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1–99.6), Caucasian (95%, 95% CI, 92.2–98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44–1.69). The patients presented at a mean age of 50 years (95% CI, 48.8–51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi2 = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5–99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches. Conclusion Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care. Level of Evidence 4. Laryngoscope, 2015

Introduction Down syndrome is a genetic condition that affects 1:737 births. Along with cardiac, otolaryngologic, and developmental anomalies, infants with Down syndrome can have swallowing difficulties resulting in respiratory infections. This study aims to characterize the airway protection and dysphagia seen in infants with Down syndrome. Methods This is a retrospective chart review of infants with Down syndrome who underwent videofluoroscopic swallow studies (VFSS) from 2008 to 2018 at a tertiary children's hospital. Demographic data and VFSS findings were collected. Results 89.8% (114/127) of infants presented with at least one element of oral dysphagia, while 72.4% (92/127) had at least one element of pharyngeal dysphagia. Sucking skills were classified as abnormal in 63.7% of the patients and bolus formation-control was determined to be deficient (abnormal) in 62.2% of the patients. Oral residuals were present in 37.8% of the patients. With regard to pharyngeal phase, the swallow initiation was considered abnormal in 53.5% of the patients. Pharyngeal residue was present in 17.3% and pharyngo-nasal reflux was present in 27.5% of the patients. Conclusions Swallowing assessments in infants with Down syndrome suspected of dysphagia should be considered, especially in those with any alterations in pulmonary health.

Importance Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score–matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Vocal fold movement impairment (VFMI) secondary to neuronal injury is a known risk after aortic surgery. Total arch replacement is technically challenging, and the incidence of vocal fold movement impairment secondary to neuronal injury after this surgery is unknown. This study examined the incidence of VFMI after total arch replacement and medialization treatment outcomes.Retrospective cohort study.All patients who underwent total arch replacement at a tertiary care center over 11 years (2006-2017) were identified through an institutional database. End points included evidence of VFMI on flexible laryngoscopy, time to diagnosis, time to treatment, need for reintubation, and intensive care unit (ICU) and hospital length of stay.Of the 358 patients who underwent total arch replacement, 63 (20%) were diagnosed with VFMI during their initial inpatient stay. Fifty patients (79%) VFMIs were left-sided, nine (14%) were right-sided, and four (6%) were bilateral. Thirty-nine patients (62%) underwent inpatient vocal fold medialization: 28 (72%) by injection laryngoplasty and 11 (28%) by type 1 thyroplasty. Those with unilateral VFMI had longer ICU (8.9 days) and hospital (19.4 days) than those with no VFMI (5.7 and 16.1 days). Among patients with unilateral VFMI, those who underwent inpatient vocal fold medialization trended toward shorter ICU (6.2 vs. 14.4 days, P = .03) and hospital stays (20.1 vs. 23.3 days, P = .4) than patients who did not have a medialization procedure.The overall incidence of VFMI after total arch replacement in our series was 20%. Both the right and left vocal folds are potentially at risk from a total arch replacement; consequently, the distribution of injury in our cohort was more heterogeneous than in other series.3 Laryngoscope, 129:699-703, 2019.

Importance Vocal fold motion impairment (VFMI) is a known risk factor following congenital heart surgery (CHS). The impact of this diagnosis on utilization and outcomes is unknown. Objective To evaluate the cost, postprocedure length of stay (PPLOS), and outcomes for neonates with VFMI after CHS. Design, Setting, and Participants A cross-sectional analysis of the 2012 Kids’ Inpatient Database (KID) of neonates who underwent CHS was carried out. The KID is an administrative data set of patients, aged 20 years or younger, and contains data on more than 10 million hospitalizations from 44 states. The KID is limited to inpatient hospitalization and contains discharge summary level of data. Patients were limited to those who were born during the hospitalization and those who were aged 28 days or younger at the time of admission for CHS. A weighted total of 4139 neonates who underwent CHS were identified, of which 3725 survived. The proportion of neonates diagnosed with VFMI was 264 (6.92%) of 3725. Exposures Congenital heart surgery. Main Outcomes and Measures Cost of inpatient hospital stay, postprocedure length of stay, odds of pneumonia, gastrostomy tube placement, and tracheostomy tube placement. Risk-adjusted generalized linear models examined differences in cost and PPLOS between neonates who underwent CHS and were diagnosed with VFMI and those who were not. Risk-adjusted logistic regression compared the odds of selected outcomes (gastrostomy, tracheostomy, pneumonia). Models were weighted to provide national estimates. Results Of 3725 neonates (aged 0-28 days), 2203 (59.1%) were male and 1517 (40.7%) were female. Neonates diagnosed with VFMI had significantly higher total cost by $34 000 (95% CI, 2200-65 000) and PPLOS by 9.1 days (95% CI, 4.6-13.7) compared with those who did not. When PPLOS was included as a covariate in the model for cost, presence of VFMI was no longer significant. There were no differences in odds of pneumonia, gastrostomy, or tracheostomy. Conclusions and Relevance Vocal fold motion impairment after CHS was associated with significant increases in cost owing to increased PPLOS. These findings provide a foundation to further investigate standardized screening for VFMI following CHS; early identification and treatment may decrease cost and PPLOS.

