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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.

The Choosing Wisely Canada campaign raises awareness amongst physicians and patients regarding unnecessary or inappropriate tests and treatments. Using an online survey, members of the Pediatric Otolaryngology Subspecialty Group within the Canadian Society of Otolaryngology – Head & Neck Surgery developed a list of nine evidence based recommendations to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations: (1) Don’t routinely order a plain film x-ray in the evaluation of nasal fractures; (2) Don’t order imaging to distinguish acute bacterial sinusitis from an upper respiratory infection; (3) Don’t place tympanostomy tubes in most children for a single episode of otitis media with effusion of less than 3 months duration; (4) Don’t routinely prescribe intranasal/systemic steroids, antihistamines or decongestants for children with uncomplicated otitis media with effusion; (5) Don’t prescribe oral antibiotics for children with uncomplicated tympanostomy tube otorrhea or uncomplicated acute otitis externa; (6) Don’t prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children; (7) Don’t administer perioperative antibiotics for elective tonsillectomy in children; (8) Don’t perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years; and (9) Don’t perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy.

Objectives/hypothesis Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. Study design Blinded modified Delphi consensus process. Setting Tertiary care center. Methods A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. Results The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. Conclusions It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. Level of evidence 5. Laryngoscope, 131:1168-1174, 2021.

Introduction Burkitt lymphoma (BL), an aggressive form of B-cell non-Hodgkin's lymphoma, arising from the nose and paranasal sinuses is relatively rare. It can present with various symptoms leading to potential misdiagnosis and delayed treatment. BL is fatal if left untreated, while early identification and treatment can improve prognosis. Objectives 1) To review clinical presentations and sites of involvement of six cases of pediatric BL with rhinologic manifestations and compare these with the current literature. 2) To raise awareness on the variety of presentations of BL in this particular anatomic location. Methods A series of six cases of pediatric (0–18 years) BL with rhinologic manifestations is presented. Age, sex, ethnicity, symptoms, imaging, staging, treatment and outcome were recorded. A systematic review of literature was also conducted using PRISMA guidelines. The search strategy used keywords related to rhinologic manifestations of BL (nasal cavity, nasopharynx, paranasal sinus etc.; Burkitt etc.) and included studies published in English and French describing patients 0–18 years of age. Results 42 patients were included (six from case series and 36 from current literature). Most common presenting symptoms were: nasal obstruction (29%), facial swelling (24%), headache (21%) and proptosis (19%). Most frequent sites of presentation were: nasopharynx (40%), maxilla (40%) and sphenoid (33%). More than half (60%) had systemic involvement, of which the most common locations were: kidney (19%), pancreas (17%) and liver (17%). Mortality from BL in children from this study population was correlated with a longer duration of symptoms prior to presentation, as well as a misdiagnosis preceding the final diagnosis of BL. Conclusions This study brings understanding to the numerous presentations of the same aggressive disease, promotes high clinical suspicion when evaluating common otolaryngologic symptoms and can guide healthcare providers in diagnosing pediatric BL with rhinologic manifestations.

Objective To develop, implement, and evaluate a longitudinal, simulation-based ethics and legal curriculum designed specifically for otolaryngology residents. Methods Otolaryngology residents were recruited to participate in a yearly half-day ethical–legal module, the curriculum of which spanned 4 years. Each module included: three simulated scenarios, small-group multisource feedback, and large-group debriefings. Scenarios involved encounters with standardized patients. Residents' ethical–legal knowledge was assessed pre- and postmodule with multiple-choice questions, and ethical reasoning was assessed by a variety of evaluators during the simulated scenario using a locally developed assessment tool. Participants completed an exit survey at the end of each module. Results Eighteen residents completed four modules from the academic years of 2008 to 2009 to 2011 to 2012. The first year was considered a pilot module, and data were collected for the following 3 years. Knowledge of legal issues improved significantly among residents (mean at pre = 3.40 and post = 4.60, P < 0.05). Residents' ethical reasoning skills also improved across years (mean 3.60/5 in 2009–2010, 3.76/5 in 2010–2011, and 4.33 in 2011–2012, P < 0.05). Survey results revealed a statistically significant self-perceived improvement in ethics reasoning skills (mean pre = 3.62, post = 4.86, P < 0.05). Participants reported that the curriculum was relevant to their practice (85%), that the debriefings were of high quality (83%), and that they would recommend this module to others (88%). Conclusion To our knowledge, this is the first study exploring a longitudinal simulation-based ethical–legal curriculum tailored to otolaryngology–head and neck surgery residents. This educational program resulted in a both objective and subjective improvement in legal and ethics knowledge and skills. Level of Evidence NA. Laryngoscope, 127:2501–2509, 2017

Objective 1) To assess the feasibility of reconstructing 2-cm-long circumferential tracheal defects with a 3D printed polycaprolactone (PCL) implant in rabbits. 2) To evaluate endoscopic, histologic, and functional characteristics of a PCL tracheal implant over time. Methods Ten New Zealand rabbits were included in this study. A 2-cm-long 3D printed PCL tracheal implant was created. All rabbits underwent surgical excision of a 2-cm-long cm segment of cervical trachea, which was reconstructed with the implant. Rabbits were sacrificed at the following time points: 0, 4, 5, 6, and 7 weeks postoperatively. At these time points, a rigid bronchoscopy was performed, and blinded evaluators calculated the percentage of airway stenosis. The tracheas were then harvested and prepared for histologic analysis. Results All rabbits survived to their date of sacrifice except for one. Rabbits were euthanized between 0 to 54 days postoperatively with a median of 30 days. All rabbits developed significant granulation tissue with an average percentage stenosis of 92.3% ± 6.1%. On histology, granulation was present with extensive neovascularization and mixed inflammatory cells. There was re-epithelialization present on the luminal surface of the PCL implant near the anastomoses but absent at the center of the implant. Conclusion This study demonstrates that our 2-cm-long 3D printed PCL tracheal implant can be used to reconstruct a tracheal defect of equivalent size in a New Zealand rabbit model in the short term. However, significant granulation tissue formation limits long-term survival. Further research is warranted to limit the granulation tissue overgrowth. Level of evidence NA Laryngoscope, 2019.

