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Objectives To describe three new cases of vincristine-induced vocal cord paresis or paralysis (VIVCPP) in children and to review the diagnosis and management of this neuropathy. Methods Retrospective case series. Diagnosis of VIVCPP was confirmed by laryngoscopy in all children. Results Less than 20 cases of VIVCPP in children have been previously documented in the literature. Of the three children in our case series, one had unilateral vincristine-induced vocal cord paresis and two had bilateral VIVCPP. The first two patients each had two separate episodes of paresis, lasting 4 months and 1 month respectively. In the last patient, whose medical course was complicated by many additional factors, vocal cord paralysis persisted for over three years. Conclusions Clinicians must evaluate children with suspected VIVCPP for concomitant symptoms and signs of vincristine neuropathies and examine the vocal cords via laryngoscopy. The effects of vincristine neurotoxicity can be waxing and waning, demonstrate delayed onset and persist well beyond drug cessation. Further studies are needed to identify effective neuroprotectants and delineate appropriate vincristine dosing in patients with vincristine neurotoxicity and cancer.

This study aimed to compare outcomes of concomitant palatoplasty and sphincter pharyngoplasty with pharyngeal flap and sphincter pharyngoplasty alone for the treatment of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome. Thirty-one cases were identified for inclusion in the study. Patients were separated into 3 surgical groups: combined palatoplasty and sphincter pharyngoplasty (n = 11), pharyngeal flap (n = 7), and sphincter pharyngoplasty (n = 13). Outcome measures included perceptual speech analyses, surgical complications, and revision rates. There were no differences in preoperative speech analysis scores (P = .31). The combined palatoplasty and sphincter pharyngoplasty procedure had similar speech outcomes compared to pharyngeal flap, and both were significantly better than sphincter pharyngoplasty alone. Complication rates (P = .61) and the need for revision surgery (P = .25) were similar among all 3 groups. Concomitant palatoplasty and sphincter pharyngoplasty may be an alternative treatment for velopharyngeal insufficiency in children with 22q11.2 deletion syndrome.

Background Voice abnormalities often go unrecognized in patients with 22q11.2 deletion because speech abnormalities become the focus of evaluation. Objective To analyze voice and vocal fold abnormalities in patients with 22q11.2 deletion by examining voice, not speech. Methods This is a case series with chart review from 2009 to 2016. Records of both a velocardiofacial syndrome (VCF) clinic and pediatric otolaryngology clinic at a tertiary pediatric hospital were reviewed. All patients with confirmed 22q11.2 deletion were identified. Cardiac, otolaryngological, speech, and voice characteristics were recorded along with surgical history. Main outcomes included voice characteristics based on speech therapy assessment, along with vocal fold or laryngeal abnormalities. Co-morbidities and surgical history were also recorded. Results 109 patients were identified with 22q11.2 deletion by genetic testing. Eighteen percent (n = 20) displayed a vocal fold or laryngeal abnormality, either congenital or iatrogenic. The most common congenital abnormalities were laryngeal web (n = 10) and subglottic stenosis (n = 7). The most common iatrogenic abnormality was paralyzed left vocal fold (n = 4). Perceptual analysis by speech therapy showed 65% (n = 71) with a voice within normal limits while 17% (n = 19) were not within normal limits. Of the 20 patients with a vocal fold abnormality, 15% (n = 3) presented a voice within normal limits, while 65% (n = 13) were not within normal limits. Of the 19 patients with a voice outside normal limits, 68% (n = 13) had a diagnosed vocal fold abnormality. Sixteen percent (n = 3) of these patients had an abnormal voice as a result of other issues. Conclusion Out of 109 patients with 22q11.2 deletion, 18% displayed a laryngeal abnormality and 17% had abnormal vocal quality. This suggests that voice and vocal fold abnormalities are important to consider in this population. Distinguishing between speech and voice abnormalities in patients with 22q11.2 deletion can help ensure appropriate intervention.

Objective Describe the factors that exacerbate upper airway obstructions (UAOs) in neonates. Study design Retrospective chart review. Setting Pediatric tertiary care hospital. Subjects and methods All neonates hospitalized between 1/1/2010 and 12/31/2014 diagnosed with either: 1) laryngomalacia, 2) Pierre Robin sequence, or 3) vocal cord paralysis were included in this study. Patient charts were reviewed to determine factors that exacerbated symptoms of airway obstruction. The independent variable was patient diagnosis, and the outcome measure was exacerbating factors. Results In patients with laryngomalacia (n = 31), 41.9% worsened with agitation, 38.7% worsened with feeding, 16.1% worsened with positioning, 0.0% worsened during sleep, and 25.8% had no aggravating factors. In Pierre-Robin patients (n = 31), 48.4% worsened with agitation, 16.1% worsened with feeding, 61.3% worsened with positional changes, 0.0% worsened during sleep, and 12.9% had no aggravating factors. In vocal cord paralysis patients (n = 25), 72.0% worsened with agitation, 8.0% worsened with feeding, 20.0% worsened with positional changes, 4.0% worsened during sleep, and 24.0% had no aggravating factors. Conclusion Airway obstruction was not reliably exacerbated during sleep for any of the diagnoses studied in this review. Our findings show that agitation exacerbates airway obstruction in most patients with vocal cord paralysis, and positioning exacerbates airway obstruction in the majority of patients with PRS. Aggravating factors in laryngomalacia are variable. These findings question the utility of polysomnography as a diagnostic tool for hospitalized neonates with these conditions. Level of evidence 4.

22q11.2 deletion syndrome (22q11.2DS) is a common genetic disorder with enormous phenotypic heterogeneity. Despite the established prevalence of developmental and neuropsychiatric issues in this syndrome, its neuroanatomical correlates are not as well understood. A retrospective chart review was performed on 111 patients diagnosed with 22q11.2DS. Of the 111 patients, 24 with genetically confirmed 22q11.2 deletion and brain MRI or MRA were included in this study. The most common indications for imaging were unexplained developmental delay (6/24), seizures of unknown etiology (5/24), and unilateral weakness (3/24). More than half (13/24) of the patients had significant radiographic findings, including persistent cavum septi pellucidi and/or cavum vergae (8/24), aberrant cortical veins (6/24), polymicrogyria or cortical dysplasia (4/24), inner ear deformities (3/24), hypoplastic internal carotid artery (2/24), and hypoplastic cerebellum (1/24). These findings reveal the types and frequencies of brain malformations in this case series, and suggest that the prevalence of neuroanatomical abnormalities in 22q11.2DS may be underestimated. Understanding indications for imaging and frequently encountered brain malformations will result in early diagnosis and intervention in an effort to optimize patient outcomes.

This article reviews the presentation of children with craniofacial anomalies by the most common sites of airway obstruction. Major craniofacial anomalies may be categorized into those with midface hypoplasia, mandible hypoplasia, combined midface and mandible hypoplasia, and midline deformities. Algorithms of airway interventions are provided to guide the initial management of these complex patients.

