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OBJECTIVE Standardization of postoperative care using clinical care guidelines (CCG) improves quality by minimizing unwarranted variation. It is unknown whether CCGs impact patient throughput in outpatient adenotonsillectomy (T&A). We hypothesize that CCG implementation is associated with decreased postoperative length of stay (LOS) in outpatient T&A. METHODS A multidisciplinary team was assembled to design and implement a T&A CCG. Standardized discharge criteria were established, including goal fluid intake and parental demonstration of medication administration. An order set was created that included a hard stop for discharge timeframe with choices "meets criteria," "4-hour observation," and "overnight stay." Consensus was achieved in June 2018, and the CCG was implemented in October 2018. Postoperative LOS for patients discharged the same day was tracked using control chart analysis with standard definitions for centerline shift being utilized. Trends in discharge timeframe selection were also followed. RESULTS Between July 2015 and August 2017, the average LOS was 4.82 hours. This decreased to 4.39 hours in September 2017 despite no known interventions and remained stable for 17 months. After CCG implementation, an initial trend toward increased LOS was followed by centerline shifts to 3.83 and 3.53 hours in March and October 2019, respectively. Selection of the "meets criteria" discharge timeframe increased over time after CCG implementation (R2 = 0.38 P = .003). CONCLUSIONS Implementation of a CCG with standardized discharge criteria was associated with shortened postoperative LOS in outpatient T&A. Concurrently, surgeons shifted practice to discharge patients upon meeting criteria rather than after a designated timeframe. LEVEL OF EVIDENCE NA Laryngoscope, 131:2610-2615, 2021.

To explore challenges and opportunities for supporting midcareer women otolaryngologists in the areas of negotiation and sponsorship.Qualitative approach using semistructured interviews.Online multi-institutional interviews.This study was performed from June to August 2021. Women otolaryngologists representing diverse subspecialties, training, and practice environments were recruited via a purposive criterion-based sampling approach. Semistructured interviews were transcribed, coded, and analyzed via an inductive-deductive approach to produce a thematic content analysis.Among the 12 women interviewees, who represented 7 subspecialties, the majority were Caucasian (58%) and in academic practice (50%). The median residency graduation year was 2002 (range, 1982-2013). Participants expressed several challenges that women otolaryngologists face with respect to negotiation, including the absence of systematic formal negotiation training, gendered expectations that women experience during negotiations, and a perceived lack of power in negotiations. Obstacles to effective sponsorship included difficulty in the identification of sponsors and the influence of gender and related systemic biases that hindered sponsorship opportunities.Notable gender disparities exist for negotiation and sponsorship in the midcareer stage for women otolaryngologists. Women start at a disadvantage due to a lack of negotiation training and access to sponsors, which is exacerbated by systemic gender bias and power differentials as women advance in their careers. This study highlights opportunities to improve negotiation and sponsorship for women, with the goal of promoting a more diverse workforce.

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.

Academic medical centers striving to implement diversity, equity, and inclusion (DEI) and antiracism initiatives often ask faculty to volunteer substantial time to committee work, recruitment, mentoring, community, and administrative responsibilities. These requests are not in lieu of current workload and seldom count toward scholarship; the service may go unrecognized, unrewarded, and uncompensated. URiM faculty (underrepresented in medicine) providing such service thus pay a minority tax when precious time is syphoned away from career-advancing activities and personal growth. The resulting strain on available resources has social, psychological, and monetary ramifications that can undermine the long-term objectives of DEI initiatives. We examine the facets of the minority tax, consider the current state of diversity, and present a roadmap to redistribute, reform, and reduce URiM taxation through shared engagement in DEI initiatives. Key interventions include ascribing value to DEI efforts, implementing evidence-based policies to reduce bias, and promoting mentorship, sponsorship, and allyship.

(1) Identify the time required for completion, submission, and acceptance of a Triological Thesis and trends for thesis acceptance. (2) Determine the current Triological Society demographics and identify variances based on separated age groups of the current membership.Retrospective review of The Triological Society database and survey of candidates and fellows.Data from the records of all candidates and fellows of the Triological Society were reviewed to determine the number of years from candidate to active fellow status for all members inducted into the Triological Society from 1990 to 2018. In addition, all current candidates, active and senior fellows were surveyed online to capture demographic data and opinions regarding the Triological Society.Since 1990, there has been a steady increase in the number of candidates and theses accepted. Of candidates successfully completing theses, 73% did so within 3 years and 90% within 5 years. Based on the 514 of 809 (64%) active and senior fellows responding to the survey, 83% reported being male and 15% female. Also, 73% reported as Caucasian, 12% Asian, 2% Hispanic, 2% Black, 0% Native American, and 2% Mixed Race. Of the 93 of 178 (52%) active candidates (those authorized to prepare a thesis) responding to the survey, 70% reported as male, 28% female, 58% Caucasian, 17% Asian, 6% Hispanic, 5% Black, 0% Native American, and 3% Mixed Race.The Triological Society continues to grow, and its membership is becoming more diverse, including more women and wider ethnic diversity. Candidates should plan for submitting their thesis as early as possible as data demonstrates the greatest likelihood of success if done within 3 years.NA Laryngoscope, 133:73-78, 2023.

