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Derek J Lam,1 Steven A Shea2 1Department of Otolaryngology–Head and Neck Surgery, 2Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USAThe awareness and understanding of the spectrum of pediatric sleep disorders has increased significantly in the last 20 years. While parents have always struggled with snoring children or behavioral difficulties around bedtime, only recently have parents and clinicians become aware of the potential long-term negative consequences of leaving these problems unaddressed. The diagnosis and management of pediatric sleep disorders can be uniquely challenging because of difficulties in assessing both the burden of disease and its downstream effects in the very young who are unable to clearly articulate their sleep-related experiences or relevant outcomes. Investigations in this age-group frequently require proxy parental assessments of sleep habits and outcomes or other innovative alternative methods of subjective assessment combined with objective measures that must be customized to the pediatric population. The impact of untreated sleep disorders during critical periods of early development on later cognition, behavior, and quality of life is potentially significant and far-reaching. This lends urgency to the need for more thorough and systematic investigation across the spectrum of pediatric sleep disorders.

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Objectives: Persistent obstructive sleep apnea (OSA) after adenotonsillectomy (AT) has been reported in 20%-30% of children. The aim of this study was to determine the predictive value of drug-induced sleep endoscopy (DISE) at the time of AT on subjective AT outcomes., Methods: This was a prospective cohort study of children aged 2-18 years being treated with AT for sleep disordered breathing (SDB) with one or more risk factors for AT failure: age >7 years, obesity, severe baseline OSA, Black race. All underwent DISE at the time of AT. Potential predictors of subjective AT outcome included age, sex, obesity, and DISE patterns. Multivariable linear regression was used to model predictors of post-AT Pediatric Sleep Questionnaire (PSQ) and OSA-18 outcomes., Results: Pre- and post-AT PSQ/OSA-18 responses were available from 194 children. Mean age was 9.3 ± 3.5 years, with 59% obese, 50% female, and 67% White. After AT, mean PSQ score decreased from 0.60 ± 0.19 to 0.28 ± 0.22, p < 0.001 and mean OSA-18 score decreased from 66 ± 21 to 37 ± 18, p < 0.001. The most frequent sites of obstruction were the tonsils (92%), nasal airway (77%), adenoids (64%), and velopharynx (65%). Multivariable regression modeling demonstrated worse outcomes with obesity, male gender, and multilevel obstruction that included the nasal airway and tongue base in addition to adenotonsillar obstruction., Conclusions: Persistent OSA and symptom burden after AT was common in this population. Obesity, male gender, and multilevel obstruction during DISE were all associated with worse subjective outcomes., Level of Evidence: 3 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Obstructive sleep apnea in newborns and infants presents a unique challenge with distinct differences in sleep physiology, etiologies, and management compared to older children. The indications for and interpretation of polysomnography are less well defined in infants. There are also no broadly accepted clinical practice guidelines for treating sleep apnea in this age group. Etiologies include general causes of upper airway obstruction in infants such as laryngomalacia, micrognathia, and nasal obstruction in addition to adenotonsillar hypertrophy. Treatment strategies must be tailored to the specific anatomic features and comorbidities of the specific patients and often require a multidisciplinary approach., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: To develop and validate a consensus international pediatric sleep endoscopy scale (IPSES) for pediatric drug-induced sleep endoscopy (DISE)., Methods: Existing published DISE ratings scales were reviewed in order to develop a consensus rating scale synthesizing the most common features and adding new elements to address areas of controversy. Samples of 30 de-identified DISE video recordings were reviewed to develop and refine the scale. After the consensus scale was defined, a separate sample of 25 de-identified DISE videos were scored with the new consensus scale by the development group and a panel of independent raters. A weighted kappa statistic was used to quantify the inter-rater and intra-rater reliability of the consensus scale at each anatomic level., Results: Among all raters, intra-rater reliability was most variable for the nasal airway (kappa range 0.33-0.94) and best for the lateral oropharynx (kappa range 0.68-0.95). Inter-rater reliability ranged from 0.43 for the nasal airway to 0.57 at the soft palate., Conclusion: The IPSES is a reliable consensus scale that reflects the most common features of existing scales and can be adopted as a universal scoring scale for pediatric DISE., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Derek J. Lam reports financial support was provided by National Heart Lung and Blood Institute., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA)., Methods: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus., Results: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated., Conclusion: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy., (© 2022 ARS-AAOA, LLC.)