The evaluation and care of children with complex swallowing, respiratory, and gastrointestinal problems is often challenging due to the need for multiple subspecialists and diagnostic procedures. Barriers to communication and disjointed care are some of the pitfalls that multidisciplinary aerodigestive programs aim to overcome. In this chapter, we will review the history of modern aerodigestive clinical programs, including proposed definitions, goals, and missions, as well as potential limitations and future challenges.

Objectives Create a head-and-neck keloid quality of life (QOL) questionnaire. Demonstrate the reliability of the keloid-specific QOL scale according to test-retest and internal consistency standards. Study Design Prospective cohort study. Methods Patients presenting to a keloid clinic in a tertiary referral institution between April 2012 and February 2013 were enrolled on their first visit. They were administered a questionnaire assessing demographics and a 21-item Likert keloid-specific survey assessing symptomatology, self-esteem, social functioning, and therapeutic motivation during their first three visits. Reliability of the keloid questionnaire was assessed for internal consistency (Cronbach's alpha) and test-retest correlations. Patients were treated with Kenalog steroid injections at each visit. The 126-point total score from the questionnaire was then compared to each subscale (physical symptoms, self-esteem, social function, and medical motivation) using a Pearson coefficient. Results The keloid QOL questionnaire showed a Cronbach's alpha of 0.87 for the overall questionnaire and ranged from 0.66 to 0.86 for individual questions. The test-retest Pearson's R was 0.70 between visits 1 and 2 and 0.77 between visits 2 and 3. The Pearson correlation between symptoms, self-esteem, social functioning, and medical motivation subscales and the overall scale were 0.77, 0.73, 0.72, and 0.57, respectively. Conclusion This head and neck keloid-specific QOL questionnaire proved to be a reproducible method of reliably assessing QOL burden on patients with head and neck keloids. Level of Evidence N/A. Laryngoscope, 125:2672–2676, 2015

Objectives/Hypothesis The purpose of this study is to review the computed tomography (CT) scans of infants, children, and adults to assess the degree of calcification of the thyroid cartilage at various ages in order to understand in which age group laryngeal ultrasound can be utilized. Study Design Retrospective. Methods Two hundred patients from newborn to 50 years who received a CT scan of the neck were identified. The Hounsfield units (HU) of the thyroid cartilage were calculated at one o'clock, four o'clock, eight o'clock, and eleven o'clock at the level of the true and false vocal fold. The Spearman correlation coefficient was calculated to evaluate the correlation between each measure and age, then a linear regression with a logarithmic transformation was applied to further study how the measures were related to age. Results The Spearman correlation coefficients ranged from 0.58 to 0.75. The P values of these coefficients were all < 0.0001, showing a significant relationship to age. The age increase by 1 year resulted in increased calcification by 1.5% to 4%. The Wilcoxon signed rank test compared the rate of calcification at each site measured. This showed that the two posterolateral sites calcify faster than the two anteromedial sites. Conclusion The thyroid cartilage calcifies at a rate that is significantly related to increasing age and calcifies in a posterolateral to anteromedial direction. Based on the HU, the thyroid cartilage is not consistently denser than soft tissue until greater than 40 years of age, which would make laryngeal ultrasound feasible for this population. Level of Evidence 4. Laryngoscope, 2015

Objectives/Hypothesis The term vocal fold nodules refers to bilateral thickening of the membranous folds with minimal impairment of the vibratory properties of the mucosa. Nodules are thought to be related to repetitive mechanical stress, associated with voice use patterns. Diagnosis is typically made in the office via either rigid or flexible laryngeal stroboscopy. Depending on the individual child, obtaining an optimal view of the larynx can be difficult if not impossible. Recent advances in high-frequency ultrasonography allows for transcervical examination of laryngeal structures. The goal of this project was to determine if laryngeal ultrasound (LUS) can be used to identify vocal fold nodules in dysphonic children. Study Design Prospective case-control study in which the patient acted as his or her own control. Methods Forty-six pediatric patients were recruited for participation in this study; the mean age was 4.8 years. Twenty-three did not have any vocal fold lesions and 23 had a diagnosis of vocal fold nodules on laryngeal stroboscopy. Recorded LUSs were reviewed by two pediatric radiologists who were blinded to the nodule status. Results There was substantial inter-rater agreement (κ = 0.70, 95% confidence interval [CI]: 0.50-0.89) between the two radiologists regarding the presence of nodules. There was also substantial agreement (κ = 0.87, 95% CI: 0.72-1) between LUS and laryngeal stroboscopy. Sensitivity of LUS was 100% (95% CI: 85%-100%) and specificity was 87% (95% CI: 66%-97%). Conclusions LUS can be used to identify vocal fold nodules in children with substantial agreement with laryngeal stroboscopy. Level of Evidence 3b Laryngoscope, 2016