Background: Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia. Methods: A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children’s hospital. Results: 13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities. Conclusion: Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities.

Background The purpose of this study was to evaluate the efficacy of sleep endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy in patients with sleep disordered breathing (SDB), including polysomnography (PSG) and swallowing outcomes. Methods A retrospective review was performed of all patients undergoing simultaneous lingual tonsillectomy and epiglottopexy over the study period. PSG objective measures were recorded pre- and postoperatively, along with demographic data, comorbidities, and descriptive data of swallowing dysfunction in the postoperative setting. Results A total of 24 patients met inclusion criteria for consideration, with 13 having valid pre- and postoperative PSG data. Successful surgery was achieved in 84.6% of patients, with no difference based on presence of medical comorbidities including Trisomy 21. Median reduction in obstructive apnea–hypopnea index (oAHI) with the procedure was 69.9%. Four patients (16.7%) had postoperative concern for dysphagia, but all objective swallowing evaluations were normal and no dietary modifications were necessary. Conclusion Combination lingual tonsillectomy and epiglottopexy in indicated patients has a high rate of success in this single-institutional study without new dysphagia in this population. These procedures are amenable to a combination surgery in appropriately selected patients determined by sleep state endoscopy in the setting of SDB evaluated with drug-induced sleep endoscopy. Graphical abstract

OBJECTIVES 1) Identify factors that influence African American physicians to choose a career in otolaryngology; 2) determine the predominant practice setting for African American otolaryngologists who can be role models; and 3) determine if the presence of an African American otolaryngologist in academic setting influences career choice. METHODS Survey methodology included a 15-item survey to determine trends in practice and factors that influenced choice of specialty. RESULTS The results were reviewed for trends influencing career choice and practice location and stratified by age group. Most African American otolaryngologists are in academic practice and have subspecialty fellowship training. Enjoying medical student clerkship was the most frequently cited reason why African Americans chose otolaryngology as a career regardless of age. Early exposure was a driving factor in those 30 to 40 years old. Receiving mentorship was less influential in career choice for all age groups, but there was a positive association between those who were mentored in training and those who mentor faculty. CONCLUSION The findings suggest the continued need for initiatives to increase African Americans in our specialty. Encouraging early exposure, intentional mentoring of students, and development of African American role models who can be mentors may help increase the number of African American otolaryngologist faculty. This can help our specialty achieve racial parity in a percentage that matches the number of African Americans in the United States workforce. LEVEL OF EVIDENCE 5 Laryngoscope, 130:2336-2342, 2020.

Laryngomalacia has been reported to contribute to the severity of obstructive sleep apnea (OSA) in children. It is unclear if surgical treatment of laryngomalacia improves polysomnography (PSG) outcomes in these patients. The objective of this study is to report the impact of supraglottoplasty on PSG parameters in children with laryngomalacia-related OSA.Retrospective case series.Tertiary care medical center.Historical cohort study of consecutive children with laryngomalacia who underwent supraglottoplasty and who had undergone overnight PSG before and after surgery.Forty-one patients were included in the final analysis: 22 (53.6%) were male, and 19 (46.3%) were female. The mean ± SEM age of patients at preoperative PSG was 1.3 ± 0.89 years (range, 0.003-2.9). In entire cohort, the mean obstructive apnea-hypopnea index score was reduced from 26.6 events/h before supraglottoplasty to 7.3 events/h after surgery (Overall, supraglottoplasty significantly improved several PSG outcomes in children with laryngomalacia. However, mild to moderate OSA was still present postoperatively in most children. This suggested a multifactorial cause for OSA in this population.