Importance: Drug-induced sleep endoscopy (DISE) is increasingly used to guide treatment decisions in children with sleep-disordered breathing (SDB). Previous reports of DISE findings in children have typically included a broad age range, but it is unclear how these patterns of obstruction vary with age., Objective: To compare patterns of airway obstruction observed during DISE in 3 age groups of surgically naive children with SDB., Design, Setting, and Participants: This cross-sectional analysis of a prospective cohort of surgically naive nonsyndromic children with SDB or obstructive sleep apnea [OSA] at risk for residual disease after adenotonsillectomy (defined as having at least 1 of these criteria: severe OSA, older than 7 years, obesity, or Black race) who were recruited between May 1, 2015, and February 28, 2020, was conducted at a tertiary children's hospital. Data analysis was conducted from September 2021 to February 2022., Exposures: DISE., Main Outcomes and Measures: DISE findings were rated at 6 anatomic sites using the Sleep Endoscopy Rating Scale (SERS). The association between age and severity of obstruction at each anatomic site and overall were compared using correlation (Kendall τ) and ordinal logistic regression analysis., Results: Data from 288 children (144 girls [50%]; 20 American Indian/Alaska Native [7%], 4 Asian [1%], 19 Black [7%], 93 Hispanic [33%], 2 Middle Eastern [1%], 6 Native Hawaiian/Pacific Islander [2%], and 203 White [70%] individuals; median [IQR] age, 9.2 [7.0-11.7] years) were stratified by participant age into preschool (age 2-5 years; 27 [9%]), younger school-aged (age 5-10 years; 146 [51%]), and older school-aged (age 10-18 years; 115 [40%]). Among these subgroups, the prevalence of multilevel obstruction was 59%, 51%, and 30%, respectively. Increasing age was inversely correlated with obstruction of the nasal airway (τb, -0.19; 95% CI, -0.29 to -0.09), nasopharynx (τb, -0.20; 95% CI, -0.31 to -0.10), velopharynx (τb, -0.16; 95% CI, -0.26 to -0.06), and overall obstruction (SERS total score: τb, -0.24; 95% CI, -0.33 to -0.14). An adjusted analysis demonstrated an inverse association between age and nasopharyngeal obstruction (odds ratio [OR], 0.84; 95% CI, 0.76 to 0.92), SERS total score (OR, 0.83; 95% CI, 0.76 to 0.90), and the number of sites of complete obstruction (OR, 0.87; 95% CI, 0.87 to 0.95)., Conclusions and Relevance: This cross-sectional analysis of data from a prospective cohort study of surgically naive children with SDB found that preschool-aged children had more frequent multilevel obstruction, more severe overall obstruction, and nasopharyngeal obstruction compared with older children. Understanding the most common sites of obstruction and expected changes with age could inform personalized treatment for children with SDB.

Objective: To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep., Methods: Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized., Results: The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research., Conclusion: Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

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., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Importance: Persistent obstructive sleep apnea after adenotonsillectomy is common in children with Down syndrome or obesity. Drug-induced sleep endoscopy could help to identify anatomic differences in these patients that might affect surgical decision-making., Objective: To assess drug-induced sleep endoscopy findings in surgically naive children with obstructive sleep apnea with obesity or Down syndrome and compare these findings with children without obesity or Down syndrome., Design, Setting, and Participants: This cross-sectional analysis of data from a prospective cohort study of patients enrolled between May 1, 2015, and December 31, 2019, was conducted at an academic tertiary care children's hospital and included a consecutive sample of surgically naive children (age 2-18 years) who underwent drug-induced sleep endoscopy at the time of adenotonsillectomy for sleep-disordered breathing. Indications for sleep endoscopy included severe sleep apnea, age older than 7 years, obesity, African American race, and Down syndrome., Exposures: Drug-induced sleep endoscopy., Main Outcomes and Measures: Sleep endoscopy findings were scored according to the Sleep Endoscopy Rating Scale. Ratings at 6 anatomic levels for children with obesity and those with Down syndrome were compared with controls without obesity or Down syndrome using several measures of effect size (Cohen d, Cramer V, and η2)., Results: A total of 317 children (158 girls [50%]; 219 [69%] White, 20 [6%] Black, and 103 [34%] Hispanic; mean [95% CI] age, 9.6 [9.2-10.0] years) were included, of whom 115 (36%) were controls without obesity or Down syndrome, 179 (56%) had obesity without Down syndrome, and 23 (7%) had Down syndrome. The mean apnea-hypopnea index was 16 (95% CI, 13-19), and the mean minimum O2 saturation was 83% (95% CI, 81%-85%). Compared with controls without obesity or Down syndrome, children with Down syndrome demonstrated greater overall obstruction (mean sleep endoscopy rating scale total score of 5.6 vs 4.8; Cohen d, 0.46), and greater tonsillar (percentage of complete obstruction: 65% vs 54%), tongue base (percentage of complete obstruction: 26% vs 12%), and arytenoid obstruction (percentage of at least partial obstruction, 35% vs 6%). Children with obesity had greater tonsillar (percentage of complete obstruction, 74% vs 54%) and less base of tongue obstruction (percentage of complete obstruction, 2% vs 12%) compared with controls., Conclusions and Relevance: In this cohort study, surgically naive children with obesity with obstructive sleep apnea had predominantly tonsillar obstruction, whereas children with Down syndrome demonstrated greater obstruction of the tonsils, tongue base, and arytenoids compared with controls. Routine drug-induced sleep endoscopy should be considered in surgically naive children with Down syndrome to help inform the surgical plan.