Introduction Tracheal pathology can be life-threatening if not managed appropriately. There are still some surgical limitations today for certain pathologies, such as in severe tracheomalacia, or when long segments of trachea need to be resected. Poly(e-caprolactone) (PCL) is a polymer that has recently gained popularity for its use in tracheal surgeries in animal models and in certain human pediatric cases in hopes of addressing these difficult situations. PCL can be 3D printed or manufactured through molds to create tracheal stents, splints, patches and even to reconstruct full circumferential tracheal defects. Objective To perform a scoping review, and explore insights into the applications of PCL for tracheal surgeries in-vivo. Methods A literature search in Embase, MEDLINE, and BIOSIS was performed to include all articles available prior to December 21, 2018 without any language restrictions. We included all original research that investigated the use of a PCL implant, stent, splint, scaffold, or graft in tracheal surgeries in-vivo. Assessment of all articles were performed by two independent authors prior to inclusion for analysis. Results A total of 27 articles were included in the study. All articles were original research studies, primarily consisting of interventional studies (92.4%), there was also 2 case reports (7.4%). Articles were published in the last decade, publications range from 2009 to 2019. The most common animal model used for the tracheal surgeries were the New Zealand rabbits (n = 19, 70%). Two studies (7%) also described the use PCL in a total of 4 human cases. To investigate the PCL reconstructed airways, histology and bronchoscopy were the most commonly implemented methods of analysis in 88.9% and 70.4% respectively. Airway analysis was also done using imaging modalities including CT scan (n = 9, 33.3%), MRI (n = 2, 7.4%), X-ray (n = 1, 3.7%). 17 (62.9%) of the studies used 3D printing processes to create their PCL implants. Conclusions Overall, this review demonstrates the feasibility of PCL in tracheal reconstruction and tracheal stenting/splinting. It highlights common trends and the limitations of the literature thus far on this topic.

Objectives Temporal bone fractures are relatively common findings in patients with head trauma. The aim of this study was to evaluate the characteristics of temporal bone fractures in the pediatric population. Study design Retrospective case series. Tertiary care pediatric academic medical center. Methods The medical records of patients aged 18 years or less diagnosed with a temporal bone fracture at the Montreal Children's Hospital from January 2000 to August 2014 were reviewed. Patient demographics, clinical presentation, mechanism of injury and complications were analyzed. Imaging studies and audiograms were also evaluated. Results Out of 323 patients presenting to the emergency department with a skull fracture, 61 presented with a temporal bone fracture. Of these, 5 presented with bilateral fractures. 47 patients had associated fractures, and 3 patients deceased. We observed a male to female ratio of 2.8:1, and the average age was 9.5 years. Motor vehicle accidents were the primary mechanism of injury (53%), followed by falls (21%) and bicycle or skateboard accidents (10%). The most common presenting signs included hemotympanum, decreased or loss of consciousness, facial swelling and nausea and vomiting. 8 patients had otic involvement on computed tomography scans, and 30 patients had documented hearing loss near the time of accident with a majority being conductive hearing loss. 17 patients underwent surgical management of intracranial pressure. Conclusion In children, fractures of the temporal bone were most often caused by motor vehicle accidents and falls. It is common for these patients to have associated fractures.

Background Effective communication has been linked to a reduction in adverse events and improved patient compliance. Currently in Otolaryngology – Head and Neck Surgery (OTL-HNS) residency programs, there is limited explicit teaching of communication skills. Our objective was to implement an educational program on communication skills for residents using multisource assessment in several simulation-based contexts throughout residency. Methods For three consecutive years, OTL-HNS residents were recruited to participate in a total of nine simulation-based clinical scenarios in which communication skills could be honed. This educational program was designed to provide instruction and practice of challenging ethics scenarios, with communication efficacy as a secondary goal. To facilitate this goal, a multisource assessment was paired with a debriefing process that involved attending staff, observing and participating residents, standardized patients, and invited content experts. Results Seventeen residents completed the curriculum for at least two consecutive years from 2009 to 2011. The internal-consistency reliability of the scenarios ranged from 0.88 to 0.96. The intraclass correlation was 0.19, as expected in this context. There was no statistical difference in the mean ratings of performance across post-graduate year (PGY) level (p = 0.201). Results from the random-intercept regression indicated that, on average, a learner’s mean rating at baseline was 3.6/5 and increased significantly by 0.25 points per year (p

Patients with cystic fibrosis (CF) frequently present with severe sinonasal disease often requiring radiologic imaging and surgical intervention. Few studies have focused on the relationship between radiologic scoring systems and the need for sinus surgery in this population. The objective of this study is to evaluate the Lund-Mackay (LM) and modified Lund-Mackay (m-LM) scoring systems in predicting the need for sinus surgery or revision surgery in patients with CF.We performed a retrospective chart review of CF patients undergoing computed tomography (CT) sinus imaging at a tertiary care pediatric hospital from 1995 to 2008. Patient scans were scored using both the LM and m-LM systems and compared to the rate of sinus surgery or revision surgery. Receiver-operator characteristics curves (ROC) were used to analyze the radiological scoring systems.A total of 41 children with CF were included in the study. The mean LM score for patients undergoing surgery was 17.3 (±3.1) compared to 11.5 (±6.2) for those treated medically (p0.01). For the m-LM, the mean score of patients undergoing surgery was 20.3 (±3.5) and 13.5 (±7.3) for those medically treated (p0.01). Using a ROC curve with a threshold score of 13 for the LM, the sensitivity was 89.3% (95% CI of 72-98) and specificity of 69.2% (95% CI of 39-91). At an optimal score of 19, the m-LM system produced a sensitivity of 67.7% (95% CI of 48-84) and specificity of 84.6% (95% CI of 55-98).The modified Lund-Mackay score provides a high specificity while the Lund-Mackay score a high sensitivity for CF patients who required sinus surgery. The combination of both radiologic scoring systems can potentially predict the need for surgery in this population.

An array of genetic syndromes has been associated with intra-oral adhesions in neonates. The primary medical issues arise from airway obstruction, feeding difficulties and poor oral development, specifically with cleft palate lateral synechia syndrome (CPLSS). Despite this, a paucity of data exists for the clinical management of intra-oral adhesions in this population. We report the cases of a father and daughter diagnosed with CPLSS who presented with respiratory and feeding difficulties at birth undergoing surgical correction. Early surgical ligation of intra-oral bands allows for a stabilization of the airway, improved feeding and oral development with a good long-term outcome.