OBJECTIVE To review our experiences with development of a single visit surgery (SVS) program for children with recurrent acute otitis media (AOM) undergoing tympanostomy tube (TT) placement the same day as their otolaryngology surgical consultation. STUDY DESIGN Retrospective cohort analysis. METHODS Retrospective series of patients participating in SVS from inception March 1, 2014 to April 30, 2020 were analyzed, with attention to factors associated with increasing interest and participation in SVS and parent experiences/satisfaction. RESULTS A total of 224 children had TT placed through SVS for AOM management. The average age of patients was 18.1 months (standard deviation 7.8 months), and 130 (58.0%) were male. The median interval between initial contact to schedule SVS, and the SVS date was 15 days (interquartile range 9-23 days). When analyzing year-over-year volumes from inception of SVS, notable increases were seen in 2016 and 2017 after a radio advertisement was played locally. A marked increase in volume was noted after implementation of a Decision Tree Scheduling (DTS) algorithm for children with recurrent AOM. Sixty-six (28.8%) procedures were performed after institution of DTS. A parent survey demonstrated high levels of satisfaction with the SVS experience. Estimations of savings to families in terms of time away from work demonstrated potential for indirect healthcare benefits. CONCLUSIONS SVS for TT placement was a successful, alternative model of care for management of children with AOM. Marketing strategies regarding SVS, and the inclusion of SVS pathway in DTS platforms increased rates of interest and choice of this option. Parents of children undergoing TT through SVS were satisfied with the overall experience. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2823-2829, 2021.

Objective Equipment necessary to perform pediatric microlaryngoscopy/bronchoscopy (MLB) varies considerably depending on the selected interventions. In procedures with equipment variability, surgical case length may be increased due to the need to procure items intraoperatively. We hypothesized that use of standardized huddle tools listing necessary equipment would be associated with a shortened case duration in MLB. Methods As part of a quality improvement initiative at our academic, tertiary care pediatric hospital, a standardized huddle sheet was created that listed options of equipment for MLB. Listed items included telescope/bronchoscope size, laryngoscope selection, interventional equipment, suspension, microscopes, and topical medications. The tool was completed by otolaryngology and shared with the circulating nurse at the beginning of the day so equipment needs could be anticipated. The tool was introduced to staff in November 2017 and to trainees in February 2018. To assess intervention impact, monthly median surgical case duration and room turnover time were retrospectively tracked using control chart analysis from March, 2017 to June 2019. Results At baseline, the centerline case duration was 49 minutes. Two months following introduction of the huddle sheet to trainees, the centerline duration decreased to 43 minutes. This change was sustained throughout the period studied. No changes in room turnover time were observed during this period. Conclusions Standardized huddle tool use prior to MLB was associated with a median decrease of six minutes of operating room time without a change in operating room turnover time. Use of similar tools in procedures with significant equipment variability may be beneficial.

Objective To provide guidance for home care tracheostomy management in the pediatric population. The mission of the IPOG is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. Methods Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). Results Survey results provide guidance for caregiver teaching, the reuse of tracheostomies and suction catheters while inpatient and following discharge, acceptable sterilization practices for tracheostomies, tracheitis workup and management, and outpatient follow-up practices. Conclusion This presentation of common home tracheostomy care practices are aimed at improving patient-centered care in the pediatric population.

To produce a sustained reduction in opioid prescriptions in patients5 years of age undergoing TA through utilization of standardized algorithms and electronic health record (EHR) automation tools.Prospective quality improvement initiative.Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED).In children5 years of age undergoing TA, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED.Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative TA patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings.4 Laryngoscope, 131:E2337-E2343, 2021.

Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.

In a large academic children's hospital ambulatory clinic, the increasing demand for Spanish interpretation exceeds the Interpreting Services Department capacity, necessitating telephone interpretation. By adding a dedicated Spanish interpreter in the otolaryngology clinic, we aimed to decrease visit times for Spanish-speaking patients and increase satisfaction. Additional aims explored if dedicated Spanish interpreters could increase patients seen per session.A quality improvement initiative investigated baseline state compared to 2 tests of change using video interpretation and dedicated, in-person interpretation. Time permitting, interpreters contacted patients before the visit to decrease missed appointments and late arrivals. Measures included clinic visit times, late arrivals, missed appointments, and family/employee satisfaction scores. Actuarial statistics forecasted if on-site Spanish interpreters would affect patients seen per session and the potential addition of sessions.In-person interpretation reduced visit times for Spanish-speaking patients from 55 to 48 minutes (Implementing dedicated Spanish interpreters may increase productivity and enhance family experience.Reducing patient visit time by 9 minutes permits 2 additional patients per clinic session (1560 visits, 390 surgeries per year). Applied institution-wide, the intervention could create 29% more capacity in the ambulatory schedule (31,000 additional visits) and reduce actuarial need for ambulatory sessions in the same clinic space.