Objective The aim of this case study is to demonstrate that post-operative complication rates of sublingual gland excision for treatment of ranulas are equal to or less than alternative methods with a lower recurrence rate than other surgical methods. Methods This was a retrospective review of pediatric patients from 2004 to 2015 at Children's Hospitals and Clinics of Minnesota. Sixteen ranulas and 6 plunging ranulas were treated via sublingual gland excision during this time frame. Data examined included age, gender, scans of the lesion, location and size of lesion, surgical procedures, complications, and recurrence. Results There were 22 patients who met criteria. Only one patient had recurrence of the lesion (4.5%). One patient reported lateral tongue numbness post-operatively, and one patient had a hypoglossal nerve injury, with tongue deviation upon exam. Both of these complications were temporary and resolved within months of the procedure. Conclusion Although sublingual gland excision is a definitive treatment for ranulas, many surgeons still utilize other methods such as marsupialization, drainage of the cyst, or excision of ranula alone as the primary method of treatment due to concerns about complications. This retrospective study demonstrates that excision of the sublingual gland is both a safe and effective method of treatment for ranulas.

Objective To describe the sleep and speech outcomes in patients with cleft palate who underwent superior adenoidectomy. Subjectives and methods This is a case series with chart review of patients with diagnoses of cleft palate and sleep disordered breathing (SDB), obstructive sleep apnea (OSA) or nasal obstruction treated with superior adenoidectomy from 1991-2015 at the Children’s Hospital of Minnesota. Postoperative clinic notes documented the changes in symptoms following surgery. All speech outcomes were recorded. Results Fifty patients (23 females, 27 males) aged 11 months to 17 years were included. Forty-six patients (92%) had improvement of sleep symptoms including snoring, nighttime restlessness, and witnessed apnea events, following superior adenoidectomy. Forty-two of the 46 patients (91%) had stable speech postoperatively with either no development or no worsening of velopharyngeal insufficiency (VPI). Conclusion Superior adenoidectomy is an effective procedure to alleviate symptoms of sleep disordered breathing in patients with cleft palate without significantly affecting speech.

This abstract was presented at the American Academy of Otolaryngology-Head and Neck Surgery Annual Meeting, Orlando, FL, September 2014 with the abstract published (Neumann C, Thompson D, and Sidman J; Assisted reproduction is not associated with increased risk of head and neck defects; Otolaryngology-Head and Neck Surgery; Vol 151, Issue 1, supplement, 2014). Objectives - Compare the rate of head and neck anomalies between children conceived via artificial reproductive technology (ART) versus those conceived via natural methods. - Determine the risk of congenital head and neck abnormalities associated with ART. Study design A retrospective chart review cross-sectional study from 2004-2014 of all patients admitted to the neonatal intensive care unit (NICU) at a tertiary pediatric hospital. Results A total of 14,857 charts were examined; 2,288 patients were conceived via ART, while 12,569 patients were conceived via natural methods. There were 8,022 males and 6,637 females. There were 40 patients born with defects via ART, while there were 681 patients born with defects via natural conception. The total occurrence of congenital malformations was higher for patients conceived naturally versus those conceived with artificial reproduction (5.41% vs. 1.74%). The odds ratio was 0.31 with a 95% CI of 0.23 to 0.43 and a P-value of < 0.0001; the relative risk of having any one of the head and neck defects with ART was 1.04 with a 95% CI of 1.03 to 1.05 and a P-value < 0.0001. Conclusion There appears to be no increased risk of congenital head and neck defects in children conceived via ART versus those conceived naturally.

(1) Describe an institutional protocol that focuses on the essential steps for decannulation of pediatric patients with long-term tracheostomies. (2) Discuss the preliminary observations of the safety of this protocol in regard to decannulation failures and successes in a selected patient population.Case series with chart review.A tertiary pediatric hospital.Subjects were pediatric patients with chronic tracheostomies undergoing decannulation. Ages ranged from 1 to 17 years old. Indications for initial tracheostomy included chronic lung disease, airway obstruction, and trauma.Subjects underwent decannulation attempt following a specific protocol. The protocol consisted of operative laryngoscopy and bronchoscopy. If the airway was deemed adequate for decannulation at that time, the tracheotomy tube was removed, and the child was monitored overnight; the patient was considered for discharge the following day if no complications arose. No routine capping, downsizing, or polysomnography was performed.Thirty-five patients fit the criteria and were decannulated within 24 hours of endoscopy. Successful decannulation served as the primary outcome. Of the 35 decannulated patients, 54% (n = 19) were discharged the day following decannulation and another 37% (n = 13) on postdecannulation day 2. There were no acute failures or readmissions. Average inpatient stay for those decannulated was 1.8 days.This study describes the preliminary observations of a decannulation protocol in a small subset of patients. The protocol resulted in no acute failures and offers a conservative approach to resource utilization, making it unique when compared with other published protocols.

The mandible is arguably the most frequently fractured facial bone in children. However, facial fractures are rare in children compared with adults, resulting in few large studies on patterns of pediatric facial fractures.To report the patterns, demographics, and cause of pediatric mandible fractures across the United States.A retrospective analysis was conducted of the Healthcare Cost and Utilization Project's National Emergency Department Sample from January 1 to December 31, 2012, using the International Classification of Disease, Ninth Revision, codes for mandible fractures (802.20-802.39) among patients 18 years and younger who presented to emergency departments. Demographics, fracture site, and fracture mechanism were analyzed to identify factors associated with fractures. Analysis was conducted from July 9 to July 28, 2015.There were 1984 records, representing a weighted estimate of 8848 cases of pediatric mandible fracture. The mean patient age was 14.0 years (95% CI, 13.6-14.3). The male to female ratio was 4:1 and females were comparatively younger, with a mean age of 12.5 years (95% CI, 11.8-13.1; P .001). The most frequently fractured sites were the condyle, in 1288 patients (14.6% [95% CI, 12.6%-16.5%]), and the angle, in 1252 patients (14.1% [12.4%-15.9%]). Associated intracranial injuries occurred in 756 patients (8.5% [7.1%-10.0%]), and cervical spine fractures occurred in 393 (4.4% [3.5%-5.4%]). The fracture site and mechanism of injury varied with age and sex. For patients 12 years and younger, the most frequent fracture site was the condyle, accounting for 636 fractures (27.9% [24.2%-31.6%]), and the most frequent cause was falls, accounting for 692 fractures (30.3% [25.9%-34.8%]). In teenaged patients (13-18 years), the angle was the most frequent fracture site, accounting for 1157 fractures (17.6% [15.6%-19.6%]), and the most frequent cause was assault, accounting for 2619 fractures (39.9% [36.4%-43.3%]). For male patients, the angle was the predominant site, accounting for 1053 fractures (15.0% [13.1%-16.8%]), and the leading cause was assault, accounting for 2360 fractures (33.5% [30.2%-36.9%]). For female patients, the condyle was the most frequent site, accounting for 369 fractures (20.3% [16.0%-24.6%]), and the leading cause was falls, accounting for 422 fractures (23.2% [18.6%-28.0%]).In this study, age and sex disparities among pediatric mandible fractures were identified. Younger patients and female patients tend to have condyle fractures caused more commonly by falls while older patients and male patients tend to have angle fractures caused by assault.NA.

