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Background: Unilateral vocal fold immobility (VFI) is a known cause of morbidity amongst children following congenital heart surgery. Injection medialization (IM) provides medial distraction and improves glottic closure. Limited objective data is available for the effect of IM in young children (<2 years‐old) with VFI. Methods: Retrospective case series of infants <2 who underwent IM for VFI after congenital cardiac surgery. Primary outcome was objective reduced risk of aspiration based on Dysphagia and Outcome Severity Scores (DOSS) on Video swallow study (VFSS) performed prior to and within 4 weeks following IM. Secondary analysis included perioperative complications and number of children who were able to avoid NG or G tube placement. Results: 17 children <2 years of age had unilateral VFI after congenital cardiac surgery and underwent IM. The median age at time of initial cardiac surgery was 6 days (IQR 3–7). There was no intraoperative or postoperative stridor or associated complications. All 17 patients had preoperative aspiration noted on VFSS. Average swallowing outcomes on VFSS improved after IM with an increase in DOSS score (preop score 3 (IQR 2–4) to postop score 6.5 (IQR 5–7) [P = 0.001]). At 2 months following IM, of the patients who had improvement in swallowing function, 50% (n = 6) were able to feed completely orally, 25% (n = 3) were fed orally with an NG wean, and 3 (25%) had a G tube placed. Conclusion: Initial results suggest that IM is safe and improves early objective swallowing outcomes in children <2 years old with VFI after congenital cardiac surgery. Level of Evidence: 4 Laryngoscope, 134:4396–4401, 2024 [ABSTRACT FROM AUTHOR]

The article in the Laryngoscope journal outlines a protocol for creating patient-specific 3D-printed airway models for slide tracheoplasty in pediatric patients. The aim is to enhance surgical training and preoperative planning by providing accurate anatomical models. The process involves image acquisition, segmentation, model design, and preparation for printing, resulting in models that mimic cartilage and tracheal walls. These models can be used for surgical simulation and training, improving multidisciplinary care and facilitating detailed discussions about operative plans. [Extracted from the article]

Objective: The objective of this study was to develop and assess multidisciplinary advanced surgical planning (ASP) sessions using three dimensional (3D) printed models for cervicothoracic slide tracheoplasty (CST). We hypothesized that these sessions would improve surgeon confidence, streamline intraoperative planning, and highlight the utility of 3D modeling. Methods: 3D‐printed patient‐specific trachea models were used in pre‐operative ASP sessions consisting of a multidisciplinary case discussion and hands‐on slide tracheoplasty simulation. Participants completed a survey rating realism, utility, impact on the final surgical plan, and pre‐ and post‐session confidence. Statistical analysis was performed via Wilcoxon and Kruskal‐Wallis tests. Results: Forty‐eight surveys were collected across nine sessions and 27 different physicians. On a 5‐point Likert scale, models were rated as "very realistic", "very useful" (both median of 4, IQR 3–4 and 4–5, respectively). Overall confidence increased by 1.4 points (+/− 0.7, p < 0.0001), with the largest change seen in those with minimal prior slide tracheoplasty experience (p = 0.005). Participants felt that the sessions "strongly" impacted their surgical plan or anticipated performance (median 4, IQR 4–5), regardless of training level or experience. Conclusion: 3D‐printed patient‐specific models were successfully implemented in ASP sessions for CST. Models were deemed very realistic and very useful by surgeons across multiple specialties and training levels. Surgical planning sessions also strongly impacted the final surgical plan and increased surgeon confidence for CST. Level of Evidence: 4 Laryngoscope, 134:3395–3401, 2024 [ABSTRACT FROM AUTHOR]

Introduction: Vocal fold motion impairment (VFMI) is a known consequence after high‐risk cardiac surgery. We implemented a universal laryngeal ultrasound (LUS) screening protocol for VFMI after the Norwood and aortic arch surgery. We hypothesized that LUS would accurately identify VFMI and predict postoperative aspiration. Methods: We implemented a screening algorithm with LUS for patients undergoing high‐risk cardiac surgery at a tertiary care pediatric hospital. Positively screened patients underwent flexible nasolaryngoscopy (FNL). Patients with an abnormal FNL underwent a video‐fluoroscopic swallow study (VFSS). Patient demographics, length of stay, and swallowing outcomes were assessed. Two‐tailed chi square and Wilcoxon rank sum tests were used to assess for differences. Results: Sixty‐seven patients underwent either Norwood or arch reconstruction over a 16‐month period and underwent universal LUS. The average birth weight was 3.24 kg (SD 0.57). Of the 67 patients, VFMI was identified by LUS and 100% confirmed on FNL in 58.21% (n = 39/67) of patients. Aspiration and penetration on VFSS were higher in the group with VFMI as compared with those without VFMI (53.8% vs. 21.4%, p = 0.008). There was no difference in length of stay between patients who did not have a diagnosis of VFMI and those found to have VFMI (41.0 days vs 45.3 days p = 0.73). Conclusions: Universal LUS screening for patients following high‐risk cardiac surgery may lead to earlier identification of postoperative VFMI and aspiration. Recognition of VFMI through this universal screening program could lead to earlier interventions and possibly improved swallowing outcomes. Level of Evidence: 3 Laryngoscope, 134:1939–1944, 2024 [ABSTRACT FROM AUTHOR]