Objective Flexible nasolaryngoscopy (FNL) is considered the gold standard for evaluation of vocal fold mobility but there has been no data on the reliability of interpretation in the infant population. Visualization may be limited by excessive movement, secretions, or floppy supraglottic structures that prevent accurate diagnosis of vocal fold movement impairment (VFMI). We sought to evaluate the inter- and intra-rater reliability of FNL for the evaluation of VFMI in young infants. Study type Case-control. Methods Twenty infants were identified: 10 with VFMI and 10 normal as seen on FNL. Three pediatric otolaryngologists reviewed the video without sound and rated the presence and/or degree of vocal fold mobility. Twelve videos were repeated to assess intra-rater reliability. Results There was substantial agreement between the reviewers regarding the identification normal vs. any type of VFMI (kappa = 0.67) but only moderate agreement regarding the degree of vocal fold movement (kappa = 0.49). Intra-rater reliability ranges from moderate to perfect agreement (kappa = 0.48–1). Conclusion FNL in infants is an extremely challenging procedure. Clinically, physicians frequently use the quality of the cry and the past medical and surgical history to help make a judgment of vocal fold movement when the view is suboptimal. These other factors, however, may bias the interpretation of the FNL. Without sound, there is only moderate inter-rater and variable intra-rater reliability for the identification of degree of movement on FNL. Otolaryngologists must be cognizant of the limitations of FNL when using it as a clinical tool or as a “gold standard” against which other modalities are measured.

Vocal fold movement impairment (VFMI), a known complication following thoracic aortic surgery, has been associated with poorer surgical outcomes, including higher pulmonary complications and longer length of stay (LOS). Awake transcervical injection laryngoplasty in the inpatient setting serves to augment pulmonary toilet function for affected patients. This study investigates clinical outcomes of patients who underwent early versus late injection laryngoplasty following aortic surgery.A 5-year review (2011-2016) of 35 patients who underwent inpatient injection laryngoplasty for VFMI following aortic repair was conducted. Data included demographics, surgery parameters, laryngologic evaluation, pulmonary complications, LOS, and mortality. Early injection was defined as within 5 days from extubation. Statistical analyses were performed using SPSS, version 17.0 (IBM Corp., Armonk, NY).All 35 patients (mean age 56, 77% male) underwent left vocal-fold injection laryngoplasty without complication. There were 15 (43%) early procedures and 20 (57%) late procedures. Mean LOS for early and late injection groups (13 vs. 20 days, respectively) significantly differed (P = 0.04, 95% confidence interval (CI) 0.3 to 14.4). Early laryngoplasty cohorts experienced less pulmonary complications (20%) than those who had late medialization (50%), but this did not reach significance (P = 0.06, 95% CI -0.3 to 8.1). The most common complication type in both groups was therapeutic bronchoscopy.Early awake injection laryngoplasty within 5 days from extubation is feasible and may improve clinical outcomes for patients with VFMI following aortic repair. Further prospective studies on this approach for VFMI after thoracic surgery are needed.4. Laryngoscope, 128:144-147, 2018.

To determine whether the risk of developing a tracheocutaneous fistula (TCF) increases with longer tracheostomy dependence times in children.Retrospective review of medical records.A retrospective chart review was conducted for all children who both underwent tracheotomy and were decannulated between 2002 and 2011 at a tertiary children's hospital. Charts were analyzed for duration of tracheostomy and evidence of TCF up to 12 months. Data for these criteria was available on 164 out of 182 patients.A significant difference in the duration of tracheostomy dependence between children with and without resultant TCF was determined by the Wilcoxon signed rank test (P = 0.0003). The relative risk (RR) of a persistent TCF was significantly increased when the duration of tracheostomy dependence was greater than 24 months (RR = 2.5217, P0.005) when compared to those decannulated before 12 months. The mean tracheostomy dependence times for children with and without TCF were 33.1 and 23.4 months, respectively. Overall, 94 children (57.3%) developed a TCF.To our knowledge, this study represents the largest collection of data for children who have been decannulated following tracheostomy placement. These data demonstrate that the risk of developing a TCF increases with longer tracheostomy dependence times in children.4. Laryngoscope, 127:2709-2712, 2017.

Objectives/Hypothesis Laryngotracheal stenosis (LTS) is largely considered a structural entity, defined on anatomic terms (i.e., percent stenosis, distance from vocal folds, overall length). This has significant implications for identifying at-risk populations, devising systems-based preventive strategies, and promoting patient-centered treatment. The present study was undertaken to test the hypothesis that LTS is heterogeneous with regard to etiology, natural history, and clinical outcome. Study Design Retrospective cohort study of consecutive adult tracheal stenosis patients from 1998 to 2013. Methods Subjects diagnosed with laryngotracheal stenosis (ICD-9: 478.74, 519.19) between January 1, 1998, and January 1, 2013, were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted. Records were reviewed for etiology of stenosis, treatment approach, and surgical dates. Stenosis morphology was derived from intraoperative measurements. The presence of tracheostomy at last follow-up was recorded. Results One hundred and fifty patients met inclusion criteria. A total of 54.7% had an iatrogenic etiology, followed by idiopathic (18.5%), autoimmune (18.5%), and traumatic (8%). Tracheostomy dependence differed based on etiology (P