The occurrence of palatal fistulae in children with a cleft palate deformity after primary palatoplasty remains a relatively common complication. Symptomatic fistulae may cause problems with nasal air escape, nasal regurgitation, decreased speech intelligibility, articulation errors, and halitosis. A thorough understanding of the multiple reconstructive options, ranging from local flaps to free tissue transfer, is important in obtaining good patient outcomes. In this article, we describe some of the most commonly used methods for palatal closure.

Objective: Tonsillectomy is one of the most common pediatric surgical procedures performed in the United States. The postoperative period can be particularly painful, and there is currently no consensus on an optimal analgesic regimen. The objective of this study was to evaluate efficacy and safety of the single drug tramadol versus codeine/acetaminophen post-tonsillectomy. Design: Prospective, double-blinded, randomized controlled trial. Setting: Large, Midwestern US pediatric hospital. Patients: Eighty-four children aged 4-15 years who underwent a tonsillectomy (with or without adenoidectomy) procedure were randomized and 74 were included in the analysis. Interventions: Group 1 received liquid codeine/acetaminophen for 10 days post-tonsillectomy (5 days scheduled, followed by 5 days as-needed). Group 2 received liquid tramadol for 10 days post-tonsillectomy (5 days scheduled, followed by 5 days as-needed). Main outcome measures: Efficacy and side effects were evaluated using a 10-day take-home diary that was completed by parents. Results: Children in both study arms reported adequate post-tonsillectomy pain management without significant differences between groups in pain scores. Oversedation was significantly higher on the day of surgery in the codeine/acetaminophen group, and itching was experienced by significantly more children in the tramadol group during the postoperative period. Conclusions: As part of multimodal analgesia, scheduled plus as-needed tramadol may be considered for children in the postoperative setting due to its analgesic properties, low potential for side effects, and good safety profile.

Objectives/Hypothesis To determine the prevalence of long-term hearing loss in patients with cleft palate who fail their universal newborn hearing screen. Study Design The study is a retrospective chart review from a tertiary pediatric center and tertiary children's hospital. Methods Newborns with cleft palate born between January 2002 and July 2012 were identified from a pediatric otolaryngology practice database. This cohort was then reduced to include only those patients who referred their universal newborn hearing screen. Postpressure equalization tube audiology results, follow-up audiology results, type of cleft, and comorbid conditions were collected for each patient who was both born with a cleft palate and referred their universal newborn hearing screen. Results A total of 317 newborns presented to the pediatric otolaryngology practice for cleft palate, with 89 (28%) having documented referred universal newborn hearing screen. At the time of data collection, 67 (75%) of 89 had normal hearing results, whereas 22 (25%) of 89 did not yet have normal hearing results. Fourteen patients had permanent hearing loss, and all 14 had a comorbid condition. Type of cleft and presence of a comorbid condition were correlated to hearing outcomes. Conclusions Newborns with cleft palate who refer their universal newborn hearing screen could postpone diagnostic hearing testing until after placement of pressure equalization tubes, unless there is a clue to permanent hearing loss such as a comorbid condition. Level of Evidence 4 Laryngoscope, 124:E384–E388, 2014

To compare surgical outcomes between pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty in the management of pediatric velopharyngeal insufficiency.Case series with chart review.Tertiary care pediatric hospital.After exclusion of children with velocardiofacial syndrome, 96 patients who underwent surgical intervention between 2008 and 2012 were identified. Surgical interventions were categorized as pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty. Main outcome measures included perceptual speech analyses, complications, and surgical revision rates.Of the 96 reviewed patients, 38 (39.6%) underwent pharyngeal flap, 20 (20.8%) sphincter pharyngoplasty, and 38 (39.6%) combined Furlow palatoplasty and sphincter pharyngoplasty. Choice of surgical intervention was based on patient characteristics, observed palatal length, and formal speech assessments. There were no differences in patient demographics or preoperative perceptual speech analysis scores among the 3 surgical groups. The mean speech improvement was significantly greater in both the pharyngeal flap (P = .031) and combined procedure (P = .013) compared with sphincter pharyngoplasty alone, but no differences were observed between the pharyngeal flap and combined procedure (P = .797). There were no differences in complications among the 3 surgical interventions (P = .220). The combined procedure required significantly less surgical revisions than the pharyngeal flap (P = .019).Combined Furlow palatoplasty and sphincter pharyngoplasty is an effective procedure for the management of pediatric velopharyngeal insufficiency and may result in superior speech outcomes and lower revision rates than sphincter pharyngoplasty and pharyngeal flap, respectively.

Although facial vascular malformations are often treated by facial plastic surgeons, no reliable validated assessment tool exists for surgeons to assess results.To use our assessment tool to analyze results from pulsed-dye laser therapy used for pediatric facial vascular malformations, and to determine interrater reliability of our assessment tool in a standard clinical environment without the use of professional photography.A blinded retrospective review of pediatric patients who underwent pulsed-dye laser therapy for treatment of hemangiomas of infancy (HOIs) and port-wine stains. Three pediatric otolaryngologists and facial plastic surgeons independently rated all of the pictures using our assessment tool.Tertiary care pediatric hospital.Pulsed-dye laser therapy was performed in 22 patients, 17 with HOIs and 5 with port-wine stains. Patients with HOIs treated only by pulsed-dye laser showed, on average, a 50% to 75% improvement in color, 1% to 24%, improvement in thickness, and 1% to 24% improvement in size of the lesion. Eight patients with HOIs underwent surgery after laser therapy, and of these, 100% saw improvement in color, thickness, and size. Port-wine stains showed a 1% to 24% improvement in color and no improvement in thickness or size. Interrater reliability for questions 1 to 6 was 0.92, 0.92, 0.93, 0.91, 0.70, and 0.10, respectively.Currently, no standardized or validated methods exist to evaluate results from intervention of pediatric facial HOIs and port-wine stains. Our assessment tool is reliable to assess patients with HOIs and port-wine stains who undergo pulsed-dye laser therapy and surgical reconstruction.3.