Children with congenital central hypoventilation syndrome (CCHS) have a PHOX2B mutation-induced control of breathing deficit necessitating artificial ventilation as life support. A subset of CCHS families seek phrenic nerve-diaphragm pacing (DP) during sleep with the goal of tracheal decannulation. Published data regarding DP during sleep as life support in the decannulated child with CCHS and related airway dynamics in young children are limited. We report a series of 3 children, ages 3.3–4.3 years, who underwent decannulation. Sleep endoscopy performed during DP revealed varied (oropharynx, supraglottic, glottic, etc.) levels of complete airway obstruction despite modification of pacer settings. Real-time analysis of end tidal CO2 and SpO2 confirmed inadequate gas exchange. Because the families declined re-tracheostomy, all 3 patients rely on noninvasive mask ventilation as a means of life support while asleep. These results emphasize the need for extreme caution in proceeding with tracheal decannulation in young children with CCHS who expect to use DP during sleep as life support. Parents and patients should anticipate that they will depend on noninvasive mask ventilation (rather than DP) during sleep after undergoing decannulation. This information may improve management and guide expectations regarding potential decannulation in young paced children with CCHS.

Kinder mit angeborenem zentralem Hypoventilationssyndrom (CCHS) haben eine auf einer PHOX2B-Mutation beruhende Störung der Atmungsregulation, die künstliche Beatmung zur Lebenserhaltung notwendig macht. Bei einigen CCHS-Patienten streben die Familien den Einsatz eines über den Nervus phrenicus wirkenden Zwerchfellschrittmachers (ZSM) im Schlaf an, um die Entfernung der Trachealkanüle zu ermöglichen. Veröffentlichte Daten über den ZSM zur Lebenserhaltung im Schlaf bei Kindern mit CCHS nach Dekanülierung und zur damit verbundenen respiratorischen Dynamik bei Kleinkindern liegen nur in begrenztem Umfang vor. Wir berichten über eine Fallserie von 3 Kindern, die im Alter von 3,3-4,3 Jahren dekanüliert wurden. Schlafendoskopien unter der ZSM-Anwendung ergaben vollständige Obstruktionen der Atemwege auf verschiedenen Ebenen (oropharyngeal, supraglottisch, glottisch usw.) trotz Modifikation der Schrittmachereinstellungen. Echtzeitanalysen des endexspiratorischen CO2 und SpO2 bestätigten einen unzureichenden Gasaustausch. Da die Familien eine erneute Tracheostomie ablehnten, wurden alle 3 Patienten zur Lebenserhaltung auf nicht invasive Maskenbeatmung im Schlaf umgestellt. Diese Ergebnisse unterstreichen, dass im Hinblick auf eine eventuelle Dekanülierung von Kleinkindern mit CCHS, bei denen ein ZSM die Lebenserhaltung im Schlaf gewährleisten soll, extrem vorsichtig vorzugehen ist. Die Patienten bzw. ihre Eltern müssen sich darauf einstellen, dass nach der Dekanülierung eine Abhängigkeit von der nicht invasiven Maskenbeatmung (anstelle des ZSM) im Schlaf bestehen bleibt. Diese Information könnte zur besseren Versorgung von Kleinkindern mit CCHS und ZSM und zu realistischen Erwartungen bezüglich der Dekanülierung beitragen.

Objective Children at high risk for respiratory complication after adenotonsillectomy are often admitted to a pediatric intensive care unit (PICU) postoperatively. Although many patients receive care in such units, it is unknown how many utilize critical care resources. Methods A review was conducted to audit intensive care needs of postadenotonsillectomy patients admitted to the PICU at a tertiary, academic, pediatric hospital between July 2013, and March 2017. Demographic information, ICU indication, polysomnogram results, and comorbidities were collected. Patients were defined as needing ICU resources based on supplemental oxygen requirements greater than 2 L between 2 to 24 hours postoperatively, more than two desaturation events in a 2-hour period, or more than hourly nursing intervention. Factors associated with utilization of ICU resources were assessed. Results One hundred and ten patients were admitted to the PICU after adenotonsillectomy. Median age was 4.2 years, median body mass index was 90.8 percentile, and median apnea hypopnea index (AHI) was 34.3. Twenty patients (18.2%) utilized ICU resources by criteria defined. Of these patients, 14 were known to need such resources by 2 hours postoperatively (70%, negative predictive value 93.8%). Neither AHI nor obesity status was correlated with need for resources; however, resource need was associated with young age, gastrostomy tube status, and neuromuscular disorders (P = 0.048, P = 0.002 and 0.013, respectively). Conclusion Most high-risk adenotonsillectomy patients do not utilize critical care resources despite their increased perioperative risk. Patients with respiratory complications are frequently identifiable within the first 2 hours of surgery. Level of evidence 4 Laryngoscope, 129:1229-1234, 2019.