Objectives/Hypothesis Alterations in swallowing can occur after tracheotomy and can result in varying degrees of aspiration. In tracheotomized adult patients, use of a Passy Muir Speaking Valve (PMV) has been shown to decrease laryngeal penetration and aspiration of foods and liquids. The objective of this study was to determine if the PMV has a similar effect on laryngeal penetration and aspiration in tracheotomized children. Study Design This is a prospective case-control study. Methods Pediatric patients with tracheotomies who were able to tolerate the PMV were identified. Modified barium swallow (MBS) was performed with and without the PMV. Two consistencies, thin liquids and purees, were used. Two speech language pathologists (SLPs), who were blinded to the PMV status, reviewed the recorded MBSs. Three swallows of each consistency were graded on an 8 point Penetration-Aspiration Scale. Residue in the vallecula, piriform sinuses, and posterior pharyngeal wall was graded. Results Twelve patients were included for analysis. Laryngeal penetration and aspiration was decreased with purees over liquids (P = 0.5 and P = 0.005, respectively) with either the sham valve or the PMV. The presence of the PMV decreased piriform sinus residue (P = 0.01); however, it did not demonstrate a decrease in laryngeal aspiration or penetration. Conclusion Unlike in adults, the presence of PMV did not decrease laryngeal aspiration or penetration in children with tracheotomies. It did, however, improve piriform sinus residue. Level of Evidence 3b. Laryngoscope, 124:1469–1474, 2014

Objective Acute postoperative sialadenitis is a previously described rare entity that has occurred following general anesthesia and has also been associated with prolonged neurosurgical procedures. We aim to better characterize this entity while performing a literature review regarding potential etiologies, diagnosis, airway management and treatment options. Methods A retrospective chart review was performed at a pediatric tertiary care center from 2000 to 2014. Charts were selected for the study utilizing an ICD-9 diagnosis of sialadenitis occurring within two weeks of a surgical procedure. Data including age, gender, medical history, preoperative diagnosis, operation length, time to symptom onset, and subsequent management were collected. An additional literature review was performed focusing on reports of post-operative acute sialadenitis involving airway compromise. Result 244 charts were reviewed and 4 patients met inclusion criteria. The average time to symptom onset was 4.3 days (range 1 h–12 days) following conclusion of the surgical procedure. Symptoms ranged from mild inflammation of the parotid gland to rapid swelling of the neck necessitating intubation. All patients were treated with standard sialadenitis treatment including hydration, antibiotics, and airway management as needed. Conclusion To our knowledge this is the first case series reviewing this entity specifically within the pediatric population. There appears to be two distinct categories of postoperative sialadenitis; one of which presents very acutely and results in massive neck swelling and airway compromise. It is important for practicing Otolaryngologists to be aware of this potentially life-threatening complication in the immediate postoperative period.

Summary Objectives Paradoxical vocal fold motion (PVFM) consists of intermittent adduction of the vocal folds during inspiration, resulting in stridor and worsened by anxiety and stress. The purpose of this study was to assess the impact of PVFM on quality of life in our pediatric patient population. Study Design This is a prospective, descriptive survey study. Methods Thirty-nine consecutive patients (ages 12–17 years) presenting with a PVFM diagnosis for respiratory retraining sessions with speech-language pathology were recruited. Patients completed a brief demographic questionnaire and the Short Form 36, version 2, a validated tool for measuring health-related quality of life. Results There were 31 (79%) girls and 8 (21%) boys with a mean age of 15.5 years. Subjects reported regular participation in competitive extracurricular activities, including track or cross country (30.8%), swimming (17.9%), and cheerleading or dancing (15.4%). Of the patients in the study, 46.2% were straight-A students. On the SF-36 (population averages normalized to a score of 50), the general health of patients with PVFM was better than that of the general population (53.27); however, their physical health limited their role activities more severely (42.82). In addition, a greater proportion of the group with PVFM was at risk for first-stage depression screening when compared with the general population (28% versus 18%). Conclusions We demonstrate a measurable detrimental impact of PVFM on health-related quality of life. This is consistent with previously published literature showing a preponderance of females with PVFM, most of whom are high achievers academically and athletically.

The term vocal fold nodules refers to bilateral thickening of the membranous folds with minimal impairment of the vibratory properties of the mucosa. Nodules are thought to be related to repetitive mechanical stress, associated with voice use patterns. Diagnosis is typically made in the office via either rigid or flexible laryngeal stroboscopy. Depending on the individual child, obtaining an optimal view of the larynx can be difficult if not impossible. Recent advances in high-frequency ultrasonography allows for transcervical examination of laryngeal structures. The goal of this project was to determine if laryngeal ultrasound (LUS) can be used to identify vocal fold nodules in dysphonic children.Prospective case-control study in which the patient acted as his or her own control.Forty-six pediatric patients were recruited for participation in this study; the mean age was 4.8 years. Twenty-three did not have any vocal fold lesions and 23 had a diagnosis of vocal fold nodules on laryngeal stroboscopy. Recorded LUSs were reviewed by two pediatric radiologists who were blinded to the nodule status.There was substantial inter-rater agreement (κ = 0.70, 95% confidence interval [CI]: 0.50-0.89) between the two radiologists regarding the presence of nodules. There was also substantial agreement (κ = 0.87, 95% CI: 0.72-1) between LUS and laryngeal stroboscopy. Sensitivity of LUS was 100% (95% CI: 85%-100%) and specificity was 87% (95% CI: 66%-97%).LUS can be used to identify vocal fold nodules in children with substantial agreement with laryngeal stroboscopy.3b Laryngoscope, 127:676-678, 2017.