Endoscopy is the gold standard for characterizing pediatric airway disorders, however, it is limited for quantitative analysis due to lack of three‐dimensional (3D) vision and poor stereotactic depth perception. We utilize structure from motion (SfM) photogrammetry, to reconstruct 3D surfaces of pathologic and healthy pediatric larynges from monocular two‐dimensional (2D) endoscopy. Models of pediatric subglottic stenosis were 3D printed and airway endoscopies were simulated. 3D surfaces were successfully reconstructed from endoscopic videos of all models using an SfM analysis toolkit. Average subglottic surface error between SfM reconstructed surfaces and 3D printed models was 0.65 mm as measured by Modified Hausdorff Distance. Average volumetric similarity between SfM surfaces and printed models was 0.82 as measured by Jaccard Index. SfM can be used to accurately reconstruct 3D surface renderings of the larynx from 2D endoscopy video. This technique has immense potential for use in quantitative analysis of airway geometry and virtual surgical planning. [ABSTRACT FROM AUTHOR]

Objective: To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy‐specific steps. Methods: A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as "keep" or "remove". In the second and third rounds, experts were asked to rate the importance of each item on a 9‐point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments. Results: The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy‐specific steps, team and personnel factors, and equipment respectively. Conclusions: The resultant assessment tool can be used to assess both tracheostomy‐specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives. Level of Evidence: 5 Laryngoscope, 133:3588–3601, 2023 [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy of interarytenoid injection augmentation (IAIA) and the ability of IAIA to predict response to interarytenoid suture augmentation (IASA) based on diet advancement on video fluoroscopic swallow studies (VFSS). Methods: Retrospective cohort analysis of patients with persistent pharyngeal dysphagia at a tertiary children's hospital with VFSS pre‐ and post‐IAIA were included between March 2011 and June 2019. Results: Median age of the 229 patients was 2.2 years (5.8 months–19 years). Interarytenoid mucosal height (IAMH) was found to be above the false vocal folds in 112 patients (53.4%) and at true vocal folds in 10 (4.9%) patients. On VFSS post‐IAIA, 95 (41.5%) patients were successfully advanced in recommended diet consistency, 115 (50.2%) were stable, and 19 (8.3%) needed thicker consistency. Paired t‐tests on pre‐ and post‐operative consistency scores showed significant improvement, p‐value of <0.0001, 95% confidence interval (CI; 0.50–0.85). Poisson regression found no covariates with significant association with improvement on IAIA. For IASA patients, 35/60 (58.3%) improved on post‐op VFSS. Paired t‐tests on pre‐ and post‐operative consistency scores showed significant improvement, p‐value of <0.0001, 95% CI (0.63–1.33). Positive predictive value for IAIA predicting response to IASA was 77% with positive likelihood ratio of 2.3. The response to IAIA versus no response to IAIA likelihood ratios were found to have a statistically significant difference (p < 0.05). Conclusions: Our study suggests IAIA yields objective improvement in swallow function on VFSS in nearly half of our patients and may be a reliable diagnostic tool to predict response to IASA in patients with persistent pharyngeal dysphagia with or without a laryngeal cleft. Level of Evidence: 3 Laryngoscope, 133:1749–1756, 2023 [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic laryngeal cleft repair (ELCR) with endolaryngeal suturing is an advanced surgical skill. This study objective was to assess the validity of 3‐dimensionally (3D) printed laryngeal suturing simulator for ELCR. Study Design: Development and validation of a simulator for ELCR. Methods: An ELCR model was developed using 3D printed and readily available materials. Participants were surveyed before and after a simulation session using five‐point Likert scale questions. Performance data was assessed using blinded expert video review and rated using a novel objective structured assessment of technical skills (OSATS) for endoscopic laryngeal suturing. Results: Twenty‐one participants ranging from residents to attendings completed the simulation session. Survey respondents reported on a five‐point Likert scale that the model was "easy to use" and "quite realistic" (both mean of 4). Confidence improved significantly in 86% of participants (p < 0.01). Overall OSATS scores (out of a total of 55) showed a median improvement in technical skills of 11.7 points (p = 0.004). OSATS demonstrated good intra‐rater (κ = 0.689 and 0.677) and moderate inter‐rater (κ = 0.573) reliability. Completion times improved from the first to the last suture by a median time of 512 to 350 s (decrease of 202 s, p = 0.002). Participants with no prior ELCR experience improved more than those with in vivo experience. Conclusion: This study demonstrates the validity of a simulator utilizing 3D printed larynges for ELCR. A novel OSATS for endoscopic laryngeal suturing was successfully implemented. Confidence, technical skills, and completion times improved with the use of the model across a variety of participants. Laryngoscope, 133:785–791, 2023 [ABSTRACT FROM AUTHOR]