Purpose of review The purpose of this manuscript is to highlight the latest advances in diagnosis and management of velopharyngeal incompetence (VPI) as it pertains to swallowing deficits in children. This is timely and relevant as otolaryngologists are often amongst the first to diagnose and treat VPI. Although nasal regurgitation of a bolus is frequently transient, persistent problems can be associated with other swallowing problems and other significant medical problems. Furthermore, velopharyngeal incompetence has implications for speech production. Recent findings Persistent VPI associated with a swallowing deficit can be an isolated anomaly with or without a cleft palate or submucous cleft palate. VPI may be secondary to a cranial neuropathy, esophageal abnormality or associated with another airway anomaly, any of which may further contribute to dysphagia. Findings of additional anomalies may be suggestive of a syndrome. Workup should explore these potential causes. When velopharyngeal incompetence is associated with dysphagia, fiberoptic endoscopic evaluation of swallow (FEES) and videofluoroscopic swallow study (VFSS) can be helpful in diagnosis and management. The advantages and disadvantages of FEES and VFSS have been well delineated over the past few years. Similarly, nasopharyngoscopy and fluoroscopy are increasingly used in diagnosis and management of VPI that is associated with hypernasal resonance disorders. Summary Concurrent medical diagnoses or syndrome manifestations are often associated with or contribute significantly to the cause of dysphagia in children with VPI. As VPI can be a sign of brainstem vagal neuropathy, the clinician should investigate by imaging the CNS if other correlative symptoms of dysphagia and examination findings are present. Endoscopy is advocated for evaluation of vocal fold function. Fluoroscopy is best for further assessment of airway protection or safety of swallow. And, whenever indicated, additional workup is recommended to determine an underlying cause of the swallowing disorder.

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.

Airway management in neonates with Pierre Robin sequence (PRS) can be challenging. The goal was to describe the algorithm developed by the authors over the past 8 years.A retrospective case series analyzing airway management in neonates with PRS admitted to the neonatal intensive care unit at a tertiary care pediatric hospital was performed. The utility of the proposed algorithm for airway management incorporating more consistent use of polysomnography (PSG), and airway assessment was assessed.A total of 31 neonates with PRS (12 men, 19 women) with a mean gestational age of 38.2 weeks were analyzed. Thirteen (41.9%) patients had a named syndrome, chromosomal abnormality, or global delay. Twenty (64.5%) patients had pre-intervention PSG, and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) ≥ 10 events/hour was identified in 19 (95.0%). Mandibular distraction osteogenesis was performed in 18 (58.1%) patients, and improved the AHI on post-operative PSGs. Direct assessment of the upper and lower airways was performed in 19 patients, and 13 (68.4%) were found to have secondary airway pathology. Presence of a concomitant syndrome was significantly associated with need for tracheostomy.The algorithm differs from previous ones in that it relies on rigorous pre- and post-intervention PSG (including with a nasopharyngeal airway), as well as that it allows flexibility between treatment options given the whole-patient clinical scenario and endoscopic findings. Results from these studies may be integrated to stratify patients into those who are most likely to benefit from conservative interventions or surgical procedures.

Introduction The diagnosis and management of type I laryngeal clefts can be controversial and varies across centers and surgeons. Using existing peer-reviewed literature to develop an expert-based consensus will help guide physicians in the treatment of these patients as well as develop research hypotheses to further study this condition. Objective To provide recommendations for the diagnosis and management of type I laryngeal clefts. Methods Determination of current expert- and literature-based recommendations, via a survey of the International Pediatric Otolaryngology Group, using a modified Delphi method. Setting Multinational, multi-institutional, tertiary pediatric hospitals. Results Consensus recommendations include diagnostic workup, medical management, pre-operative, intra-operative and post-operative considerations for type I laryngeal clefts. Conclusions This guide on the diagnosis and management of patients with type I laryngeal clefts is aimed at improving patient care and promoting future hypothesis generation and research to validate the recommendations made here.

Objectives To develop consensus recommendations for the evaluation and management of juvenile-onset recurrent respiratory papillomatosis (JORRP) in pediatric patients. Methods Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group. Results Consensus recommendations including diagnostic considerations, surgical management, systemic adjuvant therapies, postoperative management, surveillance, and voice evaluation. These recommendations are based on the collective opinion of the IPOG members and are targeted for otolaryngologists, primary care providers, pulmonologists, infectious disease specialists, and any other health care providers that manage patients with JORRP. Conclusions Pediatric JORRP consensus recommendations are aimed at improving care and outcomes in this patient population.

