Search

Laryngotracheal disruption in children is rare but life-threatening, and endolaryngeal injuries may go overlooked. We present the case of a 10-year-old boy who sustained near-complete laryngotracheal separation, multiple laryngeal fractures, and arytenoid and vocal fold avulsion following blunt cervical trauma. These injuries were not identified radiographically and only became apparent intraoperatively. Following surgical repair, the patient was successfully decannulated, eating a normal diet, and had a serviceable speaking voice within 2 months. In children, the diagnosis of severe endolaryngeal injuries may be elusive and therefore require high degree of clinical suspicion. Surgical success requires accurate diagnosis and prompt intervention. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To confirm the standard of care pertaining to postoperative mobilization practices following initial tracheostomy, to establish face validity of novel early mobilization tools, and to conduct a safety and feasibility pilot study.Study Design: Multi-institutional survey and prospective cohort study.Methods: Experts at our tertiary-care children's hospital developed an Early Pediatric Mobility Pathway for tracheostomy patients utilizing a novel risk-assessment tool. Surveys were distributed to professional colleagues in similar children's hospitals to establish face validity and incorporate respondent feedback. Additional surveys were disseminated to tertiary-care children's hospitals across the country to establish the current standard of care, and a pilot study was conducted.Results: Seventy-seven percent of respondents from tertiary hospitals across the country confirmed the standard of care to defer mobilization until the first trach change. Greater than 83% of the respondents used to establish face validity of the tools agreed with the clinical components and scoring structure. The safety and feasibility of early mobilization prior to initial trach change was confirmed with a pilot of 10 pediatric patients without any adverse events.Conclusions: Mobilization of pediatric patients prior to initial trach change is feasible and can be safe when risk factors are assessed by a multidisciplinary team.Level Of Evidence: 4 Laryngoscope, 131:E653-E658, 2021. [ABSTRACT FROM AUTHOR]

Objective: The mechanism by which recurrent croup occurs is unknown. Gastroesophageal reflux is commonly implicated, although this relationship is only loosely documented. We conducted a systematic review with a meta-analysis component to evaluate the relationship between recurrent croup and gastroesophageal reflux disease (GERD), and to assess for evidence of improvement in croup symptoms when treated.Style Design: Systematic Review and Meta Analysis.Methods: We searched five separate databases. Studies were included if they discussed the relationship between croup and GERD in children, >5 subjects, and available in English. Literature retrieved was assessed according to pre-specified criteria. Retrieved articles were reviewed by two independent authors and decisions mediated by a third author. If there was a difference of opinion after first review, a second review was performed to obtain consensus. Heterogeneity was calculated and summarized in forest plots.Results: Of 346 initial records, 15 met inclusion criteria. These were two retrospective cohort and 13 cross-sectional studies. Thirteen of 15 articles support an association between recurrent croup and GERD. Although heterogeneity is high among studies that reported prevalence of GERD, there is less uncertainty in results for improvement to recurrent croup after GERD treatment. Most studies lacked a control group and all carry a moderate-to-high risk of bias.Conclusion: There is limited evidence linking GERD to recurrent croup; Further research is needed to assess for causality as most studies are retrospective, lack a control group, and have a study design exposing them to bias. Patients treated with reflux medication appear to demonstrate a reduced incidence of croup symptoms.Level Of Evidence: 1 Laryngoscope, 131:209-217, 2021. [ABSTRACT FROM AUTHOR]

Objectives: Static Endoscopic Evaluation of Swallowing (SEES) has been demonstrated to have a strong correlation with the Videofluoroscopic Swallow Study (VFSS) in adults. In children, Fiberoptic Endoscopic Evaluations of Swallow (FEES) are frequently performed to avoid repeated VFSS; however, a subset of the population does not tolerate FEES. The purpose of this study was to evaluate the utility of a modified SEES in children.Methods: Charts of 50 consecutive patients who underwent FEES evaluations were reviewed. Patients age 3 months to 12 years undergoing SEES, FEES, and VFSS were extracted. We compared a binary assessment of outcome on SEES versus VFSS as the diagnostic standard to report characteristics, including sensitivity, specificity, and positive and negative predicted value.Results: A total of 36 patients met all inclusion criteria (mean age 2.8 years). Using the VFSS as the diagnostic standard, residue seen on SEES had a sensitivity of 80.0%, specificity of 85.7%, a positive predictive value of 88.9%, and a negative predictive value of 75.0% for predicting deep penetration or aspiration.Conclusion: SEES may be helpful for developing an initial diagnostic impression and may serve as a platform for patient and caregiver counseling. In children who are unable to cooperate with FEES, SEES may provide clinical insight in predicting an abnormal swallow study; however, a normal SEES was less reliable in predicting a safe swallow on subsequent VFSS in this patient population.Level Of Evidence: 4 Laryngoscope, 130:1590-1594, 2020. [ABSTRACT FROM AUTHOR]

