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Objective: Obstructive sleep apnea is common in children with Down syndrome (DS). Tonsillectomy is recommended as the first‐line approach in treating children with obstructive sleep apnea (OSA), however, there is limited data on the long‐term outcomes in children with DS who undergo tonsillectomy. In this retrospective study, we examined the long‐term polysomnographic and symptomatic outcomes in children with DS who underwent tonsillectomy with or without an adenoidectomy (T&A). We hypothesize that the success of T&A to treat OSA in children with DS will diminish with time. Study Design: A retrospective chart review of children with DS who underwent T&A between 2009 and 2015 was conducted. Inclusion criteria were children with at least 1 postoperative polysomnogram (PSG) within 6 months of T&A with an obstructive apnea/hypopnea index (OAHI) < 5. Outcomes were determined by subsequent clinic visits and postoperative polysomnograms: OAHI ≥ 5, snoring reported during clinic visit and time to reoccurrence. Setting: Childrens Hospital Colorado. Results: Of the 57 children with mild OSA at 1st (initial) PSG, 13/40 (33%) children had OAHI ≥ 5 at the 2nd postoperative PSG. Of the 18 patients who underwent a 3rd PSG, 4 (22%) progressed to moderate/severe OSA. A total of 17 patients out of the original 57 (30%) progressed to moderate/severe OSA with the median time for the additional post‐op PSG's being 2.3 years. Conclusion: Children with DS who have at most mild OSA (OAHI < 5) following a T&A are at risk for progressing to at least moderate OSA within 2 years after their T&A. A surveillance PSG 2 years following surgery will identify these children. [ABSTRACT FROM AUTHOR]

Objectives: Previous studies indicate children who pass an Asleep Room Air Challenge (AsRAC) do not have significant postoperative adverse respiratory events after adenotonsillectomy (T&A). Subsequently, we revised our overnight monitoring (OM) criteria, allowing patients with an obstructive apnea/hypopnea index (OAHI) ≤20 or nonsevere obesity (Class I) to be considered for same‐day surgery (SDS) if they passed an AsRAC. Our hypothesis is that our modified OM criteria would not increase the return visits or readmission rates for patients undergoing SDS within 48 h or 15 days of T&A. Methods: A retrospective review of all children aged ≥3 and <21 years who underwent T&A at a tertiary children's hospital and its satellite locations was performed from January 2017 to September 2022. Descriptive statistics and outcome measures were compared using a 3% margin noninferiority test before and after the new criteria implementation. Results: Before intervention, 3,266 (58%) T&As were performed as SDS. Afterward, 74% of T&As were performed as SDS (p‐value <0.05). There was no difference in the ED revisit rate for SDS within the 3% noninferiority margin. Following intervention, 29% more children with Class I obesity (62% vs. 33%) underwent SDS (p‐value <0.001). Afterward, 19% more children with polysomnography underwent SDS (39% vs. 20%), p‐value <0.001. After intervention, within 48 h of SDS, six (0.9%) children had revisits for bleeding and seven (1.2%) for vomiting. There were no perioperative respiratory events. Conclusion: Our revised monitoring criteria did not demonstrate an increase in ED visit or readmissions rates within 48 h or 15 days of T&A. Additionally, we found a 29% increase in Class I obese children undergoing SDS T&A. Level of Evidence: 3 Laryngoscope, 134:5223–5230, 2024 [ABSTRACT FROM AUTHOR]