To describe pediatric costochondral graft reconstruction of the absent mandibular condyle and to report the short-term and long-term outcomes and complications associated with performing this procedure in young children.Case series with a retrospective chart review.Pediatric otolaryngology clinic and tertiary children's hospital in a metropolitan area.All children treated for an absent mandibular condyle with a costochondral graft at Children's Hospitals and Clinics of Minnesota were identified from 2002 through 2011, and a retrospective chart review was performed.Ten patients aged 3 to 11 years were identified. The most common diagnosis, in 8 of 10 patients, was oculo-auriculo-vertebral syndrome. Three of the patients had a tracheostomy, of which 1 was decannulated following condylar reconstruction. Functional improvement, defined as improved symmetry, chewing, or better oral opening, was observed in 8 of 10 patients. Five patients have required no further surgeries to date, with a mean follow-up time of 3.9 years. Severe overgrowth of the graft was noted in 1 case, and partial or complete resorption of the graft was also noted in 3 cases. Overgrowth occurred after 5.7 years, whereas resorption occurred after an average of 2.5 years.Costochondral grafts are an excellent surgical treatment option for children with severe mandibular malformations. Short-term results show particular improvement in function and mandibular alignment. The mean follow-up time with no revision surgery was substantial and indicates that rib grafting is a good addition to the armamentarium of treatment for this patient population.

To determine national variations in resource utilization for primary repair of cleft lip, identify patient and institutional factors associated with high resource use, and estimate the current incidence of cleft lip in the United States.Retrospective analysis of a national, pediatric database (2009 Kids' Inpatient Database [KID]).Patients aged 1 year and younger were selected using international classification of disease codes for cleft lip and procedure codes for cleft lip repair. A number of demographic variables were analyzed, and hospital charges were considered as a measure of resource utilization.There were 1318 patients identified. The national incidence was 0.09%, with a male to female ratio of 1.8:1. Regional incidence varied from 0.07% (Northeast) to 0.10% (West). The mean age at surgery was 4.2 months. The average length of stay was 1.4 days. The national average hospital charge was $20,147, ranging from $14,635 (South) to $23,663 (West). Teaching hospitals charge an average of $9764 higher than nonteaching hospitals. The strongest predictor of charge was length of stay, increasing charge by $8102 for every additional hospital day (P.01).Regional variations exist in resource utilization for primary cleft lip repair. Resource use is higher in the West and among teaching hospitals.

Objectives/Hypothesis: To estimate the current incidence of cleft palate in the United States and to determine national variations in resource utilization for primary repair of cleft palate. Study Design: Retrospective analysis of a national, pediatric database (2009 Kids Inpatient Database). Methods: Patients aged 3 and below admitted for cleft palate repair were selected, using ICD-9 codes for cleft palate and procedure code for primary (initial) repair of cleft palate. A number of demographic variables were analyzed, and hospital charges were considered as a measure of resource utilization. Results: Primary repair of cleft palate was performed on 1,943 patients. The estimated incidence was 0.11% with male to female ratio of 1.2:1. Regional incidence ranged from 0.09% (Northeast) to 0.12% (Midwest). The mean age at surgery was 13.4 months. The average length of stay was 1.9 days. The average total charge nationwide was $22,982, ranging from $17,972 (South) to $25,671 (Northeast). Average charge in a teaching institution was $4,925 higher than for nonteaching institutions. The strongest predictor of charge was length of stay, increasing charge by $7,663 for every additional hospital day (P < 0.01). Conclusions: National variations exist in resource utilization for primary repair of cleft palate, with higher charges in Northeastern states and teaching hospitals. The strongest predictor of increased resource use was length of stay, which was significantly higher at teaching institutions. Laryngoscope, 2013

To determine the interrater reliability and construct validity of 3 separate assessment tools for assessing trainee skills in pediatric airway endoscopy simulation.An Objective Structured Assessment of Technical Skills (OSATS) was developed in which examinees were asked to name and assemble the airway foreign body instruments and retrieve a foreign body from an infant airway mannequin. Each examinee's performance was assessed in a blinded fashion by 3 pediatric otolaryngology faculty at separate residency programs using 3 assessment tools: (1) objective quantifiable measures list (eg, assists needed, forceps openings, foreign body drops), (2) 15-point OSATS checklist, and (3) Global Rating Index for Technical Skills (GRITS). Setting Otolaryngology residency program. Subjects Examinees (medical students, n = 3; otolaryngology residents, n = 17; pediatric otolaryngology faculty, n = 3) and raters (n = 3). Main Outcome Measures Interrater reliability and construct validity. Results Anonymized split-screen videos simultaneously capturing each examinee's instrument handling and the endoscopic videos were created for all 23 examinees. Nineteen videos were chosen for review by 3 raters. The interrater reliability as measured by the intraclass correlation for objective quantifiable measures ranged from 0.46 to 0.98. The intraclass correlation coefficient was 0.95 for the 15-point OSATS checklist and 0.95 for the GRITS; both showed a high degree of construct validity with scores correlating with previous experience. Conclusion Assessment tools for skills assessments must have high interrater reliability and construct validity. When assessing trainee skills in pediatric airway foreign body scenarios, the 15-point OSATS checklist developed by this group or the GRITS meets these criteria.

Objectives/Hypothesis: To review airway management in Pierre Robin sequence (PRS) newborns undergoing general anesthesia and to determine if endotracheal intubation is safe in this population. Study Design: Case series and retrospective chart review at a tertiary children's hospital. Methods: PRS newborns who underwent endotracheal intubation or other airway intervention before 3 months of age between January 2000 and July 2011 were identified from a pediatric otolaryngology practice database. Indications for airway intervention, anesthetic management, method of intubation, and comorbid conditions were collected. Results: Thirty-three PRS newborns were identified. Twenty had isolated PRS, and 13 had PRS related to a coexisting syndrome. Thirteen of 35 (37%) endotracheal intubations performed in PRS newborns prior to mandibular distraction osteogenesis were accomplished with direct laryngoscopy. The remaining 22 of 35 (63%) who failed intubation with direct laryngoscopy were intubated over a flexible fiberoptic bronchoscope. No significant difference was observed between the isolated and syndromic PRS newborns with regard to technique utilized for intubation. No patient required rescue laryngeal mask airway or emergent tracheotomy, and no case resulted in death. Conclusions: This series demonstrates that endotracheal intubation is safe and effective in PRS newborns. In patients who failed intubation with direct laryngoscopy, intubation over a flexible fiberoptic bronchoscope provided a reliable alternative method. Although airway management in PRS newborns poses a significant challenge, experienced otolaryngologists and anesthesiologists can successfully manage these difficult airway cases.