We sought to assess the feasibility of virtually assisted personalized tracheostomy tube (vapTT) implementation for patients with congenital airway anomalies (CAAs) and persistent tracheostomy tube (TT)–related respiratory failure at a tertiary pediatric hospital. Three patients (0‐18 years) with CAAs and recurrent TT‐related respiratory complications were managed with vapTT over 5 years. Patients underwent airway computed tomography acquisition with 3‐dimensional reconstruction and TT virtual modeling for shape customization. Models were transferred to Bivona for fabrication based on industry‐standard materials and processes. Clinical information and tracheoscopies assessing position, obstruction, and granulation were reviewed. Patients demonstrated resolution of visualized TT‐related obstruction, granulation, or ulceration and de‐escalation of respiratory support. Clinical events requiring urgent tracheoscopy decreased in all 3 patients. Sufficient relief of critical airway obstruction allowed progression of medical care and/or discharge. VapTTs are feasible for patients with CAA. This new frontier in personalized devices may serve uniquely challenging patient populations for whom standard treatments have failed. [ABSTRACT FROM AUTHOR]

A patient with a recurrent connection between their trachea and esophagus underwent an endoscopic repair (through the mouth with no incisions) with a graft secured via sutures, which is the first description of fully endoscopic graft placement for this pathology. Laryngoscope, 133:269–272, 2023 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: We hypothesized that the use of three‐dimensional (3D) printed tracheal models to reproducibly simulate surgical technique variations in slide tracheoplasty would demonstrate the quantitative impact of surgical variables on postoperative tracheal dimensions. Study Design: Prospective analysis of three‐dimensional printed surgical simulation models. Methods: Slide tracheoplasty was performed on 3D printed long segment tracheal stenosis models with combinations of tracheal transection incision angle (90°, 45° beveled superior to inferior, 45° beveled inferior to superior) and tracheal transection location relative to the stenosis (at midpoint, 2 mm each superior and inferior to midpoint). Postoperative computed tomography (CT) scans measured changes in tracheal length, volume, and cross‐sectional area compared to controls. Statistical analysis was performed using one‐way analysis of variance and unpaired two‐tailed t‐tests. Results: Slide tracheoplasty yielded 27 reconstructed tracheas. On average, slide tracheoplasty reduced total tracheal length by 36%. Beveled tracheal incisions yielded 9.5% longer final tracheas than straight transection incisions (P <.0001). Cross‐sectional area at the stenosis midpoint increased from 9.0 mm2 to 45 mm2 but did not vary with technique (P >.05). Total tracheal luminal volume increased from 900 mm3 to 1378 mm3 overall and was largest with beveled incisions (P =.03). More material was discarded with straight incisions compared to beveled (89 mg vs. 19 mg, P <.0001). Conclusions: Beveled tracheal transection incisions resulted in increased tracheal length, longer anastomotic segments, increased volume, and reduced tissue waste as compared to straight incisions. Offsetting the incision from the midpoint of stenosis did not significantly affect reconstructed tracheal morphology. Using 3D printed models for surgical simulation can be helpful for the quantitative study of the effect isolated surgical variables on technical outcomes. Level of Evidence: 3 Laryngoscope, 132:1306–1312, 2022 [ABSTRACT FROM AUTHOR]

Objective: Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an instrument with 2 domains: collapse and granulation. Study Design: Cross-sectional repeated testing survey. Setting: Electronic survey. Methods: A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains. Results: ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation. Conclusion: The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the performance of 4-dimensional computed tomography (4D-CT) in assessing upper airway obstruction (UAO) in patients with Robin sequence (RS) and compare the accuracy and reliability of 4D-CT and flexible fiber-optic laryngoscopy (FFL). Study Design: Prospective survey of retrospective clinical data. Setting: Single, tertiary care pediatric hospital. Methods: At initial and 30-day time points, a multidisciplinary group of 11 clinicians who treat RS rated UAO severity in 32 sets of 4D-CT visualizations and FFL videos (dynamic modalities) and static CT images. Raters assessed UAO at the velopharynx and oropharynx (1 = none to 5 = complete) and noted confidence levels of each rating. Intraclass correlation and Krippendorff alpha were used to assess intra- and interrater reliability, respectively. Accuracy was assessed by comparing clinician ratings with quantitative percentage constriction (QPC) ratings, calculated based on 4D-CT airway cross-sectional area. Results were compared using Wilcoxon rank-sum and signed-rank tests. Results: There was similar intrarater agreement (moderate to substantial) with 4D-CT and FFL, and both demonstrated fair interrater agreement. Both modalities underestimated UAO severity, although 4D-CT ratings were significantly more accurate, as determined by QPC similarity, than FFL (−1.06 and −1.46 vs QPC ratings, P =.004). Overall confidence levels were similar for 4D-CT and FFL, but other specialists were significantly less confident in FFL ratings than were otolaryngologists (2.25 and 3.92, P <.0001). Conclusion: Although 4D-CT may be more accurate in assessing the degree of UAO in patients with RS, 4D-CT and FFL assessments demonstrate similar reliability. Additionally, 4D-CT may be interpreted with greater confidence by nonotolaryngologists who care for these patients. [ABSTRACT FROM AUTHOR]