Objective: To determine if children with greater social vulnerability are more likely to experience a prolonged oxygen requirement (POR) following adenotonsillectomy to inform the need for overnight monitoring prior to discharge. Methods: A previously published prospective study assessing children observed overnight following adenotonsillectomy for obstructive sleep‐disordered breathing was reanalyzed including social vulnerability index (SVI). The outcome was POR beyond 3 h following extubation. Logistic regression was used to assess the association of SVI components with POR. SVI components were assessed as quartiles of cohort values. Final adjusted models included race, asthma, Down syndrome, and pre‐operative SpO2. Results: A total of 462 children had SVI data available and were included. 354 (76.6%) were > = 3 years of age. Overall, 351 (76%) did not have a POR. The median overall SVI percentile was 26.5 (Q1 10.4, Q3 60.1). When categorized by SVI quartiles, there was a statistically significant difference with POR for overall SVI percentile (p = 0.007), SVI household composition percentile (p = 0.033), and median SVI housing/transportation percentile (p = 0.005). Individuals with an overall SVI in the 4th quartile (greatest vulnerability) were 2.63 times more likely to experience a POR than those in the 1st quartile (lowest social vulnerability) in adjusted logistic regression (95% OR CI 1.23–5.62; p = 0.01). Conclusions: There is a significant association between greater neighborhood‐level social vulnerability and a POR following adenotonsillectomy. We propose that a child's SVI be considered when planning for the perioperative course following adenotonsillectomy. Level of Evidence: 3 Laryngoscope, 134:2449–2454, 2024 [ABSTRACT FROM AUTHOR]

Objective: Girls with Turner syndrome (TS) often have features that have been associated with obstructive sleep‐disordered breathing (oSDB). However, little is known about oSDB in TS. Herein, we aimed to characterize oSDB in young patients with TS and identify associated risk factors. Study Design: Retrospective cross‐sectional study. Setting: Tertiary care pediatric hospital. Methods: We reviewed medical records for patients diagnosed with TS seen at our institution between October 1, 2007 and December 31, 2019 with the first outpatient visit before age 6 years. The prevalence of oSDB was compared to the general pediatric population with 1‐sample binomial proportion tests. Clinical characteristics were compared between those diagnosed with oSDB and those without oSDB, and risk factors for oSDB were identified. Results: Of 151 patients with TS, 73 (48%) were diagnosed with oSDB which is 4‐fold higher than the general pediatric population (12%, P < 0.0001). In the multivariable model, adenoid, tonsillar, and inferior turbinate hypertrophy, birthweight, failure to thrive, and older age at the last clinic visit were all associated with increased odds for oSDB. Conclusion: Young children with TS have a high prevalence of oSDB and thus should be screened for oSDB. Polysomnography should be performed in those with associated risk factors and symptoms oSDB. Treatment of oSDB is imperative as individuals with TS are already at increased risk of behavioral problems, neurocognitive deficits, and growth impairment that may be worsened with oSDB. [ABSTRACT FROM AUTHOR]

Objective: To analyze the growth trajectory of children with obesity before and after adenotonsillectomy (T&A). We hypothesize that T&A will not affect the growth trajectory but children in a multidisciplinary weight management program (MWMP) will have a healthier growth trajectory. Study Design: Retrospective review. Setting: Tertiary Children's Hospital. Methods: Body mass index (BMI) trajectories of nonsyndromic children with obesity and obstructive sleep apnea (OSA) who underwent T&A were analyzed. A linear mixed effects model was fit to the BMI expressed as a percentage of the 95th percentile (%BMIp95) data. Covariates included demographic variables, pre‐ and postoperative participation in an MWMP, baseline obesity class, and time. We explored clinically meaningful interactions. BMI slope estimates before and after surgery were calculated and compared for baseline obesity classification and postoperative MWMP visits. Results: A total of 177 patients, 58% male with a mean age of 9.7 years at the time of surgery, were studied. Higher baseline obesity class (II and III), time, the interaction between obesity class III and elapsed time relative to surgical date, and the interaction between obesity class III and the postsurgical period were all significantly associated with the outcome of %BMIp95 (P <.05). There was a significantly higher %BMIp95 trajectory following surgery in patients with baseline obesity class III who did not have any postoperative MWMP visits (P <.001). Preoperative obesity visits, however, were not significantly associated with postoperative growth. Conclusion: The association between T&A and weight trajectory depends upon obesity class and participation in a MWMP. Coordinated care of children with obesity between otolaryngologists and an MWMP may improve OSA and obesity outcomes. Level of Evidence: The level of evidence: 3. [ABSTRACT FROM AUTHOR]