Objectives. To determine the prevalence of positional plagiocephaly and brachycephaly in teenagers born after the "Back to Sleep" campaign but before orthotic helmet treatment became widely available and to provide long-term outcomes data on those children with plagiocephaly who were not treated with remolding therapy. Study Design. Cross-sectional analysis.Setting. Local high schools in the Minneapolis-St Paul Metro area. Subjects and Methods. Subjects were selected if they attended participating high schools and were born after the Back to Sleep campaign began. Skull measurements, including transcranial diameter, length, and width, were taken. Overall facial appearance was inspected for any apparent abnormal characteristics. Cranial vault asymmetry and cephalic index were calculated for each participant. Plagiocephaly was diagnosed if cranial vault asymmetry was >1 cm. Brachycephaly was diagnosed if the cephalic index was >0.90. Results. There were 1045 participants, ranging from 12 to 17 years old, with an average age of 15.7 years. The prevalence of plagiocephaly was 1.1%. The prevalence of brachycephaly was 1.0%. The overall prevalence of a deformational cranial abnormality was 2.0%. Of those who met diagnostic criteria of plagiocephaly or brachycephaly, 38.1% were noted to have abnormal facial characteristics. Conclusions. The prevalence of plagiocephaly and brachycephaly in teenagers is significantly lower than the 20% to 48% prevalence found in infants in previous studies, suggesting most children will outgrow the condition without intervention. Additional studies are needed to determine which patients might benefit from treatment and which will likely have resolution without intervention, since treating all infants who meet criteria results in significant overtreatment. Language: en

Objectives/Hypothesis: The objective of this study was to describe the long-term outcomes of tracheoplasty for distal tracheal stenosis, demonstrate the utility of cardiopulmonary bypass for intraoperative airway management, and compare perioperative morbidity and mortality of slide tracheoplasty for distal tracheal stenosis to costochondral graft, and resection with end-to-end anastomosis. Study Design: Retrospective chart review. Methods: A retrospective chart review of all patients undergoing tracheoplasty for distal obstruction and also requiring the use of cardiopulmonary bypass for intraoperative airway management from 1994 to 2009 was performed. The setting for the study was a tertiary care children's hospital. Results: A total of 11 patients, aged 1 month to 12 years, were identified. Four patients underwent slide tracheoplasty, two had end-to-end anastomosis, and five had costochondral graft. Average cardiopulmonary bypass time was 120 minutes, 60 minutes, and 63 minutes, respectively. The only complication of cardiopulmonary bypass was a superficial wound infection. There was one late death due to airway obstruction after repair of severe cardiac anomalies. The numbers of bronchoscopies required for resolution of granulation tissue in the slide tracheoplasty and end-to-end anastomosis groups were less than for the cartilage graft group. Three patients in the cartilage graft group required tracheostomy, and one remained tracheostomy dependent at last follow-up. None in the slide tracheoplasty or end-to-end anastomosis groups required a tracheostomy during management. Conclusions: Improvements in operative techniques and perioperative management have led to significant decreases in morbidity and mortality. At our institution, slide tracheoplasty has become the preferred technique for all except very short segment stenosis, and cardiopulmonary bypass is used in all cases involving the distal trachea. Laryngoscope, 121:2665–2671, 2011

Introduction: There has been an increasing interest in assessment of technical skills in most medical and surgical disciplines. Many of these assessments involve microscopy or endoscopy and are thus amenable to video recording for post hoc review. An ideal skills assessment video would provide the reviewer with a simultaneous view of the examinee's instrument handling and the operative field. Ideally, a reviewer should be blinded to the identity of the examinee and whether the assessment was performed as a pretest or posttest examination, when given in conjunction with an educational intervention. Methods: We describe a simple method for reliably creating deidentified, multicamera, time-synced videos, which may be used in technical skills assessments. We pilot tested this method in a pediatric airway endoscopy Objective Assessment of Technical Skills (OSATS). Total video length was compared with the OSATS administration time. Results: Thirty-nine OSATS were administered. There were no errors encountered in time-syncing the videos using this method. Mean duration of OSATS videos was 11 minutes and 20 seconds, which was significantly less than the time needed for an expert to be present at the administration of each 30-minute OSATS (P Conclusions: The described method for creating time-synced, multicamera skills assessment videos is reliable and may be used in endosurgical or microsurgical skills assessments. Compared with live review, post hoc video review using this method can save valuable expert reviewer time. Most importantly, this method allows a reviewer to simultaneously evaluate an examinee's instrument handling and the operative field while being blinded to the examinee's identity and timing of examination administration.

We present a case of a female infant that was diagnosed on prenatal ultrasound with an oral mass, and subsequently underwent a planned EXIT procedure to secure the airway. Ultimately the epignathus teratoma was excised at 3 days of age. The number of cases in which neonates have survived epignathus teratomas has increased in the past decade due to improved prenatal imaging and the development of the EXIT procedure. This case demonstrates the importance of a multidisciplinary approach that must be established when a prenatal diagnosis raises concern for airway compromise, and the thorough work-up required for definitive management.

To develop a robust psychomotor skills curriculum to teach pediatric airway foreign body retrieval and to assess the effect of this curriculum on residents' confidence in and ability to perform the complete task in an infant airway mannequin.Instructional course. Objective Structured Assessment of Technical Skills (OSATS).Surgical simulation laboratory.A half-day simulation-based course was developed to train otolaryngology residents in bronchoscopic foreign body retrieval. This complex psychomotor skill was deconstructed into subtasks. The following curricular learning objectives were presented and assessed: understanding of tracheobronchial anatomy, ability to adequately visualize the larynx with laryngoscopy, proficiency in rigid bronchoscopy, and familiarity with foreign body instrumentation. Residents were objectively evaluated on their ability to perform the complete task on a simulator before and after the course using an OSATS grading system. Confidence in successfully assembling the instruments and completing the task was assessed at these time periods.Seventeen otolaryngology residents completed the study. Confidence in assembling the instruments and in performing the complete task increased on average by 81% and 43%, respectively (P.001). Using a 15-point OSATS grading system, the average score for the precourse was 7 and for the postcourse was 11.3 (P.001).Simulation-based subtask training shows promise as an effective and reproducible method to teach the complex psychomotor task of airway foreign body retrieval. Completion of the curriculum led to a significant improvement in residents' confidence in and ability to perform bronchoscopic foreign body retrieval in an infant airway mannequin.

Objectives: Arthrogryposis is a rare, congenital condition characterized by joint contractures of the extremities with muscle weakness and fibrosis. The otolaryngological manifestations of this disorder may include stridor, chronic aspiration, and Pierre Robin sequence, among others. Prior reports of vocal fold immobility associated with arthrogryposis have attributed it to recurrent laryngeal nerve paralysis, rather than to cricoarytenoid joint restriction. The objective of this study was to determine whether children with arthrogryposis and vocal fold immobility demonstrated laryngeal electromyography (L-EMG) findings consistent with recurrent laryngeal nerve paralysis or with cricoarytenoid joint restriction. Methods: A retrospective, institutional chart review of children with otolaryngological manifestations of arthrogryposis was performed; 6 children were identified. Three patients had vocal fold immobility documented by flexible laryngoscopy. These 3 children were prospectively evaluated with direct laryngoscopy and intraoperative L-EMG. Results: The 3 children with arthrogryposis and vocal fold dysfunction had laryngoscopy-confirmed vocal fold immobility or significant restriction of motion. The intraoperative L-EMG tracings obtained from all 3 patients demonstrated motor unit action potentials without evidence of denervation. Conclusions: This series, albeit small, suggests that the vocal fold dysfunction related to arthrogryposis may be attributable to cricoarytenoid joint restriction or poor laryngeal coordination, rather than to nerve paralysis, as originally postulated.