Objective This study aimed to describe complex tracheostoma reconstructions utilizing a pectoralis major myocutaneous flap. Results We present the case of two children who required extensive tracheostoma reconstructions. Both patients had chronic tracheostomies. The first child, aged 4, had underlying neuromuscular disorder. Her neck anatomy resulted in the formation of a keyhole stoma with erosion of the underlying cricoid cartilage. She underwent tracheostoma reconstruction using costal cartilage graft and use of a pectoralis major myocutaneous flap to recreate the superior aspect of the stoma. The second child, aged 5, had long-standing trach and underwent laryngotracheal reconstruction. In the postoperative setting, the patient developed a wound infection that resulted in breakdown of the overlying wound. A pectoralis major myocutaneous flap was required in the defect to recreate the wound bed. Both patients had successful wound bed creation and required no further procedures. Conclusion Chronic tracheostomies can result in superficial skin or tracheal breakdown, resulting in tracheostomy complications. Tracheostoma reconstruction is classically managed with debridement and local tissue flaps with use of either overlying skin or surrounding musculature. In patients with chronic wound breakdown, local tissue reconstruction can be challenging due to the fragility of the surrounding tissue. Use of virgin tissue outside the wound bed provides the best chance of recovery. The pectoralis major myocutaneous flap has the ability to be the ideal tissue source for extensive tracheostoma reconstruction. The flap is the workhorse of many head and neck oncologic procedures. The flap can provide adequate bulk from muscle and fat, overlying skin, and is within the surgical field to provide a robust blood supply. We advocate for the role of this flap in use with patients with chronic wound issues, poor wound healing, and failed prior stoma reconstructions.

Introduction The link between airway pathology and gastroesophageal reflux (GERD) has long been presumed critical to pediatric airway health. Recent studies have found no definitive correlation between the two. However, aerodigestive practitioners continue to identify GERD-related pathology as part of the workup for complex pediatric airway obstruction. Results This work presents a series of cases of airway obstruction with aerodigestive workup and GERD interventions that demonstrate the critical involvement of GERD in airway pathology. Each patient demonstrated either unusual patterns of airway injury with uncontrolled reflux on pH-impedance testing, or had resolution of airway pathology with definitive medical or surgical GERD management. Conclusions GERD can affect the airway significantly, resulting in airway inflammation, injury, and postoperative scarring. Aerodigestive programs must maintain their awareness of the detrimental effects of GERD on the airway. Better studies regarding GERD and airway injury are necessary to understand at-risk populations and optimal treatment strategies.

Objective The objective of this study was to review the utilization of a standardized tracheostomy handoff sheet to reduce tracheostomy-related complications. Methods A retrospective chart review was carried out of patients who underwent tracheostomy and had a dedicated tracheostomy handoff sheet utilized in the postoperative period. The handoff sheet contains trach size, backup trach size, airway findings, suction depth, location of maturation suture, location of stay sutures, and photograph of the wound bed on postoperative day 0. An anonymous survey of healthcare providers participating in the patient's care was undertaken regarding the utility of the dedicated trach handoff sheet. Results There were a total of 18 completed questionnaires. The majority of respondents felt the trach handoff sheet was helpful and provided vital information (4.61, scale 1–5). Hundred percent of respondents referenced the handoff sheet at some point during the hospital stay; 83% of respondents (15/18) felt the handoff sheet was more productive than a verbal handoff and 67% of respondents (12/18) preferred the sheet be available bedside rather than a digital format for reference in the electronic medical record. 89% of respondents (16/18) utilized the handoff sheet for wound care. Conclusion There are numerous aspects to proper tracheostomy care. From the immediate postoperative time period to several years out, proper care can make the difference for quality of life, respiratory standpoint, and airway safety. With a daily nursing handoff that at times can become redundant, utilization of a standardized tracheostomy handoff can lead to improve outcomes. These handoff sheets provide information deemed essential to optimal patient care and are always available bedside for review. Standardization and utilization of these tracheostomy sheets have led to decreased airway complications in emergency situations, reduced wound breakdown, and increased safety and efficiency in handoffs.

Objective To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia. Methods A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations. Results Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging. Conclusion Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.

Objectives To provide recommendations to otolaryngologists, pulmonologists, and allied clinicians for tracheostomy decannulation in pediatric patients. Methods An iterative questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group. Results Twenty-six members completed the survey. Recommendations address patient criteria for decannulation readiness, airway evaluation prior to decannulation, decannulation protocol, and follow-up after both successful and failed decannulation. Conclusion Tracheostomy decannulation recommendations are aimed at improving patient-centered care, quality and safety in children with tracheostomies.