Objective: The objective of this quality initiative project was to modify our existing institutional drug-induced sleep endoscopy (DISE) protocol so that the surgeon could consistently determine obstructive breathing patterns while minimizing children's discomfort. Methods: A quality initiative study utilizing the well-described plan-do-study-act (PDSA) process was conducted at a tertiary hospital for children with polysomnogram-documented obstructive sleep apnea who were undergoing DISE. A 4-point Likert measurement tool was created. Change in each Likert rating with subsequent PDSA cycle was tested with the Wilcoxon rank sum test (Mann-Whitney), and change across all PDSA cycles was tested with the Kruskal-Wallis equality-of-populations rank test. Results: After a series of 4 PDSA cycles with 81 children, the DISE protocol was streamlined from 14 to 9 steps. There was significant improvement for all aspects of the DISE, with a final overall median rating of 1 (excellent) for intravenous (IV) placement, scope insertion, and anesthesiologist and surgeon satisfaction (P <.01) Discussion: For sleep surgeons, DISE is quickly becoming what bronchoscopy is to the airway surgeon. Utilizing inhalational agents to obtain IV access and insert the flexible scope in the rapid "on-off" fashion optimizes DISE success regardless of the primary sedation medication and allows ample time for these agents to dissipate. Implications for Practice: Adoption of a DISE protocol that includes nasal premedication and inhalational volatile gases for IV and scope insertion at the onset provides a more predictable level of sedation that is well tolerated by the patient, enabling the otolaryngologist to create an obstructive sleep apnea treatment plan. [ABSTRACT FROM AUTHOR]

Objective. The widespread use of antibiotics for treatment of acute otitis media (AOM) has resulted in the emergence of multidrug-resistant pathogens that are difficult to treat. However, it has been shown that most children with nonsevere AOM recover without ABX. The objective of this study was to evaluate the safety, efficacy, acceptability, and costs of a non-ABX intervention for children with nonsevere AOM. Methodology. Children 6 months to 12 years old with AOM were screened by using a novel AOM-severity screening index. Parents of children with nonsevere AOM received an educational intervention, and their children were randomized to receive either immediate antibiotics (ABX; amoxicillin plus symptom medication) or watchful waiting (WW; symptom medication only). The investigators, but not the parents, were blinded to enrollment status. Primary outcomes included parent satisfaction with AOM care, resolution of symptoms, AOM failure/recurrence, and nasopharyngeal carriage of Streptococcus pneumoniae strains resistant to ABX. Secondary outcomes included medication-related adverse events, serious adverse events, unanticipated AOM-related office and emergency department visits and telephone calls, the child&apos;s absence from day care or school resulting from AOM, the parent&apos;s absence from school or work because of their child&apos;s AOM, and costs of treatment. Subjects were defined as failing (days 0-12) or recurring (days 13-30) if they experienced a higher AOM-severity score on reexamination. Results. A total of 223 subjects were recruited: 73% were nonwhite, 57% were Conclusions. Sixty-six percent of subjects in the WW group completed the study without ABX. Parent satisfaction was the same between groups regardless of treatment. Compared with WW, immediate ABX treatment was associated with decreased numbers of treatment failures and improved symptom control but increased ABX-related adverse events and a higher percent carriage of multidrug-resistant S pneumoniae strains in the nasopharynx at the day-12 visit. Key factors in implementing a WW strategy were (a) a method to classify AOM severity; (b) parent education; (c) management of AOM symptoms; (d) access to follow-up care; and (e) use of an effective ABX regimen, when needed. When these caveats are observed, WW may be an acceptable alternative to immediate ABX for some children with nonsevere AOM. Pediatrics 2005;115:1455-1465; otitis media/diagnosis, otitis media/therapy, otitis media/drug therapy, randomized, controlled trial, child, child/preschool. ABBREVIATIONS. AOM, acute otitis media; ABX, antibiotic(s); WW, watchful waiting; OM-3, otitis media symptom questionnaire, 3 items; OS-8, otoscopy score, 8 grades of severity; AOM-Si, acute otitis media total severity index; ETG-5, ear treatment group symptom questionnaire, 5 items., Acute otitis media (AOM) accounts for 60% of the antibiotics (ABX) written for children. (1) ABX treatment has contributed to the emergence of multidrug-resistant pathogens by permitting the selection of [...]