Introduction Temporal bone fractures (TBF) are traditionally classified by their angle of fracture relative to the petrous ridge, and more recently by whether or not they violate the otic-capsule. This study compared rates of hearing loss (HL) and signs of otologic dysfunction among fracture types of both classification systems, within the pediatric population. Methods Pediatric patients were retrospectively characterized from a previously identified cohort of TBF patients, diagnosed from 2000 to 2014. CT scans were reviewed and TBFs were classified first as longitudinal (L), transverse (T) or mixed (M), and then as otic-capsule sparing (OCS) or otic-capsule violating (OCV). Medical records were reviewed, and rates of HL and presenting signs were compared among L, T and M fractures, and OCS and OCV fractures. Results Forty-three patients with 47 TBFs met the inclusion criteria. Eighteen, 4 and 25 TBFs were classified as L, T and M fractures, respectively. Thirty-three and 9 were classified as OCS, and OCV, respectively. Among 24 cases of HL: 20, 3, and 1 were conductive HL (CHL), sensorineural HL (SNHL) and mixed HL, respectively. Two cases of SNHL were found among OCV fractures, with none in OCS fractures (estimated difference 0.22; 95% confidence interval 0.01–0.60). Similar rates of CHL were found across L, T and M fractures (range 36–50%), and across OCV and OCS fractures (range 42–44%). Hemotympanum was the most common presenting sign, found in 68% of TBFs and 80% of CHL cases. There were no significant differences in the incidence of signs or symptoms between fracture types. Conclusions In our cohort, both the traditional and otic-capsule radiographic classification systems failed to predict the incidence of CHL and other otologic signs in the pediatric population. Though OCV fractures conferred an increased risk for developing SNHL, we found a lower incidence than anticipated given violation to the bony labyrinth.

Background Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinges on surrounding structures and can easily be mistaken for a neoplasm. Objective The objective of this study was to shed light on this rare entity and report its diagnostic features and treatment outcomes. Methods A case series conducted in a tertiary health care center. Demographic data, clinical presentation, imaging, cultures, and treatments were recorded. Operative video illustration and key images were obtained. A review of the literature was also performed. Results A total of five cases were reviewed, four of which were concha bullosa mucoceles and one was a mucopyocele. Three of the patients had some form of previous nasal trauma. Headache and nasal obstruction were the most common symptoms with a nasal mass finding on physical examination. Computed tomography was used in all the patients, and magnetic resonance imaging was used in four of the five patients. Four patients had coexistent chronic rhinosinusitis, and three had positive bacterial cultures. All these patients were treated endoscopically either with middle turbinate marsupialization or subtotal resection. No recurrence has been noted thus far. Conclusion Concha bullosa mucocele is a rare diagnosis. Imaging characteristics are helpful in considering the diagnosis, although surgical intervention is often necessary to confirm the diagnosis and treat concha bullosa mucocele.

Background The residency match is an important event in an aspiring physician’s career. Otolaryngology – Head and Neck Surgery (OTL-HNS) is a surgical specialty that has enjoyed high numbers of applicants to its residency programs. However, recent trends in Canada show a decline in first-choice applicants to several surgical fields. Factors thought to influence a medical student’s choice include role models, career opportunities and work-life balance. The notion of perceived competitiveness is a factor that has not yet been explored. This study sought to compare competitiveness of OTL-HNS, as perceived by Canadian medical students to residency match statistics published yearly by CaRMS (Canadian Residency Matching Service), with the hope of informing future decisions of surgical residency programs. Methods An electronic survey was created and distributed to all medical students enrolled in the 17 Canadian medical schools. After gathering demographic information, students were asked to rank what they perceived to be the five most competitive disciplines offered by CaRMS. They were also asked to rank surgical specialties from most to least competitive. Publically available data from CaRMS was then collected and analyzed to determine actual competitiveness of admissions to Canadian OTL-HNS residency programs. Results 1194 students, from first to fourth year of medical school, completed the survey. CaRMS statistics over the period from 2008 to 2014 demonstrated that the five most competitive specialties were Plastic Surgery, Dermatology, Ophthalmology, Emergency Medicine and OTL-HNS. Among surgical disciplines, OTL-HNS was third most competitive, where on average 72% of students match to their first-choice discipline. When students were questioned, 35% ranked OTL-HNS amongst the top five most competitive. On the other hand 72%, 74% and 80% recognized Opthalmology, Dermatology and Plastic Surgery as being among the five most competitive, respectively. We found that fourth-year medical students were significantly more knowledgeable about the competitiveness of both OTL-HNS and Plastic Surgery compared to first-year students (p

Objectives To analyze the characteristics and the associated medical co-morbidities in children with synchronous airway lesions (SALs) found during rigid bronchoscopy. Methods Retrospective case series and chart review of patients who were found to have more than one airway lesion after undergoing airway evaluation via rigid endoscopy at a tertiary care pediatric hospital between 2001 and 2011. Patient demographics, presence of associated non-airway pathologies, and the number and types of airway lesions were collected. For analysis, airway lesions were classified based on the anatomical subsites involved (supraglottic, glottic, subglottic, tracheal and bronchial). Results Out of 592 rigid bronchoscopies performed, there were 73 cases with SALs (12.3%). Of these, only 20% of patients were term infants without associated congenital anomalies. Over 70% of patients with SALs have combinations of lesions involving the trachea, subglottis and supraglottis. Neurological anomalies and GERD were both independently associated with a three-time increase in the odds of having synchronous involvement of these three anatomical subsites (OR 3.15, 95% CI 1.06–9.41; OR 3.0, 95% CI 1.05–8.50, respectively). Glottic lesions were present in 28.7% of patients. Prematurity and cardiac anomalies were both associated with tendency of doubling the odds of glottic lesions (OR 2.34, 95% CI 0.84–6.52; OR 2.0, 95% CI 0.76–5.60, respectively). Overall, almost 10% of newly diagnosed lesions in context of SALs required an additional intervention. Conclusions The majority of patients with SALs are either born prematurely or have associated congenital anomalies. In SAL patients with associated neurological anomalies or GERD, the lesions are more likely to be localized to the supraglottis, subglottis and trachea whereas prematurity and cardiac anomalies could both be increasing the odds of a glottic lesion. High suspicious index should be kept in mind when rigid bronchoscopy is performed to not miss an associated lesion.