Objectives/Hypothesis To analyze the association between sleep duration, metabolic variables, and insulin resistance in obese children with and without obstructive sleep apnea. The decline in sleep duration has paralleled a dramatic increase in the prevalence of obesity and diabetes, suggesting a mechanistic relationship. Study Design Retrospective, case series. Methods Consecutive obese patients 3 to 12 years of age who underwent polysomnography (PSG) and a metabolic panel and who completed a 14-item sleep questionnaire were analyzed. All laboratory testing was conducted within 3 months of PSG. Total sleep times were obtained from the PSG and confirmed by the questionnaire. Results A total of 171 patients (55.0% male) were studied. All patients were obese (body mass index [BMI] z score > 95th percentile). Patients were categorized into three groups: short sleepers, borderline sleepers, and optimal sleepers. Eighty-six (50.3%) patients were short sleepers, 71 (41.5%) were borderline sleepers, and 14 (8.2%) were optimal sleepers. The mean BMI z score was 3.13 ± 1.3 in short sleepers, 3.3 ± 1.1 in borderline sleepers, and 3.5 ± 1.5 in optimal sleepers (P = .39). There was no statistical difference in high- and low-density lipoprotein levels (P = .21 and P = .76, respectively) and total cholesterol (P = .43) among subgroups. Triglycerides, blood glucose, insulin, and homeostasis model assessment–insulin resistance were significantly higher in short sleepers when compared to borderline or normal sleepers (P = .008, P < .001, P < .001, and P < .001, respectively). Conclusions Short sleep duration was correlated with alterations in metabolic variables and insulin resistance in obese patients. This raises concern for development of comorbid conditions that can persist into adulthood. Level of Evidence 4 Laryngoscope, 2016

Objective To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia. Methods Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). Results Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy. Conclusion Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

Introduction Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation. Objective Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy. Methods Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method. Results Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: • on a standard definition of Suprastomal Collapse • that there is clinical importance between significant and insignificant collapse • that the gold standard diagnostic modality is endoscopic examination under anesthesia • that the severity of collapse is a major determinant in the surgical approach • that surgical intervention is the first line management in combined anterior and lateral Suprastomal Collapse. Conclusion This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

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.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.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.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.5 Laryngoscope, 129:244-255, 2019.

Objectives/Hypothesis Fiberoptic endoscopic evaluation of swallowing (FEES) is the only instrumental exam that can be used to assess swallowing in a breastfeeding infant. There is minimal data on its efficacy and safety in this patient population. Analyze the common indications for, findings of, and safety of FEES exam in breastfeeding infants. Study Design Case series. Methods Consecutive 10 months old or younger breastfed infants undergoing a FEES exam between June 1, 2012, and August 1, 2014, at a university-based, tertiary care urban children's hospital were studied. Common indications for and findings of FEES, as well as complications of the procedure, were determined. Results Twenty-four FEES were reviewed on 23 patients. There were 14 males (58%). The average age was 14 weeks, and two children were premature. Common indications for FEES were feeding difficulties (52%), noisy breathing with/without feeding (28%), and cyanosis (16%). Of the patients who participated in active breastfeeding during the exam, a functional swallow was identified in 12.5%. The remaining patients demonstrated dysphagia characterized by laryngeal penetration (83%) and/or direct aspiration (50%). The most common findings were laryngeal edema (29%), anterior displacement of glottis structures (14%), and cobblestoning (11%). There was no morbidity directly associated with the procedure. No cyanosis or respiratory distress occurred during or immediately after the procedure. Conclusion Performing FEES exams on breastfeeding infants is safe and effective. There is no other instrumental evaluation of swallowing to assess dysphagia in this population. Level of Evidence 4. Laryngoscope, 126:1681–1686, 2016

Objectives To develop consensus recommendations for peri-operative tracheotomy care in pediatric patients. Methods Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group. Results Consensus recommendations including pre-operative, intra-operative, and post-operative considerations, as well as sedation and nutrition management are described. These recommendations are based on the collective opinion of the IPOG members and are targeted to (i) otolaryngologists who perform tracheotomies on pediatric patients, (ii) intensivists who are involved in the shared-care of these patients, and (iii) allied health professionals. Conclusion Pediatric peri-operative tracheotomy care consensus recommendations are aimed at improving patient-centered care in this patient population.

We report on a father and his 4-year-old son sharing a characteristic dysmorphic facial phenotype (including hyperteleroism, prominent forehead, and wide nasal bridge), macrocephaly, hearing loss, palatal clefting, developmental delay, hypotonia and bony abnormalities including marked cranial sclerosis and sclerosis of the ribs and long bones, which evolved in severity in the son between the ages of 2 and 4 years. The father's radiographs also showed prominent coarse striations, patchy metaphyseal sclerotic plaques, markedly increased bone density and cortical thickening of long bones, and significant degenerative changes in the thoracic spine. The son has an additional history of sleep apnea resulting from multi-level airway obstruction that includes adenoid hypertrophy, lingual tonsil hypertrophy, subglottic stenosis, and supra-arytenoid tissue consistent with laryngomalacia and tracheomalacia. The clinical, radiographic, and genetic findings in father and son are consistent with a sclerosing skeletal dysplasia syndrome with similarities to mixed sclerosing bone dysplasia (MSBD) including metaphyseal plaques, osteopathia striata, and cranial sclerosis (OS-CS). This family may represent one of the first descriptions of familial inheritance and evolving phenotype in MSBD. The evidence for male-male transmission would support the existence of an autosomal mechanism of inheritance for a novel form of MSBD with characteristic syndromic features.