Objective: To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea., Methods: A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG)., Results: Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA., Conclusion: The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To assess the impact of the 2011 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline on practice patterns in obtaining preadenotonsillectomy (AT) polysomnography (PSG) for pediatric sleep-disordered breathing (SDB)., Study Design: Retrospective cohort study., Setting: Tertiary children's hospital., Subject and Methods: The study population included all patients referred to our pediatric otolaryngology clinic for consideration of AT for SDB during two 12-month time periods: before (2010-2011) and after (2015-2016) publication of the 2011 AAO-HNS guideline. Demographic, insurance, comorbidity, and Pediatric Sleep Questionnaire (PSQ) variables were assessed for association with pre-AT PSG using bivariate and multivariate logistic regression analysis., Results: A greater percentage of patients underwent pre-AT PSG in 2015-2016 vs 2010-2011 (30% vs 22%, P = .001). On multivariate analysis, presence of neuromuscular disorder was the only predictor associated with pre-AT PSG in 2010 to 2011 (odds ratio [OR], 3.00; 95% CI, 1.10, 8.06; P = .03). Presence of neuromuscular disorder (OR, 2.54; 95% CI, 1.51, 4.29; P < .0001), craniofacial anomaly (OR, 2.32; 95% CI, 1.20, 4.50; P = .013), or Down syndrome (OR, 3.45; 95% CI, 1.54, 7.72; P = .003) was associated with pre-AT PSG in 2015 to 2016. Positive PSQ screen was significantly associated with decreased odds of pre-AT PSG in both time periods., Conclusion: After publication of the 2011 AAO-HNS guideline, there was a significant but modest increase in pre-AT PSG utilization in children with SDB and high-risk comorbidities at our institution, consistent with AAO-HNS guideline recommendations. However, overall guideline adherence remains low and may reflect limitations in PSG testing capacity.

Objectives/hypothesis: Create a competency-based assessment tool for pediatric tracheotomy., Study Design: Blinded, modified, Delphi consensus process., Methods: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items., Results: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus., Conclusions: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure., Level of Evidence: 5 Laryngoscope, 130:2700-2707, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion., Methods: Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15., Results: Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P < .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1., Conclusion: This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing., Level of Evidence: 2B Laryngoscope, 130:2256-2262, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Objective: (1) Determine the correlation of awake tonsil scores and preadenotonsillectomy (pre-AT) sleep endoscopy findings. (2) Assess the relationship between polysomnographic AT outcomes with awake tonsil scores and sleep endoscopy ratings of tonsil and adenoid obstruction., Study Design: Retrospective case series with chart review., Setting: Tertiary care children's hospital., Subjects and Methods: Children aged 1 to 18 years who underwent sleep endoscopy and AT from January 1, 2013, to August 30, 2016, were included. Pre-AT sleep endoscopy findings were scored with the Sleep Endoscopy Rating Scale. Awake tonsil scores and sleep endoscopy ratings were compared with Spearman correlation. Associations between changes in pre- and post-AT polysomnography parameters and (1) awake tonsil scoring and (2) sleep endoscopy scoring were assessed with 1-way analysis of variance and linear regression., Results: Participants included 36 children (mean ± SD age, 6.8 ± 4.3 years; 68% male, 44% obese). Awake tonsil scores and sleep endoscopy ratings were strongly correlated ( R = 0.58, P = .003). Awake tonsil scores were not associated with changes in any polysomnography parameters after AT (all P > .05), while sleep endoscopy ratings of adenotonsillar obstruction were significantly associated (all P < .05, R 2 = 0.16-0.35). Patients with minimal adenotonsillar obstruction during sleep endoscopy had less improvement than those with partial or complete obstruction (mean obstructive apnea-hypopnea index change: -8.2 ± 11.5 vs -15.9 ± 14.3, and -46.8 ± 31.3, respectively; P < .001)., Conclusions: In children at risk for AT failure, assessment of dynamic collapse with sleep endoscopy may better predict the outcome of AT than awake tonsil size assessment, thus helping to inform surgical expectations.