Objective: Vocal fold immobility with resultant dysphagia is a known cause of morbidity in the pediatric population. Herein we evaluate the efficacy and adverse events of injection laryngoplasty in children.Study Design: Case series with chart review.Setting: Tertiary academic children's hospital.Subjects and Methods: Patients <12 years of age with unilateral vocal fold immobility, dysphagia, and objective swallow study data were included. Primary outcome measures included perioperative adverse events and the ability to advance the diet, as defined by initiation of oral feeds or reduction in thickener following postoperative swallow study.Results: The mean age of the cohort (N = 41) was 43.83 months (range, 0.5-144 months), and 46.3% of patients were <18 months old. Perioperative adverse events included increased oxygen requirement (n = 3), prolonged operating room time secondary to tenuous cardiopulmonary status (n = 2), and postoperative readmission within 30 days (n = 1). A total of 63.63% (n = 21 of 33) of patients safely advanced their diet following objective improvement on swallow study. Patients undergoing injection laryngoplasty ≤6 months of the onset of vocal fold immobility were more likely to advance their diet following surgery.Conclusion: Injection laryngoplasty has the potential to advance or initiate an oral diet for children with vocal fold immobility, including those in the first months of life. It is relatively free of adverse events, but certain limitations in the pediatric population must be considered. Preoperative characteristics, including timing of injection and premorbidity diet, may guide clinicians in predicting those patients most likely to advance their diet following injection laryngoplasty. [ABSTRACT FROM AUTHOR]

Objectives: Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies.Methods: Standard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site-specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria.Results: Thirty-three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative-/intraoperative-/procedure-related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site-specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable.Conclusion: This consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta-analyses, quality improvement, transfer of information, and surgeon self-assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient.Level Of Evidence: 5 Laryngoscope, 129:244-255, 2019. [ABSTRACT FROM AUTHOR]

Recurrent respiratory papillomatosis (RRP) is a potentially lethal disease caused by the human papillomavirus (HPV) and characterized by recurrent papillomas in the aerodigestive tract. BEST PRACTICE SUMMARY Administration of systemic bevacizumab earlier in the RRP disease process may provide the benefit of decreased disease progression in addition to minimizing surgical sequelae. Currently, the mainstay of RRP treatment is via surgical intervention, with a minority of patients requiring adjuvant medical therapies during their disease. [Extracted from the article]

Objectives/hypothesis: Children with bilateral true vocal fold immobility (BTVFI) may present with significant airway distress necessitating tracheostomy. The objective of this study was to review our preliminary experience with the anterior-posterior cricoid split (APCS), an endoscopic intervention used as an alternative to tracheostomy in children with BTVFI.Study Design: Multicenter review.Methods: A review of patients undergoing endoscopic APCS for BTVFI at four institutions was performed. Patients were evaluated for the ability to ventilate without the requirement for tracheostomy or reintubation. Additional data extracted included the duration of intubation following APCS, the requirement for additional procedures, and demographics. Surgical success was defined as the ability to avoid tracheostomy and to cap or decannulate without respiratory symptoms if a tracheostomy was present prior to APCS.Results: Nineteen APCS procedures were performed between October 2010 and June 2016. There were 12 male patients, the mean age at APCS was 4.7 months. BTVFI was primarily idiopathic (58%) and associated with other comorbidities (74%). All patients were candidates for tracheostomy prior to APCS. Fourteen patients (74%) were considered surgical successes. Of the unsuccessful patients, three (66%) required tracheostomy following APCS, and one was treated with a posterior cartilage graft. There was one nonsurgical mortality greater than 2 months after APCS and thought to be unrelated to the airway.Conclusions: Endoscopic APCS appears to be a safe and effective intervention for pediatric BTVFI. Under the correct circumstances, this can be performed as a single procedure, obviating tracheostomy. Further study is warranted.Level Of Evidence: 4. Laryngoscope, 128:257-263, 2018. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study was to report our clinical experience in the surgical management of patients with posterior glottic diastasis (PGD) secondary to prolonged intubation and/or laryngotracheoplasty (LTP) during childhood. Methods: We reviewed the charts of patients with a history of prolonged intubation and/or LTP who had undergone surgical correction for PGD at our institution between 2010 and 2014. We documented demographic data and pertinent information regarding medical and surgical histories. The Pediatric Voice Handicap Index (pVHI) and/or the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) were used to assess patients both before and after undergoing treatment for voice disorders. Results: Six patients met our inclusion criteria. With 1 exception, all patients with complete voice data demonstrated improvements in perceptual, patient-reported, and acoustic voice measures. There were no perioperative complications. Conclusion: Our case series demonstrates that operative intervention can lead to improved voice in carefully selected patients with PGD secondary to prolonged intubation and/or LTP during childhood. Patients exhibited postoperative improvement in loudness and vocal endurance; however, they also exhibited a degree of compromise in voice quality. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 2-year-old boy presented with a history of intermittent left cheek swelling. Topics discussed include how contrast-enhanced computed tomography (CT) revealed a heterogeneously enhancing lytic lesion centered in the left maxillary sinus, histologic evaluation revealing a proliferation of neoplastic cells and which led to the diagnosis of langerhans cell histiocytosis (LCH).