Objectives/Hypothesis: Children who do not require oxygen beyond 3 hours after surgery and pass a sleep room air challenge (SRAC) are safe for discharge regardless of polysomnogram (PSG) results or comorbidities. Study Design: Cross‐sectional prospective study. Methods: All children observed overnight undergoing an adenotonsillectomy for obstructive sleep‐disordered breathing were prospectively recruited. Demographic, clinical, and PSG characteristics were stratified by whether the patient had required oxygen beyond 3 hours postoperatively (prolonged oxygen requirement [POR]) and compared using t test, chi‐squared test, or Fisher's exact test depending on distribution. Optimal cut points for predicting POR postsurgery were calculated using receiver operating characteristic curves. The primary analysis was performed on the full cohort via logistic regression using POR as the outcome. Significant characteristics were analyzed in a logistic regression model, with significance set at P <.05. Results: A total of 484 participants met the inclusion criteria. The mean age was 5.65 (standard deviation = 4.02) years. Overall, 365 (75%) did not have a POR or any other adverse respiratory event. In multivariable logistic regression, risk factors for POR were an asthma diagnosis (P <.001) and an awake SpO2 <96% (P =.005). The probability of a POR for those without asthma and a SpO2 ≥ 96% was 18% (95% confidence interval: 14–22). Age, obesity, and obstructive apnea/hypopnea index were not associated with POR. Conclusions: In conclusion, all children in our study who are off oxygen within 3 hours of surgery and passed a SRAC were safe for discharge from a respiratory standpoint regardless of age, obesity status, asthma diagnosis, and obstructive apnea/hypopnea index. Additional investigations are necessary to confirm our findings. Level of Evidence: 3 Laryngoscope, 132:1675–1681, 2022 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To reanalyze the growth trajectory and assess longitudinal changes of children undergoing adenotonsillectomy (AT) versus watchful waiting (WW) enrolled in the Childhood Adenotonsillectomy Trial (CHAT) study and to determine if an AT increases the risk of obesity in children. Study Design: Reanalysis of prospective cohort investigation. Methods: The study analyzed publicly available data from CHAT, including 3 months visit data not previously included in a prior publication. Statistical comparisons and mixed‐effects modeling were done using age‐ and sex‐specific BMI expressed as a percentage of the 95th percentile (%BMIp95). P <.05 was considered significant. Results: Children in the AT group, especially if underweight at baseline, had an increased rate of weight gain, with 100% of underweight children in the AT group becoming normal weight compared to 20% for WW. However, the rate of weight gain, as measured by the %BMIp95 trajectory for both AT and WW groups, was not significantly different when baseline weight status and obstructive sleep apnea (OSA) resolution were accounted for. Comparisons of %BMIp95 between treatment groups at baseline, 3‐ and 7‐month follow‐up visits also failed to identify statistically significant differences (P >.05). Overall for the entire cohort, resolution of OSA was associated with a decreased weight trajectory (P <.001). Conclusions: AT compared to WW is not associated with an increased risk of excessive weight gain. Otolaryngologists should be aware of this updated analysis when discussing AT surgical outcomes with families. Level of Evidence: 2 Laryngoscope, 132:1289–1294, 2022 [ABSTRACT FROM AUTHOR]