Purpose of Review: Pediatric chronic rhinosinusitis (CRS) is a common condition that is often misdiagnosed and can be challenging to treat. This review aims to 1) Review definitions, presentation, complications, and management of CRS in children. 2) Highlight the paucity of evidence in the management of pediatric CRS., Recent Findings: There are few studies supporting the usual recommended medical therapy for pediatric CRS (antibiotics, nasal saline irrigations, intranasal steroid). Adenoidectomy remains a mainstay of surgical treatment, but recent evidence demonstrates the utility of balloon sinuplasty and functional endoscopic sinus surgery (FESS) for patients who fail adenoidectomy alone., Summary: Pediatric CRS is distinct from ARS and adult CRS. It is a common problem that is poorly studied, in part because of significant symptomatic overlap with related conditions. Recent evidence supports the use of surgical treatment in children who fail medical management. However, further outcome studies are needed to better evaluate the effectiveness of current medical and surgical management protocols., Competing Interests: Conflict of Interest Lourdes Quintanilla-Dieck and Derek J. Lam declare that they have no conflict of interest.

Study Objectives: (1) To assess the predictors for obtaining polysomnography (PSG) in children undergoing adenotonsillectomy (AT) for sleep-disordered breathing, and (2) to estimate the adherence to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline recommendations for pre-AT PSG., Methods: This was a retrospective cohort study of children who were seen in the Pediatric Otolaryngology Clinic and underwent AT for sleep-disordered breathing over a 13-month period at a single tertiary care children's hospital. Patients with and without pre-AT PSG were compared using bivariate and logistic regression analysis to identify predictors for PSG. Electronic medical records were reviewed for demographic variables, medical comorbidities, and PSG data. Adherence to AAO-HNS guideline recommendations was estimated by calculating the proportion of patients who had a PSG among those who met the recommended criteria for pre-AT PSG., Results: Mean age was 6.6 ± 3.6 years with 53% male. A total of 65 of 324 children (20%) underwent PSG prior to AT. The only factor significantly associated with pre-AT PSG was age 1 to 3 years (odds ratio 4.5, 95% confidence interval [2.2, 9.0], P < .001). Among patients who met AAO-HNS criteria for pre-AT PSG, 28 of 128 (20%) underwent PSG compared to 35 of 186 (19%) who did not meet criteria (odds ratio 1.0, 95% confidence interval [0.6, 1.9], P = .87)., Conclusions: Among children who underwent AT, the only significant predictor of obtaining pre-AT PSG was age 1 to 3 years. The rate of adherence to the AAO-HNS guideline recommendations was low (20%), which represents an educational opportunity., (© 2018 American Academy of Sleep Medicine.)

Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.