Objectives/Hypothesis To evaluate the acceptability and reliability of the Multiple Mini Interview (MMI) for the selection of applicants to an Otolaryngology–Head and Neck (OTL–HNS) residency program. Study Design Prospective observational study. Methods Canadian medical graduates applying to the OTL–HNS residency program at McGill University in 2011 and 2012 underwent a 7-station MMI. Upon completion, the major stakeholders commented on and rated various aspects of the MMI using a 7-point Likert scale. Descriptive statistics were used to analyze the quantitative portion of the exit survey, while content analysis and thematic description was applied to qualitative data. Interrater reliability was examined with intraclass correlation coefficients. Results Data was collected from 45 applicants and 18 evaluators. The majority of applicants (>80%) felt that the MMI helped them present their strengths and was free of any gender, cultural, or age bias. Assessors (>85%) agreed the MMI evaluated a valid range of competencies, and that it tested more aspects of an applicant than did traditional interviews. Both applicants and assessors (>70%) agreed that the MMI was a fair process, and both preferred it over the traditional interview. Overall, interrater reliability of the MMI was good. Conclusion This is the first study to examine how the MMI interview process can be adapted for admission to an OTL–HNS residency program, while showing both good acceptability for all major stakeholders and good reliability. Level of Evidence N/A Laryngoscope, 124:91–96, 2014

Summary Rhabdomyomatous mesenchymal hamartoma (RMH) is an uncommon congenital lesion typically involving the midline structures of the head and neck. Although benign, it is sometimes associated with other congenital malformations. The present study describes three cases of RMH: a 2-month-old girl with a left nostril mass, a 3-year-old boy with a midline neck mass and a 2-month-old boy with a lesion near the sternal notch. The objectives of this report are to inform otolaryngologists about the clinical features of this rare entity and to alert clinicians about its association with congenital anomalies in the head and neck region. We also present a review of the literature.

Summary Sinonasal lymphomas are uncommon malignancies. We report the case of a 17-year-old boy who was diagnosed with ALK-negative anaplastic large T cell lymphoma (ALCL) of the sinonasal tract. This is a unique case because of the involvement of three separate sites. It highlights several important concepts related to sinonasal lymphomas including the fact that the diagnosis is often difficult to make, delays to diagnosis are common, and several biopsies are often necessary to reach an accurate diagnosis. Furthermore, we believe this to be the first reported case of ALK-negative anaplastic T cell lymphoma of the sinonasal tract.

Summary Objectives Determine the exact incidence of pulmonary involvement in recurrent respiratory papillomatosis (RRP); explore available treatments and their effectiveness; determine the characteristics of cases that progress to lung cancer. Data sources MEDLINE, EMBASE, and the Cochrane Library databases between 1966 and 2007; reference lists of retrieved publication. Study selection Studies investigating recurrent respiratory papillomatosis with lung involvement. Age limited to 20 years of age to qualify for the diagnosis of juvenile-onset RRP. Data extraction Data pertaining to study design, population demographics, risk factors, site of involvement, investigation including the determination of the human papillomavirus type, treatment, and outcomes including the development of cancer. Data synthesis No randomized control trials were retrieved. Hundred and one studies met our inclusion criteria (23 cohorts, 4 case series, 72 case reports, 2 open trials) with 161 cases of lung involvement identified. From the cohort studies we could estimate the incidence of lung involvement in RRP at 3.3%. The incidence of cancer in cases with lung involvement was 16%. We could not draw conclusions regarding treatment effectiveness in lung involvement, as that was not evaluated except in case studies. It would nevertheless appear that Interferon is not effective and the use of intravenous Cidofovir needs to be better evaluated. Conclusion Well-designed, hypothesis-driven randomized control trials and prospective cohort studies are warranted to improve our understanding of the mechanisms underlying the development of lung involvement in RRP, the risks associated with different HPV types, the efficacy of potential therapeutic options as well as the risk of progression to cancer.

Summary Objectives : We report a case of a teratoid type dermoid cyst of the tongue with a sinus tract to the submental skin. Study design : Case report. Methods : We present a 3-month-old infant with a dermoid cyst of the tongue with a sinus tract to the submental skin and review of the literature on dermoid cysts of the tongue. Results : This rare case presented as an enlarging tongue mass and difficulty feeding. A midline submental skin pinpoint discharge revealed to be a sinus tract connecting the cyst to the skin. Complete excision of the cyst and sinus tract through midline ventral tongue and submental incisions was performed. Conclusion : Although dermoid cysts of the tongue are rare they should be part of the differential diagnosis of tongue masses and presence of a sinus tract should be considered in such cases.

Summary Dentigerous cysts are the most common developmental odontogenic cysts of the jaw, arising from impacted, embedded or unerupted teeth. Although mostly solitary, multiple cysts occur in association with syndromes such as mucopolysaccharidosis type VI, cleidocranial dysplasia, basal cell nevus syndrome, and Gardner's syndrome. Multiple cysts in non-syndromic patients are extremely rare, occurring almost exclusively in the mandible. We report the case of a four-year-old girl with painless right-sided facial swelling, diagnosed with two dentigerous cysts in the right maxillary sinus, who successfully underwent enucleation. To our knowledge this is the only case of multiple unilateral maxillary dentigerous cysts in a healthy, non-syndromic patient.

Adenotonsillectomy (T&A) has established effectiveness for the treatment of obstructive sleep apnea (OSA). However, more than 20% of children with OSA have respiratory compromise requiring medical intervention in the postoperative period. The reasons for this complication are not well-defined. We aimed to compare the nature and severity of sleep-disordered breathing in children with mild and severe OSA on the first night following adenotonsillectomy. Ten children were classified into groups of mild and severe OSA, based on preoperative testing. On the first night after T&A, they underwent polysomnography, including electroencephalograph, submental electromyography, bilateral electro-oculograms, monitoring of respiratory movements, heart rate, ECG, and oxygen saturation. Sleep-disordered breathing was assessed by the apnea-hypopnea index, the SaO 2 nadir, and the desaturation index, including dips in saturation below 90% (DI 9 0 ). Sleep quality was assessed by sleep efficiency, time spent in each sleep state, and respiratory arousal index. Obstructive events occurred postoperatively in all children, but were more frequent in those with severe OSA preoperatively: the median (interquartile range) mixed/obstructive apnea/hypopnea indicies were 6.9 (2.2-9.8) events/hr and 21.5 (15.1 -112.1) events/hr for the mild OSA group and the severe OSA group, respectively (P=0.009). Obstructive events were the major cause of desaturation during sleep postoperatively. Sleep quality was severely disrupted in both groups, with reductions in both slow-wave sleep and rapid eye movement sleep. In conclusion, despite removal of obstructing lymphoid tissue, upper airway obstruction occurred on the first postoperative night in children with OSA. This study is the first to demonstrate the mechanism of respiratory compromise after adenotonsillectomy, a common postoperative complication in children with severe OSA.