Vocal fold movement impairment (VFMI) due to neuronal injury occurs in 20% to 30% of surgeries in the region of the aortic arch. Early injection laryngoplasty can aid with postoperative pulmonary toilet in these high-risk cardiovascular patients. The purpose of this study is to determine whether continuing antiplatelet and anticoagulation therapy during awake transcervical injection laryngoplasty surgery is safe, and if there is any increase in bleeding complications in these patients.This is a retrospective review of patients undergoing awake injection laryngoplasty surgery for VFMI between 2013 and 2016 at a tertiary academic center specializing in aortic and mediastinal diseases. Records were reviewed for patients regarding baseline antiplatelet or anticoagulation therapy, and whether these medications were stopped or continued preoperatively. The primary outcome was bleeding complications.Of the 95 surgeries reviewed, 44 (46%) were performed for patients on antiplatelet therapy, and 71 (75%) for patients on anticoagulation therapy. None of the patients on antiplatelet therapy had their treatment discontinued. Of the patients on anticoagulation, 13 (16.4%) had their therapy held prior to surgery. There was no observed difference in bleeding complications between patients who were continued on antiplatelet or anticoagulation treatment versus those whose therapy was withheld.These results suggest that patients undergoing awake transcervical injection laryngoplasty for VFMI can be maintained on antiplatelet or anticoagulation therapy without increased risk of bleeding. Further larger studies are needed to confirm these findings.4. Laryngoscope, 127:1850-1854, 2017.

Objective: To describe this institution’s experience with and the long-term outcomes of early type 1 thyroplasty for unilateral vocal fold paralysis (UVFP) following surgery on the aortic arch. Study Design: Retrospective chart review with telephone questionnaire. Setting: Academic tertiary care center. Subjects and Methods: Three hundred forty-eight patients with UVFP following surgery on the aortic arch since 1999 were identified; 40 were available for follow-up. The number of revision procedures following initial thyroplasty was ascertained, and the Voice Handicap Index (VHI) was administered by telephone. The hypothesis that early thyroplasty produced voice outcomes and revision rates comparable to injection laryngoplasty was established prior to the initiation of data collection. Results: Six out of the 40 patients (15%) required revision thyroplasty following their initial procedure. Mean VHI of all patients was 36.0 (SD, 27.2). Mean VHI was significantly different in the 18 to 39 age group (13.1) when compared to the 40 to 59 (51.8) and 60+ (37.7) age groups ( P = .013). Mean follow-up since initial thyroplasty was 46.5 months (SD, 42.2). Conclusions: In the setting of aortic arch surgery with injury to the recurrent laryngeal nerve, early thyroplasty produces voice outcomes comparable to those achieved in the literature with repeated injection and delayed thyroplasty and can be considered in select populations.

Tonsillitis is one of the most common childhood infections. Occasionally, it can lead to one of the most common deep space head and neck infections, peritonsillar abscess. The epidemiology, microbiology and treatment of tonsillitis and peritonsillar abscess are similar and crucial for the primary care physician, infectious disease specialist, otolaryngologist, and emergency medicine physician to understand. The routine use of tonsillectomy as a treatment option for recurrent tonsillitis and peritonsillar abscess has decreased over the last decade and clearer indications for surgery have emerged. This chapter provides an overview of the most recent literature regarding the epidemiology, microbiology, diagnosis, complications and management of tonsillitis and peritonsillar abscess. It also discusses the indications for tonsillectomy along with its complications.

Laryngotracheal clefts can be a cause of chronic aspiration and cough in children. While there are 4 subtypes, they can be grouped into 2 separate clinical entities. Type 3 and 4 clefts, in which tracheoesophageal communication can extend from the larynx into the trachea and down to the carina, are very rare with early presentation such as dramatic aspiration, bronchial flooding, and respiratory distress. Surgical repair for these anomalies is challenging with a nearly 50% mortality rate. In contrast, type 1 and 2 clefts, which extend to or through the cricoid, can be more difficult to identify. The incidence of type 1 cleft ranges from 0.2% in cadaveric studies to 7.6% in children undergoing direct laryngoscopy for chronic cough or recurrent pneumonia. Patients with type 1 or 2 clefts may go undiagnosed for years with recurrent aspiration, pneumonia, chronic cough, and swallowing difficulties. However, identification and effective management is critical as these patients can go on to develop chronic lung...