Develop an evidence-based model for predicting operative endoscopy findings in patients with recurrent croup.Case series with chart review.Tertiary care children's hospital.Retrospective chart review was performed on 124 patients who received consultation for recurrent croup between 2000 and 2009. Direct laryngoscopy and bronchoscopy findings were categorized as normal, mildly abnormal (incidental findings or grade I subglottic stenosis), moderately abnormal (grade II subglottic stenosis), or severely abnormal (grade III-IV subglottic stenosis).Of 124 consultations for recurrent croup, 81 patients (average age 3.5 years) underwent operative endoscopy. Normal examinations occurred in 33 of 81 (41%). Abnormal findings were encountered with the following frequency: mildly abnormal, 40 of 81 (49%); moderately abnormal, 6 of 81 (7.5%); and severely abnormal, 2 of 81 (2.5%). Relative risk (RR) of either moderately abnormal or severely abnormal findings was increased for patients who had a history of previous intubation (RR = 9.8; P = .002), prematurity (RR = 6.4; P = .01), or inpatient consultation (RR = 5.3; P = .028). The rate of moderately or severely abnormal findings in patients without the risk factors of intubation and age younger than 1 year was 0 of 48 (0%; confidence interval, 0%-7.4%). Mild abnormalities in this group were encountered in 27 of 48 (56%).Mild airway abnormalities are common in children with recurrent croup and cannot be ruled out based on history. In the absence the risk factors of previous intubation, age younger than 1 year, or inpatient consultation, the incidence of a significantly abnormal finding is quite low. A predictive model based on this evidence is discussed.

Background The definitive cause of most cases of recurrent salivary gland inflammation in children remains unknown. Relatively little has been written about the use of sialendoscopy as a diagnostic and therapeutic tool in children. Objective To evaluate the safety and efficacy of sialendoscopy as a diagnostic and therapeutic tool for recurrent salivary gland inflammation in children. Study Design Retrospective case series. Methods Medical records of all patients who underwent sialendoscopy for recurrent salivary gland inflammation from a single tertiary-care pediatric otolaryngology practice were reviewed. Comparison of pre-procedure vs. post-procedure frequency and severity of disease was reviewed. Operative reports, images, and video were analyzed for causes of inflammation. Results Six patients (aged 3–16 years old) underwent sialendoscopy (3/6 bilateral parotid, 2/6 unilateral parotid, 1/6 unilateral submandibular). There were no complications. No post-operative recurrence was noted in 3/6 patients; decreased frequency of recurrence was noted in 2/6 patients; repeat sialendoscopy was required in 1/6. Operative findings from sialendoscopy from 10 parotid glands showed fibrinous debris (7/10), mucoid debris (1/10), purulent debris (1/10), or duct stenosis (1/10). No stones were noted. Conclusions Sialendoscopy is a safe, minimally invasive procedure that may decrease the frequency of recurrences for salivary gland inflammation in children. In contrast to previously published work, the most common cause of salivary gland obstruction in this series was debris, rather than stones. Increased use of sialendoscopy as a diagnostic and therapeutic tool will allow for improved understanding of the causes of and management for recurrent salivary gland inflammation in children.

Patients with cleft lip and palate present the pediatric facial plastic surgeon with numerous challenges. This congenital anatomic anomaly carries with it associated cosmetic deformity, speech disorders, dental abnormalities, and deficient maxillofacial growth. This article describes proven techniques in cleft lip and palate surgical repair. The repair of unilateral cleft lip, bilateral cleft lip, and cleft palate are demonstrated. The accurate performance of these reconstructive surgical maneuvers is an important achievement in the overall care for children affected by cleft lip and palate.

Objectives: To determine the complication rate and the patient satisfaction of titanium osseointegrated ear implants for congenital microtia and anotia. To discuss external ear prostheses as a treatment option for children with microtia. Study Design: Retrospective chart review of patient records from a tertiary pediatric otolaryngology practice. Methods: The charts were reviewed for all pediatric patients who had undergone titanium implants for attachment of auricular prostheses from 2000–2006. Data collected included demographic information, congenital syndrome, number and size of screws placed, occurrence of skin reactions, presence of other complications, and length of time patients wore the prosthetic ear. Results: Eight patients, nine ears, were implanted. Median age was 7 years old. 6/8 had oculoauriculovertebral (OAV) syndrome, and 2 had isolated microtia. All titanium screws achieved complete osseointegration, and no implants have failed. 5/27 (18%) of the screws contacted dura, but no patients exhibited CSF leak, meningitis, or other central complications. 3/9 ears developed skin complications at the abutment sites, and 1/9 required revision soft tissue surgery. All the patients without current skin complications wear their prosthesis full time during waking hours. Conclusions: Titanium osseointegrated ear prosthesis is a safe and useful procedure for children with microtia. It should be presented as an option for these patients, with low complication rates and high acceptance rates by the patients. Laryngoscope, 2009

To investigate whether children with less than 48 hours of localized symptoms of deep neck infection are less likely to have an abscess on CT scan.Case series.The charts of children seen in a tertiary children's hospital for deep neck infections between 2000 and 2007 were reviewed.Of 179 children identified, 167 (93.3%) underwent a CT scan of the neck of which 102 (61.1%) were positive for abscess. There was no significant difference in the rate of abscess on CT between children with less than 48 hours of localizing symptoms and 48 or more hours of symptoms at 58.1 percent and 58.3 percent, respectively (P = 0.98). Furthermore, there was no significant difference in age, gender, C-reactive protein levels, disease location, or length of stay between children with and without abscess on CT. White blood cell counts were significantly higher in the abscess group (P = 0.01); however, the median white blood cell count in both groups was above normal.Because duration of symptoms does not predict finding of abscess on CT, it is appropriate to obtain a CT scan upon presentation in all children with symptoms concerning for neck abscess.

Summary Objective The aim of this study is to determine whether cross-infection occurs between infections in the sinuses and lower airways in Cystic Fibrosis patients, and to determine whether the infections begin in the sinuses before spreading to the lungs. Methods Retrospective study of pediatric Cystic Fibrosis patients who underwent simultaneous sinus surgery and bronchial washings. The results of the cultures were reviewed to determine if the same organisms colonized both the sinuses and lower airways. Results Staphylococcus aureus (Staph. Aureus) was found in 40.7% of the sinuses but only 33.3% of the lower airways. One patient had Staph. Aureus in the lower airway but not the sinuses. Pseudomonas, Hemophilus Influenza, and Moraxella showed similar patterns: multiple instances of positive sinus cultures and negative bronchial cultures, but only a small number of cases with positive lower airway cultures and negative sinus cultures. Conclusion The data showed that as patients age, they are more likely to have infections in both upper and lower airways, but infections start in the upper airways at a younger age. In many cases, organisms were cultured from sinuses in patients who had negative lower airway cultures. In only a few instances, organisms grew in the lower airways and not the sinuses. In most cases, the bacteria that caused sinus infections at a young age caused the lung infections in older patients. This is the paper to show that bacteria spread from the sinuses to the lungs to cause infections in Cystic Fibrosis patients, and not vice-versa.