Objective: Nasopharyngeal adenoids may serve as a mechanical obstruction to the eustachian tube and contribute to the pathophysiology of otitis media (OM). The purpose of this study was to determine whether abutment of adenoids laterally against the torus tubaris affects the outcome of patients requiring pressure equalization tubes (PET) for OM. Study Design: Randomized, controlled, prospective clinical trial. Method: Patients requiring PET for recurrent acute OM or OM with persistent effusion were randomized into two groups: 1) PET placement and 2) PET placement and adenoidectomy, regardless of whether the adenoids were abutting or not abutting the torus tubaris. Patients were followed for a minimum of 1 year to determine rate of treatment failure, defined as recurrence of acute OM (>3 times/year), OM with effusion, or reinsertion of PET. Results: Of the 34 patients in the abutting group, 16 patients underwent only PET insertion, of whom 8 (50%) failed, whereas 18 patients had combined PET placement and adenoidectomy, of whom 3 (17%) failed. There was a statistical difference between these two groups (P

Hemangiopericytoma is a rare vascular tumor, usually occurring in adults. The tumor is believed to originate from pericytes, the contractile cells surrounding capillaries. It has predilection for the musculoskeletal system. Clinically, the tumor occurs at any age, with highest incidence between the third and sixth decades and without any sex predilection. Head and neck hemangiopericytoma incidence in all age groups ranges from 9.4 to 28%. In children, head and neck hemangiopericytoma is as frequent as 35%, with the highest frequency (46%) found in infants. We report a case of hemangiopericytoma of the tongue in a 6-year-old child resembling to the infantile/congenital type, which was treated by a combination of surgery, chemotherapy, and brachytherapy. This approach has resulted in a normal functioning tongue for the past 5 years.

Background The aim of this study was to determine the frequency and type of respiratory complications after urgent adenotonsillectomy (study group) for comparison with a control group of children undergoing a sleep study and adenotonsillectomy for obstructive sleep apnea syndrome. A second aim was to assess risk factors predictive of respiratory complications after urgent adenotonsillectomy. Methods The perioperative course of children who underwent adenotonsillectomy between January 1, 1999, and March 31, 2001, was reviewed. Two groups of children were identified from two different databases: the hospital database for surgical procedures (the study group) and the sleep laboratory database (the control group). The retrospective chart review focused on the preoperative status (including an evaluation for obstructive sleep apnea), anesthetic management, and need for postoperative respiratory interventions. Results A total of 64 consecutive cases for urgent adenotonsillectomy were identified, and 54 children met the inclusion criteria. Thirty-three children (60%) had postoperative respiratory complications necessitating a medical intervention; 11 (20.3%) required a major intervention (reintubation, ventilation, and/or administration of racemic epinephrine or Ventolin), and 22 (40.7%) required a minor intervention (oxygen administration). Six children (11.1%) required reintubation in the recovery room for respiratory compromise. Risk factors for respiratory complications were an associated medical condition (odds ratio, 8.15; 95% confidence interval, 1.81-36.73) and a preoperative saturation nadir less than 80% (odds ratio, 5.54; 95% confidence interval, 1.15-26.72). Sixteen (49%) of the medical interventions were required within the first postoperative hour. Atropine administration, at induction, decreased the risk of postoperative respiratory complications (odds ratio, 0.18; 95% confidence interval, 0.11-1.050. Control Group Of 75 children who underwent a sleep study and adenotonsillectomy, 44 had sleep apnea and were admitted to hospital after elective adenotonsillectomy. Sixteen (36.4%) children had postoperative respiratory complications necessitating a medical intervention. Six percent of the children (n = 3) required a major medical intervention. No child required reintubation for respiratory compromise. Conclusions Severe obstructive sleep apnea syndrome and an associated medical condition are risk factors for postadenotonsillectomy respiratory complications. Risk reductions strategies should focus on their assessment.

Mucus overproduction is commonly found in airway disease in patients with cystic fibrosis. Interleukin-9 (IL-9) has been shown to mediate airway hyper-responsiveness and mucus overproduction. Recently, the calcium-activated chloride channel hCLCA1 has been described to be upregulated by IL-9 and has been thought to regulate the expression of soluble gel-forming mucins. We sought to examine the expression of IL-9, interleukin-9 receptor (IL-9R), and hCLCA1 in the upper airway of patients with cystic fibrosis in comparison to healthy control subjects and to demonstrate the relationship of IL-9, IL-9R, and hCLCA1 expression with mucus production.Prospective design.Biopsy samples from nasal polyps of four patients with cystic fibrosis, nasal mucosa of six patients with cystic fibrosis, sinus mucosa of eight patients with cystic fibrosis, and nasal mucosa of six healthy control subjects were stained with periodic acid-Schiff (PAS) to identify mucus glycoconjugates. IL-9, IL-9R, and hCLCA1 expression was determined by immunocytochemical study.We demonstrated significant increases in IL-9, IL-9R, and hCLCA1 immunoreactivity in the mucosa of patients with cystic fibrosis compared with that found in control subjects (P.05). There were no significant differences between the different locations (nasal polyps, nasal mucosa, and sinus mucosa) in the patient group (P.05). We also observed a significant increase in the number of mucus-producing cells in biopsy specimens from patients with cystic fibrosis in comparison to control subjects. A positive correlation was found between hCLCA1-positive cells and IL-9-positive cells (correlation coefficient [r] = 0.79, P.05) or IL-9R-positive cells (r = 0.92, P.05). Moreover, a positive correlation was also present between PAS-positive (mucus-producing) cells and hCLCA1-positive cells (r = 0.64, P.05) or IL-9R-positive cells (r = 0.64, P.05).Increased expression of IL-9 and IL-9R, as well as upregulation of hCLCA1, in mucus-overproducing epithelium of patients with cystic fibrosis supports the hypothesis that IL-9 contributes to mucus overproduction in cystic fibrosis. Expression of hCLCA1 may also be responsible, in part, for the overproduction of mucus. These preliminary findings suggest that hCLCA1 might be an interesting new therapeutic target to control mucus overproduction in airway disease in patients with cystic fibrosis.

Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly the tongue. They have, however, been described in all areas of the body. Their presentation in the trachea is exceedingly rare, with their presence in the pediatric trachea being an even rarer occurrence. We describe a case of a granular cell tumor of the trachea in a 10-year-old boy with a dramatic, almost lethal, presentation. This is followed by a review of the literature, including pathology and treatment options.

Objective: We tested the hypothesis that a 6-week course of a nasal glucocorticoid spray would decrease the severity of obstructive sleep apnea in children with adenotonsillar hypertrophy. Study design: We conducted a randomized, triple-blind, placebocontrolled, parallel-group trial of nasal fluticasone propionate versus placebo in 25 children aged 1 to 10 years with obstructive sleep apnea proven on polysomnography. The primary outcome was the change from baseline in the frequency of mixed and obstructive apneas and hypopneas. Results: Thirteen children received fluticasone, and 12 received placebo. The mixed/obstructive apnea/hypopnea index decreased from 10.7 ± 2.6 (SE) to 5.8 ± 2.2 in the fluticasone group but increased from 10.9 ± 2.3 to 13.1 ± 3.6 in the placebo group, P =.04. The mixed/obstructive apnea/hypopnea index decreased in 12 of 13 subjects treated with fluticasone versus 6 of 12 treated with placebo, P =.03. The frequencies of hemoglobin desaturation and respiratory movement/arousals also decreased more in the fluticasone group. Changes from baseline in tonsillar size, adenoidal size, and symptom score were not significantly different between groups. Conclusion: Nasal fluticasone decreased the frequency of mixed and obstructive apneas and hypopneas, suggesting that topical corticosteroids may be helpful in ameliorating pediatric obstructive sleep apnea. (J Pediatr 2001;138:838-44)

Foreign bodies of the sinuses are uncommon. Few reports exist in the English literature. Among these, the frontal and maxillary sinuses are most often involved. Ethmoid and sphenoid foreign bodies are rare and tend to present with chronic symptoms due to delayed diagnosis. We present a case of an acute presentation of a foreign body involving the orbit and ethmoid sinus in a 12-year-old male.

Numerous authors have sought to describe genotype-phenotype correlations in cystic fibrosis (CF), notably to pancreatic insufficiency and lung disease. However, few studies have focused on the association between the F508del genotype and response to sinus surgery. The objective of this study is to assess the effect of the F508del genotype on sinonasal disease severity and outcomes following functional endoscopic sinus surgery (FESS) in a pediatric population.A retrospective chart review of 153 children with CF seen at a tertiary care pediatric hospital from 1995 to 2008 was performed. Patients were classified into one of three groups according to F508del genotype, either as homozygous, heterozygous or not carrying a F508del mutation. The sinonasal disease phenotype of the three groups was compared based on clinical and radiological findings, extent of endoscopic sinus surgery and rate of revision surgery.The relationship between the F508del genotype and pancreatic insufficiency was confirmed (p0.05). There was no association between the F508del genotype and increased need for FESS (p=0.75). Moreover, no association was established between F508del homozygosity and presence of nasal polyps, Lund-Mackay score, extent of surgery or length of postoperative hospitalization. The rates of revision surgery did not differ significantly among the three genotypes analyzed (p=0.59).There is no clear association between the F508del genotype and an increased need for FESS, extent of surgery, or revision surgery. Given the phenotypic variability of sinonasal disease in patients with CF, a prospective study is needed to better understand outcomes following FESS and the contribution of gene modifiers to this effect.

This is a case report of a 13 years old boy with a thyroid rupture secondary to a hockey stick blunt trauma to his neck and a literature review focused on diagnosis and management. There are 14 other cases in the literature, 7 of which required surgical intervention mainly to evacuate a hematoma. The case in this review did not develop any complications. This is the first reported case in the literature of thyroid gland rupture due to a blunt trauma in a child. Patients with thyroid gland rupture should be monitored closely for developing a hematoma or thyroid storm.

Solitary plexiform neurofibromas of the intraparotid facial nerve are extremely rare tumours that can present a diagnostic challenge. Knowledge of their existence is key to its proper management. Only two cases have been reported in the English literature. We describe the first paediatric case of an intraparotid facial nerve solitary plexiform neurofibroma.

Objective: 1) To determine the reliability of the Multiple Mini Interview (MMI) for resident selection into an otolaryngology–head and neck surgery (OTL-HNS) program. 2) To assess the degree of acceptance by major stakeholders (interviewers and applicants) towards the MMI when compared to traditional interviews.Method: Canadian medical graduates applying to OTL-HNS residency programs underwent MMI in 2011 and 2012. MMI had 7 stations evaluating unique candidate attributes. Stations include surgical skills assessment and 2 simulation scenarios with standardized actors for noncognitive traits. Reliability was determined, and upon completion, stakeholders rated aspects MMI using 7-point Likert scale.Results: Data were collected from a total of 45 applicants and 19 evaluators. Overall interrater reliability of the MMI was good. The majority of applicants (>80%) felt that MMI helped them present their strengths and that it did not have any gender, cultural, or age bias. Assessors (>85%) felt that the MMI evalu...

Objective: Determine the prevalence of asthma in children who underwent rigid bronchoscopy (RB) for a suspected foreign body aspiration (sFBA) in the tracheobronchial tree, and to identify characteristics of patients who could benefit from a trial of anti-asthma treatment prior to undergoing a diagnostic bronchoscopy.Method: Retrospective chart review of children with sFBA in the tracheobronchial tree who underwent RB at the Montreal Children’s Hospital (2001-2009). Patient characteristics such as delay between initial choking episode and first otolaryngology evaluation, clinical findings, radiologic findings, bronchoscopic findings, and history of asthma were analyzed.Results: A total of 55 children underwent a RB for sFBA. Foreign bodies (FB) were found in 36 of these, one of which was asthmatic (2.78%, P < .05). In the 19 children who had a negative bronchoscopy (no FB), four were asthmatics (21.1%, P < .05). The mean time from the suspected initial choking event to the first otolaryngology evaluation ...