Objectives/hypothesis To analyze the patterns of surgical frequency in pediatric patients undergoing surgery with CO(2) laser ablation for juvenile onset recurrent respiratory papillomatosis (JORRP). The hypothesis is that over time there is a high variability in surgical frequency independent of the use of an adjuvant therapy. Study design Retrospective case review. Methods All pediatric patients treated surgically with the CO(2) laser for JORRP by two senior surgeons at a tertiary pediatric hospital over an 11-year period were evaluated. Regression analysis was performed. An online survey was conducted of the American Academy of Pediatric Otolaryngology membership on their practice patterns regarding JORRP. Results Twenty-nine patients were identified, and of those, 20 were included in regression analysis. Several distinct patterns were noted. Only five of the 20 patients (25%) had a constant rate of procedures throughout the observation period. Three (15%) of the patients had continual decrease and one (5%) of the patients had a continual increase in the surgical rate throughout the study period. Eleven (55%) had a fluctuation in the pattern of their recurrences. When queried on how they approach when to repeat intervention for JORRP patients, more than 16 responses were given, and the most common determinants included standard set interval, previous operative findings, and previous interval. Conclusions The natural fluctuation in intersurgical intervals without the use of any adjuvant therapy confounds the use of intersurgical interval as an outcome measure for the success of adjuvant therapy. Accelerations and decelerations were noted but cannot be explained.

To determine whether patients with Zenker diverticulum are more likely to have stasis of secretions in the left piriform sinus, on in-office endoscopy, than patients with nonspecific dysphagia.A case-control study.A subspecialty swallowing clinic.All patients with radiographically confirmed Zenker diverticulum who were evaluated over a 5-year period were selected. A control group with dysphagia due to radiographically confirmed esophageal dysmotility, prominent cricopharyngeal bar, or stricture was identified. Two blinded laryngologists reviewed the recorded laryngopharyngoscopies.Thirty-four patients with Zenker diverticulum were identified; 11 were excluded because of previous surgery or other neurological conditions. Twelve (52.17%) of the remaining 23 Zenker diverticulum patients and 2 of the 73 (2.74%) control patients had greater pooling in the left versus right piriform sinus (2-tailed t test, P.0001). The sensitivity of this physical examination finding in identifying patients with Zenker diverticulum was 52.17% (95% confidence interval, 31.08%-72.58%) and specificity was 97.26% (95% confidence interval, 89.56-99.52%). Patients with Zenker diverticulum less than 4 cm in size had increased pooling in the left versus right piriform compared with larger diverticulums. After surgical intervention, there was a statistically significant decrease in the asymmetrical pooling (2-tailed t test, P = .0067).Increased pooling in the left compared with the right piriform, on in-office endoscopy, is predictive of the presence of a Zenker diverticulum. This information can sharpen clinical acumen in evaluating patients with dysphagia. In turn, it will help the clinician counsel the patient regarding diagnosis and radiographic imaging.

Create a head-and-neck keloid quality of life (QOL) questionnaire. Demonstrate the reliability of the keloid-specific QOL scale according to test-retest and internal consistency standards.Prospective cohort study.Patients presenting to a keloid clinic in a tertiary referral institution between April 2012 and February 2013 were enrolled on their first visit. They were administered a questionnaire assessing demographics and a 21-item Likert keloid-specific survey assessing symptomatology, self-esteem, social functioning, and therapeutic motivation during their first three visits. Reliability of the keloid questionnaire was assessed for internal consistency (Cronbach's alpha) and test-retest correlations. Patients were treated with Kenalog steroid injections at each visit. The 126-point total score from the questionnaire was then compared to each subscale (physical symptoms, self-esteem, social function, and medical motivation) using a Pearson coefficient.The keloid QOL questionnaire showed a Cronbach's alpha of 0.87 for the overall questionnaire and ranged from 0.66 to 0.86 for individual questions. The test-retest Pearson's R was 0.70 between visits 1 and 2 and 0.77 between visits 2 and 3. The Pearson correlation between symptoms, self-esteem, social functioning, and medical motivation subscales and the overall scale were 0.77, 0.73, 0.72, and 0.57, respectively.This head and neck keloid-specific QOL questionnaire proved to be a reproducible method of reliably assessing QOL burden on patients with head and neck keloids.N/A.

Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes.Medical record abstraction.Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up.Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1-99.6), Caucasian (95%, 95% CI, 92.2-98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44-1.69). The patients presented at a mean age of 50 years (95% CI, 48.8-51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi(2) = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5-99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches.Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care.4. Laryngoscope, 126:1390-1396, 2016.

Objectives/Hypothesis To determine utility of surveillance direct laryngoscopy and bronchoscopy (DLB) in children with chronic tracheostomies by examining the frequency of operative intervention in children undergoing an annual DLB. Study Design Retrospective medical record review and analysis of operative findings and interventions. Methods A retrospective chart review was conducted of all children with tracheostomies who underwent surveillance DLB between 2003 and 2012 at a tertiary children's hospital. Charts were reviewed for demographics, indication for tracheotomy, symptoms prior to DLB, dates of DLB, and operative findings and interventions. Results A total of 489 patients underwent 1,094 DLBs. Two hundred fifty-three DLBs (23%) were accompanied by preprocedural symptoms including bleeding; increased secretions; infection; and changes in ventilation requirement, swallow, or voice. Six hundred nineteen procedures (58%) required 817 interventions. Common interventions performed included debridement of granulation tissue (41%), tracheostomy tube exchange (27%), and subglottic dilation (10%). The presence of preprocedural symptoms and indication for tracheostomy did not predict need for intervention during DLB (P > .05). Conclusions In pediatric tracheostomy patients undergoing surveillance DLB, most procedures (58%) required operative intervention for airway optimization. These data support our current practice of yearly surveillance DLB in asymptomatic pediatric tracheostomy patients and aim to facilitate the development of clinical practice guidelines regarding chronic tracheostomy care in pediatric patients. Level of Evidence 4 Laryngoscope, 125:2393–2397, 2015