Objectives/hypothesis: Assess the reliability of a Sleep Endoscopy Rating Scale (SERS) and its relationship with pediatric obstructive sleep apnea (OSA) severity., Study Design: Retrospective case series of pediatric patients who underwent drug-induced sleep endoscopy (DISE) at the time of surgery for OSA from January 1, 2013 to May 1, 2014., Methods: Three blinded otolaryngologists scored obstruction on DISE recordings as absent (0), partial (+1), or complete (+2) at six anatomic levels: nasal airway, nasopharynx, velopharynx, oropharynx, hypopharynx, and arytenoids. Ratings were summed for a SERS total score (range, 0-12). Reliability was calculated using a κ statistic with linear weighting. SERS ratings and obstructive apnea-hypopnea index (OAHI) were compared using Spearman correlation. A receiver operating characteristic (ROC) analysis determined the ability of the SERS total score to predict severe OSA (OAHI >10)., Results: Thirty-nine patients were included (mean age, 8.3 ± 5.1 years; 36% obese; mean OAHI, 19.1 ± 23.7). Intrarater and inter-rater reliability was substantial-to-excellent (κ = 0.61-0.83) and fair-to-substantial (κ = 0.33-0.76), respectively. Ratings correlated best with OAHI for the oropharynx (r = 0.54, P = .02), hypopharynx (r = 0.48, P = .04), and SERS total score (r = 0.75, P = .002). In ROC analysis, a SERS total score ≥6 demonstrated sensitivity/specificity of 81.8%/87.5%, respectively, and correctly classified 84% of patients., Conclusions: The SERS can be applied reliably in children undergoing DISE for OSA. Ratings of the oropharynx, hypopharynx, and SERS total score demonstrated significant correlation with OSA severity. A SERS total score ≥6 was an accurate predictor of severe OSA., Level of Evidence: 4. Laryngoscope, 126:1492-1498, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Superior mesenteric artery (SMA) syndrome is a rare but potentially fatal complication following spinal fusion for scoliosis. The aims of our study were to identify clinical features and evaluate their importance in SMA syndrome following posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients and to recommend a simple approach for the recognition and management of SMA syndrome. This is an IRB-approved study. Three patients in our series and 11 patients from other published case reports who underwent PSF for adolescent idiopathic scoliosis were included in our study. Patient demographics, clinical presentation, investigations, and management were recorded and analyzed. In this combined series of 14 patients (mean age 14.8 years), the main presenting clinical features included vomiting of any kind (92.9%), abdominal pain/tenderness (57.1%), abdominal distension (42.9%), bilious vomiting (35.7%), and hypoactive bowel sounds (28.6%). Most patients presented within 2 weeks of surgery (71.4%). In total, 50% of patients presented with both vomiting (of any kind) and abdominal tenderness. The number of presenting symptoms appeared to be directly related to the severity of SMA syndrome. Our second patient had intermittent vomiting on postoperative day (POD) 3, which was initially considered as insignificant; she was discharged on POD 9 and readmitted for recurrent vomiting, during which SMA syndrome was diagnosed. Our first patient presented in the classical manner. Our third patient had bilious vomiting after discharge that started on POD 13 and increased in frequency until readmission on POD 27. Vomiting and abdominal pain are nonspecific symptoms following PSF; differentiating between SMA syndrome and postoperative ileus can be challenging. The highest index of suspicion applies to patients who present within the first week with symptoms of vomiting and abdominal pain. We propose an algorithm for the management of SMA syndrome, which includes a focused clinical assessment to evaluate for intestinal obstruction, followed by an abdominal radiography and barium contrast study if clinical assessment is positive. An early referral to general surgery should be considered especially for high-risk patients (BMI<5% percentile, sagittal kyphosis). Early diagnosis of SMA syndrome allows for early intervention, reducing the likelihood of future complications and need for surgery.

Importance: Patients with severe micrognathia are predisposed to airway obstruction. Mandibular distraction osteogenesis (MDO) is an alternative to tracheotomy that lengthens the mandible in order to improve the retrolingual airway. This study presents outcomes from one of the largest cohorts reported., Objective: To assess the rate and predictors of surgical success and complications among (1) patients who underwent MDO prior to other airway procedures (MDO first), and (2) patients who required an initial tracheotomy and were subsequently treated with MDO (tracheotomy first)., Design, Setting, and Participants: Retrospective cohort study at a tertiary care pediatric medical center of patients diagnosed as having micrognathia resulting in symptomatic airway obstruction (Pierre Robin sequence) and who underwent MDO from September 1995 to December 2009., Interventions: Electronic medical records were reviewed. Multivariable regression analysis was used to assess for predictors of outcome., Main Outcomes and Measures: Rates of surgical success (defined as either tracheotomy avoidance or decannulation) and complications. Potential predictors included demographics, syndrome presence, follow-up time, and surgical history., Results: A total of 123 patients (61 in MDO-first subgroup, 62 in tracheotomy-first subgroup) underwent MDO during the study period. Median age at time of distraction was 21 months (range, 7 days-24 years). Surgical success and complication rates were 83.6% and 14.8% in the MDO-first subgroup and 67.7% and 38.7% in the tracheotomy-first subgroup. Tracheotomy-first patients were more likely to have a syndromic diagnosis (66.0% vs 43.0%; P = .009) and were older at the time of MDO (median age, 30 months vs 5.1 months; P < .001). Poorer odds of success were associated with the need for 2 or more other airway procedures (odds ratio [OR], 0.14 [95% CI, 0.02-0.82]) in the MDO-first subgroup and craniofacial microsomia or Goldenhar syndrome (OR, 0.07 [95% CI, 0.009-0.52]) in the tracheotomy-first subgroup., Conclusions and Relevance: Mandibular distraction osteogenesis has a high rate of success in avoiding tracheotomy. Patients who required a tracheotomy before MDO had a lower success rate in achieving decannulation and a higher rate of complications. However, these patients also had a higher rate of syndromic diagnoses and associated comorbidities. Patients with Goldenhar syndrome have a decreased likelihood of surgical success.