OBJECTIVE: To describe the interventions required for successful airway management in children with Pierre Robin Sequence (PRS). STUDY DESIGN: Case series. SUBJECTS AND METHODS: The records of both a cleft and craniofacial clinic and a pediatric otolaryngology clinic were searched, and all children with PRS were identified. Data concerning feeding interventions, airway interventions, and comorbid conditions were extracted. RESULTS: Seventy-four cases of PRS were identified. Thirty-eight of the 74 children required airway intervention other than prone positioning. Fourteen of these 38 were managed nonsurgically with nasopharyngeal airway and/or short-term endotracheal intubation, whereas the remaining 24 required surgical intervention. Eighteen of the 24 underwent distraction osteogenesis of the mandible, one underwent tracheostomy, and five underwent tracheostomy followed by eventual distraction. CONCLUSION: In our series, over 50 percent of children with PRS required an airway intervention. These were both nonsurgical and surgical. As otolaryngologists, we must be prepared for the challenges children with PRS may present and the interventions that may be necessary to successfully manage these difficult airways.

Computed tomographic (CT) scans are often obtained before mandibular distraction osteogenesis in patients with isolated Pierre Robin sequence. There is concern regarding the risk of radiation exposure from CT in children.To evaluate whether preoperative CT is necessary for adequate airway, feeding, and aesthetic outcomes following mandibular distraction with external distraction devices in infants with isolated Pierre Robin sequence.In a retrospective review of medical records, infants who underwent mandibular distraction between January 1, 1998, and September 30, 2014, at 2 tertiary children's hospitals were identified using procedure codes. Data analysis was conducted December 1, 2014, to March 31, 2015. Fifty-two patients fit the inclusion criteria of isolated Pierre Robin sequence or Stickler syndrome, of being younger than 9 months at the time of distraction, and of use of external distractors. Forty-two of these infants did not receive preoperative CT imaging.Mandibular distraction osteogenesis for isolated Pierre Robin sequence or Stickler syndrome.Number of infants who were able to avoid tracheostomy or achieve decannulation, who were able to avoid placement or achieve removal of a gastrostomy tube, and in whom there were no intraoperative complications, no open-bite deformity, no malocclusion, no asymmetry, and no postoperative complications.In comparison with the 10 infants who underwent preoperative CT, all 42 of the infants (100%) who did not receive preoperative CT imaging successfully avoided tracheostomy or achieved decannulation (P = .04) and 40 patients (95%) did not require placement of a gastrostomy tube or were able to undergo gastrostomy tube removal postoperatively (P .001). There were no significant differences between the CT and non-CT groups in the other 5 outcome measures. Two patients (5%) required postoperative gastrostomy tube placement, 2 patients (5%) had minor intraoperative complications that might have been anticipated with CT, 2 patients (5%) demonstrated malocclusion, and 1 infant (2%) had asymmetry at the end of the distraction phase.This series suggests that the absence of preoperative CT does not compromise functional or aesthetic outcomes in mandibular distraction with external distraction devices in infants with isolated Pierre Robin sequence or Stickler syndrome. This finding has implications for cost containment and reduction of radiation exposure to a vulnerable population.4.

Objective To report a case of fibrodysplasia ossificans progressiva (FOP) initially presenting as a neck mass and alert the practicing otolaryngologist to the imperative to avoid harmful biopsy. Case A 2-year-old male presented with a firm left posterior neck mass and bilateral great toe malformations. Imaging was non-diagnostic and after 2 weeks of antibiotics the lesion was larger. At surgical biopsy, the mass was pale, firm, and avascular. Histopathology showed low grade fibromyxoid tissue. Rheumatology service diagnosed FOP based on clinical examination of neck mass, bilateral great toe deformities, stiff joints. Biopsy proved unnecessary and the patient developed heterotopic ossification at the site of surgical trauma. The patient was started on anti-inflammatories and steroids with minimal benefit. This case highlights the need for a broader understanding among clinicians who may encounter patients with FOP regarding the clinical aspects of diagnosis and the potential harm caused by surgical interventions.

Objective To demonstrate a case series of granulocytic sarcoma of the head and neck found in the pediatric population and review long-term outcomes. Methods A pathology database at a tertiary hospital was searched for patients with biopsy specimens from the head and neck diagnosed as granulocytic sarcoma. Results There were 6 cases between 1992 and 2004 that met inclusion criteria. Subjects’ age ranged from 22 months to 14 years old. In three cases, the patients were diagnosed with acute myeloid leukemia (AML) based on biopsy results; 2 patients were already diagnosed with AML when diagnosed with granulocytic sarcoma, and in 1 case, a relapse of AML was diagnosed. In all cases, patients began induction chemotherapy. Two patients died during induction chemotherapy from infection. The remaining 4 patients underwent bone marrow transplants. One patient had a relapse post-transplant and died. Only one patient was healthy two years post-transplant. Conclusion The results of this series suggest granulocytic sarcoma must be on the differential when tumors present in the head and neck region in pediatric patients. In our series, 100% of the patients with granulocytic sarcoma had underlying AML. The long-term prognosis of patients with AML who developed granulocytic sarcoma is quite poor.

Rosenfeld et al in their recent article "Office Insertion of Tympanostomy Tubes without Anesthesia in Young Children" describe using a "papoose board for restraint" while performing a procedure resulting in severe pain for a significant number of children: a myringotomy and tube insertion. In 2016, it is inappropriate to perform elective painful procedures in children without treatment to avoid or minimize pain. We strongly disagree with the authors' conclusion "that office insertion of tubes in young children is a feasible alternative to general anesthesia for caregivers and clinicians who are comfortable with this choice."

Distraction osteogenesis was originally described in the early 1900s and was clinically applied and advanced in the 1950s by Ilizarov and Ledyaev and their colleagues in Siberia [1,2]. They applied the principle of osteotomies and gradual long-bone distraction for patients with leg-length discrepancies secondary to war injuries. Since their landmark report, many investigators have described use of this technique for lengthening lower and upper legs, arms, fingers, and, recently, the craniofacial skeleton. The first report of clinical distraction of the human mandible was in 1992 by McCarthy, Schreiber, Karp, et al [3]. Today, distraction osteogenesis is a well-accepted technique for reconstruction of the deficient mandible, midface, orbits, and cranium. There are several studies on distraction in the recent literature, but the bulk of them lack objective, long-term data. Most centers have their own protocols based on clinical experience. As distraction osteogenesis is increasingly used in all age groups, the long-term data should be forthcoming.