Lymphangiomas present commonly in the head and neck region with over 90% of lesions diagnosed before 2 years of age. These lesions have rarely been reported as a cause of acute upper airway obstruction and to date, there are very few reports in the literature documenting the presence of lymphangiomas in the larynx. We present the case of a previously asymptomatic 13-year-old girl with Joubert's syndrome, who presented with acute airway obstruction while undergoing extubation for a routine dental procedure. Near-complete obstruction of her supraglottis from a lymphangioma necessitated tracheotomy to secure the airway. The diagnostic work-up and management of this patient and her post-operative course are discussed. This case illustrates the insidious presentation of a laryngeal lymphangioma and emphasizes the management options for such patients.

Stridor is a relatively common symptom during the neonatal period. The most probable cause of inspiratory stridor and supralaryngeal airway obstruction in infancy is laryngomalacia. Laryngeal cysts are known to be found in association with supraglottic prolapse and are a rare yet potentially lethal cause of respiratory distress in the newborn. In the absence of more alarming presenting signs, the vallecular cyst, a form of laryngeal cyst, frequently defies diagnosis. We present a series of illustrative cases to raise awareness of vallecular cyst to help reduce the therapeutic delays that are currently encountered clinically.A retrospective case series of four patients was reviewed. Each patient presented initially with stridor and additional signs of upper airway obstruction shortly after birth and was later diagnosed with vallecular cyst.The predominant presenting signs were stridor (four cases), signs of respiratory distress (three cases), failure to thrive (three cases), poor feeding (two cases), and cyanotic spells (one case). Age at presentation ranged from 16 days to 8 months. A definitive diagnosis was achieved by flexible laryngoscopy in all four cases. Coexistent laryngomalacia was found in three of the four cases. Primary outcomes at 1 month following marsupialization were complete remission in all four cases.The challenge in making an early diagnosis of vallecular cyst, especially when laryngomalacia is comorbid, has been reaffirmed in our case series. Diagnosis requires a high index of clinical suspicion in combination with careful inspection of the tongue base with direct examination and/or appropriate imaging modalities.

Laryngopharyngeal reflux (LPR) was recently implicated in the etiology of otitis media with effusion (OME). To study the hypothesis that gastric juice reaches the middle ear through the nasopharynx and eustachian tube, we evaluated the presence of pepsinogen in the adenoid tissues of children with otitis media with effusion (OME) and compared them with the tissues of a control group of children without OME.In the study group, middle ear effusions (MEEs) and adenoidal tissue biopsies were obtained from patients undergoing simultaneous tympanostomy tube placement and adenoidectomy. In the control group, adenoid specimens were taken during adenoidectomy (+/- tonsillectomy) from children with no history of OME. The adenoid tissues were analyzed immunohistochemically to confirm the presence of pepsinogen. Normal gastric tissue was used as a positive control and lymphatic tissue as a negative control. Total pepsinogen levels of MEE were measured with enzyme-linked immunosorbent assay.Adenoid tissue of the OME group (n = 25) demonstrated significantly higher pepsinogen immunoreactivity when compared with the adenoid tissue of the control group (n = 29), specifically in staining of both the epithelia (p.0001) and the subepithelia, (p.001). The presence of pepsinogen was detected in 84% of MEEs from the OME group, at concentrations 1.86 to 12.5 times higher than that of serum. Pepsinogen messenger ribonucleic acid was not demonstrated in any of the adenoid tissues of the OME group.LPR plays an important role in the pathogenesis of OME as gastric reflux reaches the middle ear through the nasopharynx and eustachian tube to cause OME.

To document the most important postoperative adenotonsillectomy morbidities, with an emphasis on prolonged hospitalization and readmissions.Retrospective chart analysis.We reviewed 2067 cases of adenotonsillectomies performed at our institution over a period of 6 years.Of these cases, 1927 patients had undergone tonsillectomy by electrocautery and adenoidectomy by suction-coagulator, of whom 9.3% required admission. The incidence of admissions owing to bleeding was 1.7%, whereas admissions owing to respiratory and gastrointestinal complications represented 3.7% and 5.2%, respectively. Compared with the literature and our institution's previous results, these morbidity values were found to be either comparable or significantly lower (p.05).We attribute this improvement to our use of electrocautery-based techniques not only for tonsillectomy but also for adenoidectomy.

Objective: To compare the analgesic efficacy of hydrogen peroxide (H2O2) mouth rinse with control for post-tonsillectomy pain management. Design: Double-blinded, prospective, randomized, controlled clinical trial. Patients and Methods: Thirty-seven patients from 5 to 14 years old undergoing electrocautery tonsillectomy were randomized to either the H2O2 mouth rinse or the water rinse (control) group. For 14 days, patients recorded pain levels twice daily using a visual analogue scale. Analgesic uses, as well as any complications, were also noted by the patients. Results: Thirty-seven patients completed the study, 21 in the treatment group and 16 in the control group. Mean postoperative days of pain were 10.3 and 8.3, respectively, and differed significantly (p = .008). Mean postoperative days of analgesic use were 9.0 and 6.7, respectively, and differed significantly (p = .005). Only one incidence of postoperative hemorrhage occurred in the study group. Conclusion: In our study, the H2O2 mouth rinse does not provide a better analgesic effect than the water rinse for posttonsillectomy pain relief.

Otitis media with effusion (OME) is a chronic inflammatory disease of the middle ear space characterized by the accumulation of fluid. Previous investigations have suggested that the immunopathologic mechanism underlying the development of middle ear effusion in patients with allergy is largely due to the effects of T(H)2 mediators. The composition of the inflammatory substrate in the effusions of allergic otitis media is similar to the late-phase allergic response seen elsewhere in the respiratory tract, such as in asthma and in allergic rhinitis.To determine whether the middle ear compartment may be a component of the united airways in allergic disease by comparing the inflammatory profiles of the middle ear to the upper airway.Middle ear effusions, torus tubaris (Eustachian tube mucosa at the nasopharyngeal orifice), and adenoidal tissue biopsies were obtained from 45 patients undergoing simultaneous tympanostomy tube placement for OME and adenoidectomy for adenoid hypertrophy. The cellular and cytokine profiles of each site were investigated by using immunocytochemistry (elastase, CD3, major basic protein) and in situ hybridization (IL-4, IL-5, IFN-gamma mRNA). Atopic status was determined for each patient by using skin prick testing.Eleven of the 45 patients with OME (24%) were atopic. The middle ear effusions of atopic patients had significantly higher levels of eosinophils, T lymphocytes, and IL-4 mRNA + cells ( P.01) and significantly lower levels of neutrophils and IFN-gamma mRNA + cells ( P.01) compared with nonatopic patients. The nasopharyngeal tissue biopsies revealed similar cellular and cytokine profiles.In atopic patients with OME, the allergic inflammation occurs on both sides of the Eustachian tube, both in the middle ear and in the nasopharynx. The results of this study support the concept that the middle ear may be part of the united airway in atopic individuals.