Routine computed tomography (CT) for vocal fold movement impairment (VFMI) without an apparent cause is common. However, given increased cancer risk associated with ionizing radiation exposure, our purpose is to evaluate the utility of routine scans for these patients.Retrospective case series.Houston, Texas.A 5-year review of patients with VFMI diagnosed at an academic institution was conducted. For patients without an apparent cause (eg, recent head, neck, or cardiothoracic surgery or known malignancy), CT head/neck and chest was performed to evaluate the recurrent laryngeal nerve course. Data included demographics, symptoms, radiography, and interventions. Statistical analyses were performed via χ(2) analysis.Of 406 patients with VFMI, 47 (11%) patients had no apparent cause clinically. Routine CT revealed abnormalities in 10 (21%) patients, of which only 3 (6%) could account for VFMI: benign thyroid adenoma (1), papillary thyroid cancer (1), and an esophageal mass (1). The most common lesion detected involved the thyroid. Demographic data and symptom type were not significantly associated with detection of a VFMI-attributable lesion on CT. Overall, routine CT did not identify a focal etiology in 94% patients with VFMI without an apparent cause.Routine pan-CT evaluation failed to reveal an etiology in 94% of patients with VFMI without an apparent cause. Patients may be subjected to health risks associated with radiation exposure without significant diagnostic benefit. Further studies should consider more judicious use of CT in the context of risk factors and safer imaging modalities as the initial diagnostic step.

Importance Infants with vocal-fold motion impairment (VFMI) have an increased risk of aspiration and pulmonary complications. Flexible nasolaryngoscopy (FNL) is the gold standard for evaluation of vocal-fold mobility. Although safe, FNL causes measurable physiologic changes. Noxious stimuli, especially in neonates in the cardiovascular intensive care unit, may cause imbalance between the pulmonary and systemic circulations and potentially circulatory collapse. Objective To examine whether bedside measurement of infant cry volume using a smartphone application can be a screening tool for vocal-fold movement in FNL. Design, Study, and Participants This case-control study performed from December 1, 2013, through January 31, 2015, included 42 infants in the intensive care unit at Texas Children's Hospital, Houston. Main Outcomes and Measures Patient cry volume in decibels was recorded using a smartphone application placed 12 in from their mouth. Results Forty-two infants were identified at the intensive care unit (median age, 33 days; 20 [48%] female and 22 [52%] male), 21 with VFMI and 21 without, based on FNL findings. A statistically significant difference was found in the mean cry volume of infants with (76.60 dB) and without (85.72 dB) VFMI. The absolute difference in the mean cry volume was 9.12 dB (95% CI, 2.74-15.50 dB). A cry volume of 90 dB or greater had a sensitivity of 90.4% (95% CI, 71%-97%) for identification of normal vocal-fold mobility. A cry volume of 75 dB or less had a specificity of 90.5% (95% CI, 71%-97%) for the identification of VFMI. The mean (SE) area under the receiver operating characteristic curve was 0.721 (0.080) (95% CI, 0.565-0.877). The cry volume, however, was not a good screen for aspiration. Conclusions and Relevance Bedside measurement of the cry volume with a smartphone application can be used by untrained health care professionals to screen patients for further evaluation of vocal-fold mobility using FNL.

Opera performance is physiological and emotional, and singing performers utilize their larynges in often strenuous ways. Historically, the training of a classical voice has been considered the paragon of healthy singing. However, the natural history of a performing larynx has not been studied systematically. There is paucity of scientific studies to guide practice patterns, particularly with regard to the course and extent of post-performance physiologic and acoustic changes.A prospective case series was carried out.Principal singers in the Houston Grand Opera's 2012-2013 repertory were enlisted, for a total of seven singers. Stroboscopy was performed prior to the start of rehearsals, and at the completion of the opera's run. Data points included erythema, edema, masses or lesions, mucosal waveform, supraglottic posture; acoustic measurements were also performed.There were statistically significant differences (P 0.05) in the mucosal wave on pre- and postperformance stroboscopic examinations. Acoustical measures did not achieve statistical significance, but there was a trend toward increased harmonic-to-noise ratio in postperformance measures, as well as decreased frequency range and reading FThis pilot study describes physiologic and acoustic changes that may occur over the course of a series of rehearsals and performances in the operatic larynx. In so doing, it highlights a need for larger studies with increased frequency of serial examinations to study in a systematized way what may be natural reactive changes that occur during performance.