Children and young teenagers with adolescent idiopathic scoliosis (AIS) not infrequently present with Cobb angles in excess of 40° at the first clinic visit. This study aimed to establish the incidence of this group of patients, identify the possible factors that may account for the late presentation, and make appropriate recommendations where applicable. This is an institutional review board-approved study. The index posteroanterior spinal radiographs of all 1176 AIS patients who presented to our institution between January 2007 and December 2011 were independently reviewed by two authors (J.Z.J.L. and K.B.L.L.). Patients with curves 40° or greater were included. An interviewer-administered survey was conducted by phone interview to obtain demographic information and identify possible factors for late presentation. The incidence of late presenters was found to be 5.5% (65/1176). The response rate was 73.8% (48/65). Twenty-four (50.0%) respondents acknowledged delaying seeking help after initial suspicion of scoliosis. The reasons cited most were that they were 'too busy' and 'did not know it was scoliosis'. Thirteen (27.1%) respondents attempted 'alternative' treatment before their first specialist appointment, of which 'Chinese Sinseh massage' was the most popular. Thirty-two (66.7%) respondents were not aware of AIS before their diagnosis. In conclusion, the incidence of late presentation in AIS is 5.5% in this series and significantly higher than the published figure of 0.1%. A time delay in seeking help because of a poor understanding of the condition and the failure to appreciate the importance of early specialist review may have contributed toward this relatively high incidence. Patient education and emphasis on timely specialist review can enhance and complement school screening to reduce the incidence of late presentation.

Objective: To determine if the implementation of the closed intensive care unit (ICU) at our institution altered clinical outcomes in patients who had undergone microvascular free flap reconstruction of the head and neck by the Otolaryngology-Head and Neck Surgery Service., Design: Retrospective medical chart review., Setting: A single tertiary medical center., Patients: The open ICU cohort had 52 flaps performed on 50 patients, and the closed ICU cohort had 52 flaps performed on 52 patients., Main Outcome Measures: Fifty-two free flap reconstructions of head and neck defects were performed on 50 patients who were admitted to an open ICU. The length of stay (LOS) in the ICU and hospital and incidence of complications were compared with those of 52 patients who underwent 52 free flap reconstructions and were admitted to a closed ICU over a separate period., Results: The mean length of stay in the ICU was 44 and 45 hours in the open and closed ICU cohorts, respectively (P = .90). The incidence of surgical and medical complications was similar in the open and closed ICU cohorts (P > .05)., Conclusions: There does not appear to be a significant difference in patient outcome between open and closed ICU care in our study.

Objective To investigate the association between velopharyngeal insufficiency (VPI), a common finding after cleft palate repair, and various risk factors, including cleft width.Methods We performed a retrospective cohort study of patients with isolated cleft palates repaired from 2003 to 2008 at a tertiary children's hospital. Patients were observed postoperatively for development of VPI and palatal fistula. The primary risk factor was cleft width. Covariates included cleft length, age at surgery, and presence of associated syndrome. Logistic regression analysis was used to calculate adjusted and unadjusted odds ratios (ORs).Results The cohort comprised 61 patients. Mean (SD) patient age at the time of cleft repair was 13 (3) months. Fistula rate was 3%. Overall rate of postoperative VPI was 32%. We found significant associations between VPI diagnosis and increasing age in months at the time of palate repair (OR, 1.4 [95% CI, 1.2-1.7]) and between VPI and cleft width greater than 10 mm (OR, 5.3 [95% CI, 1.8-15.6]). The association between VPI and cleft width was similar after adjustment for cleft length, patient age, and syndrome presence (OR, 4.5 [95% CI, 1.1-18.7]).Conclusions Our results suggest that increased palatal cleft width is associated with a greater risk of postoperative VPI. Clinicians should consider this when counseling patient families for cleft palate repair.

Objective: To investigate the association between craniofacial anomalies and diagnosis with obstructive sleep apnea (OSA) in a large, population-based sample of children., Design: Retrospective case-control study., Methods: Cases of OSA (n = 1,203) were identified by International Classification of Diseases-9 codes consistent with OSA in the 1987-2003 Washington State inpatient discharge database among children ≤18 years of age and born in Washington state. For each case, five controls without OSA (n = 6,015) were randomly selected from the remaining Washington State births, frequency matched by birth year. Congenital anomaly diagnoses and covariates were extracted from discharge data for all inpatient hospitalizations during the study period and linked birth certificate data. Multiple logistic regression was used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the associations between congenital anomalies (including subgroups) and OSA., Results: An OSA diagnosis was strongly associated with the presence of any craniofacial anomaly (adjusted OR 38, 95%CI [24, 60]) and, in particular, with orofacial cleft (adjusted OR 40, 95%CI [17, 94]) and Down syndrome (adjusted OR 51, 95%CI [20, 128]). OSA was less associated with any noncraniofacial malformation (adjusted OR 4.1, 95%CI [3.1, 5.3]), which may reflect the relatively small effect of inpatient exposure bias in the associations above., Conclusions: The presence of congenital craniofacial anomalies is strongly associated with inpatient diagnosis of OSA. These findings persist even after control of major potential biases. Parents and clinicians should consider screening for OSA among children with craniofacial anomalies.