Study Objectives: Severe respiratory distress of neonates with Robin sequence is traditionally managed by surgery. Stanford orthodontic airway plate treatment (SOAP) is a nonsurgical option. The study aimed to determine whether SOAP can improve polysomnography parameters of neonates with Robin sequence., Methods: Polysomnography of neonates with Robin sequence treated with SOAP at a single hospital were retrospectively analyzed. Patients without polysomnography at all 4 time points (pre, start of, mid, and posttreatment) were excluded. Data were analyzed using a linear mixed effects model., Results: Sixteen patients were included. All patients had cleft palate. The median age (minimum, maximum) at the start of treatment was 1.1 months (0.3, 5.1) with the treatment duration of 4.5 months (3.5, 6.0). The mean obstructive apnea-hypopnea index (95% confidence interval) decreased from 39.3 events/h (32.9, 45.7) to 12.2 events/h (6.7, 17.7) ( P < .001), obstructive apnea index decreased from 14.1 (11.2, 17.0) events/h to 1.0 (-1.5, 3.5) events/h ( P < .001), and oxygen nadir increased from 79.9% (77.4, 82.5) to 88.2% (85.5, 90.8) ( P < .001) between pre and start of treatment. Respiratory improvements were sustained during and after the treatment. All patients avoided mandibular distraction osteogenesis or tracheostomy following SOAP., Conclusions: As being a rare diagnosis, the number of participants was, as expected, low. However, the current study shows that SOAP can improve polysomnography parameters, demonstrating its potential utility before surgical interventions for neonates with Robin sequence and cleft palate experiencing severe respiratory distress., Citation: Choo H, Sidell DR, Kim J-W, Ahn H-W, Day HS, Sullivan SS. Nonsurgical improvement of severe upper airway obstruction in infants with Robin sequence and cleft palate using Stanford orthodontic airway plate treatment. J Clin Sleep Med . 2024;20(11):1807-1817., (© 2024 American Academy of Sleep Medicine.)