Summary Background Exposure to bacterial products in early life could protect against development of atopy. We examined the effect of bacterial lipopolysaccharide on allergic inflammation and expression of cytokines and lipopolysaccharide receptor (toll-like receptor 4; TLR4) in nasal mucosa of 15 atopic children and ten atopic adults. Methods Explanted mucosa was cultured with allergen with or without lipopolysaccharide (0·1 mg/L) for 24 h. Immunocytochemistry and in-situ hybridisation were used to phenotype the cells and cytokines. Findings In explants from atopic children, lipopolysaccharide prevented allergen-induced T-helper type 2 (Th2) inflammation and upregulated Th1 cytokine reactivity and expression. These effects were blocked by antibody to interleukin 10. In children but not in adults, lipopolysaccharide caused increases of three times in T-cell reactivity, five times in T-cell proliferation, and four times in expression of interleukin 10 compared with mucosa stimulated with allergen alone. This difference in response was mirrored by lipopolysaccharide-induced increases in TLR4 reactivity in children but not adults. TLR4 receptor was expressed by CD3-positive T cells, and TLR4-positive cells contained interleukin 10. Lipopolysaccharide increased expression of cells positive for both CD3 and TLR4; both TLR4 and interleukin 10; and both CD4 and CD25. Interpretation Lipopolysaccharide inhibits allergic inflammation in nasal mucosa of atopic children by skewing local immune responses from Th2 to Th1 and upregulating production of interleukin 10. These effects are mediated by TLR4. Our results emphasise an important difference between adults and children in their ability to respond to bacterial products. These differences could have a role in normal maturation of the immune system.

To our knowledge, this is the 1st reported case of steroid-induced obstructive cardiomyopathy in a child being treated for subglottic stenosis. As well, although born at 27 weeks, our patient was over 4 kg and 4 months of age (44 weeks corrected gestational age). This appears to be a phenomenon chiefly involving premature babies in the neonatal period with no reports of this occurring in patients greater than 40 weeks corrected gestational age. Signs of cardiac hypertrophy include tachycardia, new cardiac murmur, increased oxygen requirements, decreased urine output, and decreased peripheral perfusion. Diagnosis and eventual recovery was confirmed with serial echocardiograms. Knowledge of this serious side effect of dexamethasone will allow otolaryngologists to intervene early and prevent a potentially deadly complication.

Objective. Obstructive sleep apnea (OSA) in children is usually effectively treated by adenotonsillectomy (T&A). However, there may be a waiting list for T&A, and the procedure is associated with an increased risk of postoperative complications in children with OSA. Needed is a simple test that will facilitate logical prioritization of the T&A surgical list and help to predict children who are at highest risk of postoperative complications. The objective of this study was to develop and validate a severity scoring system for overnight oximetry and to evaluate the score as a tool to prioritize the T&A surgical list.Methods. This study comprised 3 phases. In phase 1, a severity score was developed by review of preoperative overnight oximetry in children who had urgent T&A in 1999–2000. In phase 2, the score was validated retrospectively in 155 children who had polysomnography (PSG) before T&A in 1992–1998. In a phase 3, a 12-month prospective evaluation of a protocol based on the score was conducted.Results. In phase 1, a 4-level severity score was developed on the basis of the number and the depth of desaturation events (normal to severely abnormal, categories 1–4). In phase 2, the McGill oximetry score correlated with severity of OSA by PSG criteria. In phase 3, a clinical management protocol was developed based on the score. Of 230 children tested, 179 (78%) had a normal/inconclusive oximetry (category 1) and went on to have PSG. Those with a positive oximetry (categories 2–4; 22%) had no additional sleep studies before T&A. Timing of T&A was based on oximetry score, leading to a significant reduction in waiting time for surgery for those with higher oximetry scores. Postoperative respiratory complications were more common with increasing oximetry score.Conclusions. Overnight pulse oximetry can be used to estimate the severity of OSA, to shorten the diagnostic and treatment process for those with more severe disease, and to aid clinicians in prioritization of T&A and planning perioperative care.

The aim of this study was to determine the frequency and type of respiratory complications after urgent adenotonsillectomy (study group) for comparison with a control group of children undergoing a sleep study and adenotonsillectomy for obstructive sleep apnea syndrome. A second aim was to assess risk factors predictive of respiratory complications after urgent adenotonsillectomy.The perioperative course of children who underwent adenotonsillectomy between January 1, 1999, and March 31, 2001, was reviewed. Two groups of children were identified from two different databases: the hospital database for surgical procedures (the study group) and the sleep laboratory database (the control group). The retrospective chart review focused on the preoperative status (including an evaluation for obstructive sleep apnea), anesthetic management, and need for postoperative respiratory interventions.A total of 64 consecutive cases for urgent adenotonsillectomy were identified, and 54 children met the inclusion criteria. Thirty-three children (60%) had postoperative respiratory complications necessitating a medical intervention; 11 (20.3%) required a major intervention (reintubation, ventilation, and/or administration of racemic epinephrine or Ventolin), and 22 (40.7%) required a minor intervention (oxygen administration). Six children (11.1%) required reintubation in the recovery room for respiratory compromise. Risk factors for respiratory complications were an associated medical condition (odds ratio, 8.15; 95% confidence interval, 1.81-36.73) and a preoperative saturation nadir less than 80% (odds ratio, 5.54; 95% confidence interval, 1.15-26.72). Sixteen (49%) of the medical interventions were required within the first postoperative hour. Atropine administration, at induction, decreased the risk of postoperative respiratory complications (odds ratio, 0.18; 95% confidence interval, 0.11-1.050.Of 75 children who underwent a sleep study and adenotonsillectomy, 44 had sleep apnea and were admitted to hospital after elective adenotonsillectomy. Sixteen (36.4%) children had postoperative respiratory complications necessitating a medical intervention. Six percent of the children (n = 3) required a major medical intervention. No child required reintubation for respiratory compromise.Severe obstructive sleep apnea syndrome and an associated medical condition are risk factors for postadenotonsillectomy respiratory complications. Risk reductions strategies should focus on their assessment.