Background: Studies comparing different categories of nasal measures have reported inconsistent results. We sought to compare validated measures of the nasal airway: anatomic (acoustic rhinometry), physiological (nasal peak inspiratory flow), and subjective experience (Nasal Obstruction Symptom Evaluation Scale and a visual analog scale [VAS])., Methods: This prospective cross-sectional study of 290 nonrhinologic patients included upright and supine rhinometry (minimum cross sectional area [MCA] and volume) and flow (mean and maximum) measurements, as well as subjective measures. Associations between measures were evaluated with Spearman correlations and multivariate linear regression, adjusting for age, sex, race, body mass index, and smoking history., Results: Correlations between objective (rhinometry and flow) and subjective categories of nasal measures ranged from -0.16 to 0.03 (mean correlation, -0.07 +/- 0.05), with 0 significant correlations of 16 tested. Correlations between anatomic (rhinometry) and physiological (flow) categories ranged from 0.04 to 0.15 (mean correlation, 0.10 +/- 0.03), with 0 significant correlations of 16 tested. In contrast, within each category (rhinometry, flow, and subjective), all correlations were significant (13 correlations, all p < 0.001) and ranged from 0.62 to 0.99. Of 16 adjusted associations between objective and subjective measures, 14 were not significant (p > 0.05); only upright and supine MCAs were significantly associated with the VAS (both, p < 0.05)., Conclusion: Validated anatomic, physiological, and subjective nasal measures may assess different aspects of the nasal airway and provide complementary information. Future studies should be directed at developing a composite measure including components from all three categories of nasal measurement.

Objectives: 1) To compare nasendoscopy (NE) and multiview fluoroscopy (MVF) in assessing velopharyngeal gap size; and 2) to determine the relationship between these assessments and velopharyngeal insufficiency (VPI) severity., Study Design and Setting: Retrospective review of consecutive patients with VPI at a tertiary care children's hospital, assessed with NE and MVF between 1996 and 2003., Results: 177 subjects. NE and MVF gap areas were correlated (R = 0.34, 95% CI 0.26-0.41). In adjusted analysis, VPI severity was associated with: 1) NE gap area (OR = 2.78, 95% CI 1.96-3.95), 2) MVF gap area (OR 1.64, 95% CI 1.37-1.95), 3) age <5 years (OR 3.30, 95% CI 1.47-7.38), and 4) previously repaired cleft palate (OR 0.48, 95% CI 0.25-0.94)., Conclusions and Significance: NE and MVF assessments provide complementary information and are correlated. Both are associated with VPI severity. However, the "bird's-eye view" provided by NE has a stronger correlation with VPI severity than MVF., Ebm Rating: B-2b.

Object: The purpose of this study was to test the hypothesis that balloon angioplasty is superior to papaverine infusion for the treatment of proximal anterior circulation arterial vasospasm following subarachnoid hemorrhage (SAH). Between 1989 and 1995, 125 vasospastic distal internal carotid artery or proximal middle cerebral artery vessel segments were treated in 52 patients., Methods: Blood flow velocities of the involved vessels were assessed by using transcranial Doppler (TCD) monitoring in relation to the day of treatment with balloon angioplasty or papaverine infusion. Balloon angioplasty and papaverine infusion cohorts were compared based on mean pre- and posttreatment velocity at 24 and 48 hours using the one-tailed, paired-samples t-test. Balloon angioplasty alone was performed in 101 vessel segments (81%) in 39 patients (75%), whereas papaverine infusion alone was used in 24 vessel segments (19%) in 13 patients (25%). Although repeated treatment after balloon angioplasty was needed in only one vessel segment, repeated treatment following papaverine infusion was required in 10 vessel segments (42%) in six patients because of recurrent vasospasm (p < 0.001). Seven vessel segments (29%) with recurrent spasm following papaverine infusion were treated with balloon angioplasty. Although vessel segments treated with papaverine demonstrated a 20% mean decrease in blood flow velocity (p < 0.009) on posttreatment Day 1, velocities were not significantly lower than pretreatment levels by posttreatment Day 2 (p = 0.133). Balloon angioplasty resulted in a 45% mean decrease in velocity to a normal level following treatment (p < 0.001), a decrease that was sustained., Conclusions: Balloon angioplasty is superior to papaverine infusion for the permanent treatment of proximal anterior circulation vasospasm following aneurysmal SAH.