Importance: Pain management following pediatric adenotonsillectomies is opioid-inclusive, leading to potential complications., Objective: To investigate the use of suprazygomatic maxillary nerve (SZMN) blocks to reduce pain and opioid use after pediatric intracapsular adenotonsillectomy and to measure recovery duration and incidence of complications., Design, Setting, and Participants: This was a randomized, blinded, prospective single-center tertiary pediatric hospital that included 60 pediatric patients (2-14 years old) scheduled for intracapsular adenotonsillectomy from November 2021 to March 2023. Patients were excluded for having combined surgical procedures, developmental delay, coagulopathy, chronic pain history, known or predicted difficult airway, or unrepaired congenital heart disease. Participants were randomized to receive bilateral SZMN blocks (block group) or not (control group)., Intervention: SZMN block administered bilaterally under general anesthesia for intracapsular adenotonsillectomy., Primary Outcomes and Measures: Opioid consumption, FLACC (Face, Legs, Activity, Cry, Consolability) scores, and rates of opioid-free postanesthesia care unit (PACU) stay. Secondary outcomes were recovery duration and incidence of adverse effects, ie, nausea, vomiting, block site bleeding, and emergency delirium., Results: The study population included 53 pediatric patients (mean [SD] age, 6.5 [3.6] years; 29 [55%] females; 24 [45%] males); 26 were randomly assigned to the SZMN block group and 27 to the control group. The mean (SD) opioid morphine equivalent consumption during PACU stay was 0.15 (0.14) mg/kg for the 27 patients in the control group compared with 0.07 (0.11) mg/kg for the 26 patients in the block group (mean difference, 0.08; 95% CI, 0.01-0.15; Cohen d, 0.64). The block group had a higher incidence of opioid-free PACU stays (n = 7 patients; 58%) compared with the control group (n = 15 patients; 26%) (mean difference, 32%; 95% CI, 5%-53%). Patients in the block group experienced lower FLACC scores (0.7 vs 1.6; mean difference, 0.9; 95% CI, 0.2-1.6; Cohen d, 0.7). The overall occurrence of adverse events was similar in the 2 groups, with no reported nerve block-related complications., Conclusions and Relevance: The results of the randomized clinical trial indicate that SZMN blocks are a useful adjunct tool for managing postoperative pain in pediatric intracapsular adenotonsillectomy. Use of these blocks during adenotonsillectomy provided clinically meaningful reductions of postoperative opioid consumption with a low risk of complications., Trial Registration: ClinicalTrials.gov Identifier: NCT04797559.

Laryngotracheal disruption in children is rare but life-threatening, and endolaryngeal injuries may go overlooked. We present the case of a 10-year-old boy who sustained near-complete laryngotracheal separation, multiple laryngeal fractures, and arytenoid and vocal fold avulsion following blunt cervical trauma. These injuries were not identified radiographically and only became apparent intraoperatively. Following surgical repair, the patient was successfully decannulated, eating a normal diet, and had a serviceable speaking voice within 2 months. In children, the diagnosis of severe endolaryngeal injuries may be elusive and therefore require high degree of clinical suspicion. Surgical success requires accurate diagnosis and prompt intervention.

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., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: Create a competency-based assessment tool for pediatric tracheotomy., Study Design: Blinded, modified, Delphi consensus process., Methods: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items., Results: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus., Conclusions: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure., Level of Evidence: 5 Laryngoscope, 130:2700-2707, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Segmental mandibular defects can result after the treatment of various pathologic processes, including osteoradionecrosis, tumor resection, or fracture nonunion with sequestration. The variety of etiologies and the frequency of occurrence make the reconstruction of segmental mandibular defects a topic of significant interest. Despite these incentives, a well-established small-animal model of the segmental mandibulectomy, including composite resection, does not exist. The objective of this study is the creation of a reliable animal model that can be used to study the reconstruction of en bloc mandibular defects. Surgical techniques and an array of reconstructive options are described., Study Design: Description of an animal model., Setting: Animal laboratory at a quaternary care university medical center., Methods: We present an Animal Research Oversight Committee-approved prospective analysis of survival operations in the rat model. A detailed, stepwise description of surgical technique and relevant intraoperative anatomy is presented. Postoperative management, early pitfalls, surgical complications, and future applications are discussed., Results: A total of 72 operations were performed by a single individual between July and October 2010. Two intraoperative and 9 postoperative complications were recognized. There were 6 orocutaneous fistulas, 2 abscesses, and 1 seroma. There were 4 fatalities, which were attributed to anesthetic complications (2, intraoperative), hematoma formation (1, postoperative), and foreign-body aspiration (1, postoperative)., Conclusion: This novel animal model reliably replicates the en bloc segmental mandibular defects seen in our patient population and can be manipulated to achieve a wide variety of research objectives.

Objectives: To evaluate the diagnostic accuracy and to assess the utility of preoperative ultrasonography in the pediatric patient with a midline neck mass., Study Design: Diagnostic test study., Setting: Tertiary care university hospital., Subjects and Methods: An institutional review board (UCLA Office of the Human Research Protection Program)-approved retrospective review of pediatric patients undergoing excision of a midline neck mass between 1999 and 2010 at a tertiary care institution was performed. The preoperative imaging modality, imaging diagnosis, and pathologic results were evaluated., Results: Forty patients were included in this review. This study failed to demonstrate an association between preoperative ultrasound-based diagnoses and postoperative pathologic results (P > .99)., Conclusion: Ultrasonography is commonly used in the workup of a midline neck mass in the pediatric population. Despite the utility of preoperative ultrasonography, the diagnostic accuracy of this imaging modality may have significant limitations.