Objectives:Fibrovascular polyps of the hypopharynx and esophagus are rare, and the majority of the literature is comprised of case reports. The goals of this study are: 1) Present one of the largest series of patients from a single institution that presented with fibrovascular polyps; 2) Describe their presentation focusing on airway management and clinical demographics; 3) Discuss our surgical management and demonstrate how it has evolved from open to endoscopic approaches.Methods:A retrospective review was conducted with four patients that presented to a tertiary medical center with fibrovascular polyps between 1990 and 2012. Patient demographics, clinical presentations, surgical approaches, and diagnostic studies were analyzed.Results:The average age at presentation was 72 years (range 59 to 85 years). Among the four patients, two presented with airway compromise requiring tracheotomy. All patients had removal of the polyp shortly after presentation; two underwent transcervical approaches with lateral ...

Summary Objective/Hypothesis Young classical singers in training have a wide variety of knowledge about the anatomy and physiology of the voice and vocal pathology and harbor anxiety about treatment of vocal fold disorders. This study aimed to examine differences in knowledge, experience, and anxiety across levels of training at elite conservatories and young artist programs in the United States. Study Design Prospective cohort questionnaire. Methods Undergraduate (50), master's (35), and doctoral/young artist (25) singers (n = 110) were given an 80-point questionnaire assessing experience with vocal pathology, otolaryngologists, speech pathologists, and participation in choir or teaching. Participants were asked questions to test their medical knowledge in vocal anatomy, physiology, and care. They were also asked questions about their anxiety about medical visits and vocal pathology and about their habits in the care of their own voices. Results There was no statistically significant difference in test scores for vocal knowledge across the three levels of training ( P = 0.47). Mean scores were just above 50% with standard deviations around 12–13 points. The lowest score was 26% and the highest score was 84%. Doctoral/young artist-level participants were more anxious regarding general office visits to an otolaryngologist compared with undergraduate and master's level participants. There were no other significant differences by level of training regarding anxiety about vocal pathology, scope examinations, or visits to a speech pathologist. There were no significant differences in self-reported levels of knowledge. All groups of young singers expressed marked interest in expanding their knowledge of anatomy and physiology, speech pathology, care of the vocal mechanism, and vocal disorders. Conclusions More advanced singers do not have significantly greater knowledge of vocal form and function and are more anxious about visits to otolaryngologists and vocal pathology; a clear majority of singers indicate interest in knowing more. There is thus ample opportunity for innovation in the development of medical curricula in the instruction of young singers and clear interest in more knowledge on their part.

Awoman in her 90swith no significant medical history presented to the otolaryngology clinic with a chief concern of worsening hoarseness over several years. She had not experienced shortness of breath, gastric reflux, smoking, cough, dysphagia, odynophagia, fevers, or chills. Findings from a physical examination were remarkable for a rough voice. Flexible nasolaryngoscopy revealed normal abduction and adduction of the vocal folds with a white sessile lesion starting at the right midfold on the superior and medial surfaces that crossed the midline to involve the entire left vocal fold as shown in the Figure, A. Histopathologic images of the biopsied lesion are shown in the Figure, B-D. Vocal folds A

Objective: Provide insight into: 1) The frequency of viral vs bacterial hospitalized croup at Texas Children’s Hospital. 2) The epidemiology of hospitalized croup. 3) The efficacy of applying operative direct laryngoscopy and bronchoscopy (DL and B) in the detection of other significant respiratory pathology.Method: A retrospective chart analysis of 345 patients with the coded diagnosis of croup at TCH between 2003 and 2011 was carried out. Patients with tracheostomy, epiglottitis, and non-respiratory complications were excluded from the study. Patient information from children with a DL and B was compared to those without the procedure and tabulated into diagnostic and therapeutic criteria. DL and B findings were categorized as normal, grade 1 ( 90%).Results: Of the 345 patients, 125 were girls (36.2%) and 224 were boys (64.9%; mean age, 3.25 years). Of these, 25 patients (7.25%) underwent operative endoscopy. Of these 25, 7 ...

To analyze the patterns of surgical frequency in pediatric patients undergoing surgery with CO(2) laser ablation for juvenile onset recurrent respiratory papillomatosis (JORRP). The hypothesis is that over time there is a high variability in surgical frequency independent of the use of an adjuvant therapy.Retrospective case review.All pediatric patients treated surgically with the CO(2) laser for JORRP by two senior surgeons at a tertiary pediatric hospital over an 11-year period were evaluated. Regression analysis was performed. An online survey was conducted of the American Academy of Pediatric Otolaryngology membership on their practice patterns regarding JORRP.Twenty-nine patients were identified, and of those, 20 were included in regression analysis. Several distinct patterns were noted. Only five of the 20 patients (25%) had a constant rate of procedures throughout the observation period. Three (15%) of the patients had continual decrease and one (5%) of the patients had a continual increase in the surgical rate throughout the study period. Eleven (55%) had a fluctuation in the pattern of their recurrences. When queried on how they approach when to repeat intervention for JORRP patients, more than 16 responses were given, and the most common determinants included standard set interval, previous operative findings, and previous interval.The natural fluctuation in intersurgical intervals without the use of any adjuvant therapy confounds the use of intersurgical interval as an outcome measure for the success of adjuvant therapy. Accelerations and decelerations were noted but cannot be explained.