Purpose: The clinical diagnosis of deep vein thrombosis (DVT) is unreliable. Contrast phlebography (CP) continues to be the gold standard, but it is invasive. Although duplex ultrasonography is an accurate, noninvasive alternative, it is expensive, technically demanding, and time-consuming. We postulated that light reflection rheography (LRR), a noninvasive method of assessing the quantity and rate of venous emptying, might be a reliable and inexpensive bedside approach to screening patients with clinically suspected DVT., Methods: With LRR, infrared light is beamed onto the skin, and the amount of backscattered rays are detected, which indirectly measures the amount of blood present in a volume of the epidermis beneath the LRR probe. Applied to the calf muscle pump, LRR can provide a noninvasive method of assessing blood volume changes in the sample area of skin, in response to venous hemodynamic changes in the lower limb., Results: Sixty-nine limbs in 61 patients undergoing CP for clinically suspected DVT over a period of 12 months also underwent LRR, either just before or within 24 hours of undergoing phlebography. The criteria for diagnosing DVT on CP were presence of filling defect or nonfilling of a venous segment. The result of LRR was considered positive for DVT if the rate of venous emptying was 0.35 or less. With these criteria a sensitivity of 96.4% and specificity of 82.9 were obtained. This resulted in a positive predictive value of 79% and a negative predictive value of 97.1%., Conclusions: LRR is a simple, inexpensive, and noninvasive bedside test that takes 10 minutes to perform. It is highly sensitive with a high negative predictive value, detecting most cases of DVT, reliably ruling out DVT, and eliminating the need for more time-consuming and costly studies. Therefore it seems to be an appropriate screening test in patients with clinically suspected DVT.

A survey was conducted to assess the extent to which behavior therapy techniques were employed by clinical psychologists in Hong Kong. The most popular techniques included those that could be grouped under the self-management package and the least popular techniques generally involved an aversive element, or were in vivo. The use of behavior therapy was correlated with the younger age range of the treatment clientele. The results and the future development of behavior therapy were discussed in terms of cultural issues, training and the theoretical orientations of the respondents.

This paper describes Friends Can Be Good Medicine, a multi-media, mental health promotion campaign conducted in 1982 throughout California. The creative design, pilot-test, implementation and results are reviewed. Conceptually, Friends was derived from evidence linking supportive personal relationships with increased physical and mental health. Three major campaign elements were: broadcast media, an array of educational materials, and community activities. Evaluation findings revealed that Friends was most effective when campaign elements reinforced one another. Resulting changes in knowledge, attitudes, and intentions among those reached by Friends were maintained after one year. It is contended that, for better or worse, mass media is part of the health care system.

Increasing recognition of the importance of social support for health has not been accompanied by commensurate increases in knowledge about how to strengthen natural support networks on a large scale. This study evaluated the impact of California's innovative "Friends Can Be Good Medicine" public education campaign in promoting social support. Campaign impact was assessed with pre-, post-, and long-term follow-up interviews with a panel sample of 340 adults in the six county Fresno media market area. Comparisons of exposed and unexposed individuals found that the campaign appeared to have measurable impact on knowledge, attitudes, behavioral intentions, and support enhancing behavior. Follow-up interviews indicated that these gains maintained themselves over the course of a year. The campaign was most effective when it utilized multiple channels of communication. In Fresno City, where there was the most intensive combination of community activities and media exposure, respondents indicating substantial likelihood of engaging in support enhancing behavior increased from 42% to 59% compared to smaller gains in areas which relied primarily on community implementation, and no gains in areas where exposure to the campaign was limited to mass media. The campaign appeared particularly effective with people who had experienced the death of someone close to them during the past year, and within that group, gains were largest among respondents below average in initial levels of social support.

The expansion of mental health services during the 1960s from a single remote mental hospital to centers and clinics in mainstream communities fostered the development of community psychology in Hong Kong. Few psychologists were initially involved in the local community mental health movement, but its momentum resulted in increasing numbers of practitioner psychologists working in community-based service settings. Community psychology in Hong Kong today consists primarily of service delivery, but also includes applied research, community organization/consultation, and community education. Despite having many parallels with the American situation, key concepts underpinning the practice of community psychology in the Territory possess their own character as a reflection of nuances in the local scene. Prospects for the continued development of community psychology in Hong Kong appear favorable. Of special relevance is the field's potential contribution to a better understanding of the psychological phenomena associated with the Territory's sociopolitical transformation in 1997.