We present a unique and medically complex case of improved voice after lingual thyroidectomy. A 10-year-old boy with multifactorial dysphonia presented with bilateral vocal fold lesions and sulci in the context of hypothyroidism as a result of a congenital lingual thyroid gland. Despite hormone replacement, medical treatment for asthma, allergy, cough, and possible reflux, as well as voice therapy, the dysphonia persisted. Significant improvement in both subjective and objective voice measures was achieved after surgical removal of the lingual thyroid gland, which allowed for maintenance of a consistent euthyroid state. Lingual thyroidectomy is typically reserved for cases of bleeding and dysphagia. This case supports dysphonia as a possible additional indication for lingual thyroidectomy.

Two infants presented with intermittent stridor and evidence of laryngomalacia on flexible laryngoscopy. The first was a 10-month-old girl who had undergone 3 supraglottoplasty surgeries at an outside institution, without long-term resolution of symptoms. She was found during our evaluation to have a Chiari malformation. Laryngomalacia symptoms resolved after suboccipital decompression and C1 laminectomy, and the patient remained symptom-free at 6-month follow-up. The second infant was a 24-day-old boy with velocardiofacial syndrome who was found to have posterior cervicomedullary junction compression at the level of C1. He underwent C1 laminectomy for decompression of the brain stem, which resulted in immediate resolution of symptoms, and he remained symptom-free at 12-month follow-up. Neurologic abnormalities have been reported in up to 50% of infants with laryngomalacia. As such, brain stem dysfunction should be considered among the causes of laryngomalacia during evaluation, especially in patients with failure of supraglottoplasty. Both of these infants had resolution of symptoms after their neurosurgical procedures.

Laryngomalacia is a well described cause of newborn stridor. The spectrum of disease presentation, progression, and outcomes is varied. Some infants will have inconsequential stridor where others will develop feeding symptoms or even severe or life-threatening complications of airway obstruction. The purpose of this review is to identify factors that influence disease severity and outcomes.Review of the current literature and a prospectively collected database shows that patient factors that influence disease severity include APGAR scores, resting SAO2 level at time of presentation, and the presence of a secondary airway lesion. Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) contribute to feeding symptoms. Medical co-morbidities of GERD/LPR, neurologic disease, congenital heart disease, a genetic syndrome, or anomaly also contribute to disease severity and additively affect surgical outcomes. Those with severe disease requiring surgery who have GERD/LPR and one additional co-morbidity are more likely to require revision supraglottoplasty. Those with three medical co-morbidities are more likely to require tracheostomy.Most with laryngomalacia will have mild to moderate symptoms and not require surgical intervention. Those with GERD/LPR have symptoms improvement from acid suppression therapy. Those with severe enough disease to require supraglottoplasty will have minimal complications and good outcomes if multiple medical co-morbidities are not present. Those with multiple medical co-morbidities could be offered supraglottoplasty as the first intervention but counseled that tracheostomy may be required.

To determine the feasibility of providing streamlined same-day evaluation and surgical management of children with recurrent otitis media or chronic serous otitis media who meet criteria for tympanostomy tube (TT) placement.Retrospective matched case series.Tertiary care children's hospital.A comparison group (age, sex, insurance product) was utilized to determine if the same-day process decreased facility time and surgical time for the care episode. A parent satisfaction survey was administered.Thirty children, with a median age of 16 months (range, 12-22 months), participated in the same-day surgery process for TT. Twenty-one patients (70.0%) were male, and these patients were matched to a comparison group (similar age, sex, and insurance product) having non-same-day (routine) TT placement. The same-day patients spent significantly less time in clinic for the preoperative physician visit (average, 15 minutes) when compared with the non-same-day patients (average, 51.5 minutes; P.001). The operative experience for the same-day patients was similar to the non-same-day patients (average, 145 vs 137 minutes, respectively; P = .35), but the overall experience was significantly shorter for the same-day patients (average, 151 vs 196 minutes for comparisons; P.001). All parents surveyed in the same-day group were satisfied with the efficiency of the experience.The same-day surgery process for management of children who meet the criteria for TT placement is a model of improved efficiency of care for children who suffer from otitis media.