Objectives:Determine whether it is more cost beneficial to partake in a medical mission trip to developing countries to complete cleft repairs or to support medical professionals in providing local care.Methods:Retrospective analysis of surgical costs per patient of different types of US-based charitable organizations. We compared financial information of 3 separate 501(c)(3)s for fiscal years 2011 and 2012. Cost per surgery was determined through expenses and total number of surgeries. Two organizations focus on service-based missions (typically US-trained surgeons and other clinicians traveling to developing countries to complete surgeries over a 1-2 week period). The third organization focuses on funding local surgeons (who are already trained and have proven expertise) to complete cleft repairs. This organization pays local clinicians to complete surgeries, and in return, surgeons upload results to an electronic medical record system so outcomes and progress can be tracked.Results:The cost per patient...

Objectives:Multiple efforts are under way to develop methodologies to allow tympanostomy tube (TT) placement in young children under conscious sedation where there can be significant head motion. This practice modification would provide an option for TT placement without the risk of general anesthesia and the potential for procedures being performed in an office.Methods:Investigators evaluated a tool designed to perform a quick, single pass tube delivery across the tympanic membrane with a downward force of motion in a moving child under conscious sedation. Training required bench evaluation and the use of general anesthesia before performing conscious sedation cases.Results:A total of 176 TTs were performed in 89 children at 3 institutions. Ninety-one TTs in 46 children used general anesthesia, and 85 TTs in 43 children used conscious sedation. Conscious sedation included nitrous oxide in 35 children and midazolam plus nitrous oxide in 8 patients. All cases used phenol as a topical anesthetic. Twelve chi...

Objectives:(1) Compare the rate of head and defects between children conceived via assisted reproductive technology (ART) versus those conceived via natural methods. (2) Determine the risk of congenital head and neck abnormalities associated with ART.Methods:A retrospective chart review was conducted of all patients admitted to the neonatal intensive care unit over 10 years at Children’s Hospital of Minneapolis. The patients were divided into 2 groups: patients who were conceived via ART and patients who were conceived naturally. Each chart was evaluated for 15 different head and neck malformations, 11 of which were included in data analysis due to statistical significance.Results:There were a total of 14,857 charts examined; 2288 patients were conceived via ART, while 12,569 patients were conceived via natural methods. There were 40 patients born with defects via ART, while there were 681 patients born with defects via natural conception. There were a total of 9039 males and 6637 females. The total occur...

Objectives/Hypothesis To demonstrate that neonatal ventilators can expose patients to high noise levels through bone conduction (BC) as well as air conduction (AC). Study Design Observational study. Methods Three ventilators and various settings on a positive airway pressure machine (continuous, high bilevel, and low bilevel pressure) were tested. A sound level meter was used to measure the noise levels at a set distance from the ventilator to represent AC, on the ventilator circuit to represent BC at the alveolus, and within the ventilator circuit. Results The BC sound levels (74.1, 81.1, 86, 89.2 dBC) were significantly higher than the AC sound levels (72.8, 72.9, 70, 71.7 dBC) for the jet ventilator, continuous positive airway pressure setting, low bilevel setting, and high bilevel setting, respectively (P

Objective: To determine if simultaneous, bilateral lateral rhinotomies for medial maxillectomies would result in central skin or bone loss in pediatric patients with invasive fungal disease. Study Design: Retrospective chart review. Setting: Tertiary care children's hospital. Patients: Three children underwent surgery between April 1996 and June 1998. Ages at treatment ranged from 11 to 14 years. All had bilateral, biopsy-proven invasive fungal disease of the lateral walls of the nose. All were undergoing chemotherapy for acute lymphocytic leukemia (ALL) or acute myelocytic leukemia (AML). Intervention: Bilateral lateral rhinotomies for medial maxillectomy. Two of 3 also had simultaneous total septectomy. Main Outcome Measure: Skin survival and patient survival. Results: All three patients had bilateral simultaneous medial maxillectomy for invasive fungal disease in the presence of profound pancytopenia secondary to treatment of leukemia. One patient had minor nasal edema postoperatively, but none showed any loss of the central nasal skin or facial skeleton. All patients survived the invasive fungal disease with follow-up of at least 24 months. All patients underwent multiple debridements after the original surgery, and 3 of 6 eyes had permanent epiphora requiring dacryocystorhinostomies. Conclusions: Bilateral simultaneous lateral rhinotomies are safe in children and did not result in any central skin loss. Aggressive bilateral surgery for invasive fungal disease is compatible with a good esthetic outcome and long-term survival.

Objectives To examine the spectrum of fetal head and neck anomalies that may prompt prenatal referral and to determine the frequency of these consultations. Study design Case series with chart review. Methods The billing databases of two urban pediatric otolaryngology practices were queried for ICD-9 codes corresponding to fetal anomalies between January 2010 and December 2012. The pediatric otolaryngology practices in this study evaluate all fetal head and neck anomalies referred to their respective institutions, including craniofacial disorders. Results Over a three-year period, 53 women presented for fetal otolaryngology consultation, with each practice seeing approximately one consultation every 6 weeks (every 5 weeks (JDS) and every 7 weeks (ARS)). The average maternal and gestational age at presentation were 28.7 years and 27.2 weeks, respectively. 83% of the cases ( n = 44) involved some form of cleft lip with or without cleft palate. Other head and neck anomalies included fetal goiter/other congenital neck mass (9% ( n = 5)) and micrognathia (6% ( n = 3)). Macroglossia ( n = 1) and facial cleft ( n = 1) each accounted for 2% of cases. Cleft mothers presented earlier in pregnancy (average 26.8 weeks) than those with a neck mass (average 32.3 weeks) ( p Conclusions Depending on the referral practices at a given medical center, craniofacial surgeons rather than pediatric otolaryngologists may be evaluating the majority of fetal head and neck anomalies, as orofacial clefts account for most prenatal consultations. The wide spectrum of congenital neck masses may or may not demand monitoring of the airway during the peripartum period.

To describe airway management of children with limited oral opening that does not allow for routine orotracheal intubation by direct laryngoscopy. To analyze the incidence and outcome of airway compromise or loss in patients without a tracheostomy in place.Case series with chart review.Tertiary children's hospital.Children with limited oral opening that does not allow for routine orotracheal intubation.Children treated at Children's Hospitals and Clinics of Minnesota from 1997 to 2012 with severe trismus were identified and included in the study. Hospital and clinic records were reviewed.Ten children (mean age, 13 years; range, 7-17 years) were identified for inclusion into the study. A total of 109 operations requiring general anesthesia (average of 10.9 per patient; range, 0-23) were performed on patients without a tracheostomy in place. Flexible fiber-optic nasotracheal intubation was performed in 58 cases. The remainder of airway control was by mask ventilation (33 cases), various methods of orotracheal intubation (10 cases), unknown (6 cases), and laryngeal mask airway (2 cases). There was a total of 118 patient-years of follow-up without a tracheostomy tube in place (average of 11.8 years per patient). During this period, there were no episodes of acute airway compromise that resulted in neurologic deficits.Children with limited oral opening that does not allow for routine orotracheal intubation with direct laryngoscopy may be safely managed without a tracheostomy, even when the child requires frequent procedures under general anesthesia.