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Objectives: To determine the cause of obstructive sleep-disordered breathing using drug-induced sleep endoscopy (DISE) in infants without co-morbidities and with normal clinical examination. Methods: This prospective study was conducted between December 2019 and June 2022 (31 mo). All infants referred for obstructive sleep-disordered breathing with normal clinical examination and flexible laryngoscopy were included and underwent DISE. The location of the obstructive sites was scored similarly according to the NAVOTEL scoring system, previously established and validated by authors' team. Results: Thirty-two infants were included. DISE identified an obstructive site in 94% of cases. The mean age was 16.4 mo, and the median was 16.7 mo. The obstructive sites found were isolated sleep laryngomalacia (37.4%), adenotonsillar hypertrophy (21.8%), isolated adenoidal hypertrophy (6.3%), adenotonsillar hypertrophy associated with sleep laryngomalacia (6.3%), circumferential upper airway narrowing (6.3%), glossoptosis (6.3%), isolated inferior turbinate hypertrophy (3.1%), adenoidal and tongue base hypertrophy (3.1%), and adenoidal hypertrophy with sleep laryngomalacia (3.1%). No obstructive causes could be found in 2 cases (6.3%). DISE identified an obstructive site in 30/32 patients (93.8%) and guided the surgical management in 26/32 cases (81.3%) during the same general anesthesia. The infants without surgical obstacles were referred for medical treatment. Conclusions: DISE is an excellent diagnostic and pre-therapeutic tool in infants with no apparent cause at the awake examination to identify the obstructive sites and guide the treatment. [ABSTRACT FROM AUTHOR]

Background: Respiratory disease is a predominantly observed problem in neonates. Moreover, the application of flexible bronchoscopy in newborns is gradually increasing. This study aimed to investigate the value of bronchoscopy in neonates respiratory abnormalities and evaluate the safety of bronchoscopy application. Methods: Clinical data and outcomes of 56 neonates who underwent flexible bronchoscopy were retrospectively analyzed. Correlations among indications for bronchoscopy, findings, and clinical diseases were assessed. Results: A total of 56 neonates had a minimum weight of 1200 g at the time of bronchoscopy, while the minimum gestational age at birth was 26 + 1 weeks. A total of 22 cases (39.3%) had two or more clinical indications; the five most common indications were respiratory distress in 24 (42.9%), stridor in 22 (39.3%), pulmonary atelectasis in 10 (17.6%), feeding difficulty in 10 (17.6%), and difficult weaning from mechanical ventilation in 6 (10.7%) cases. A total of 13 types of abnormalities were detected in the respiratory tract. The most common abnormalities were laryngomalacia in 29 (59.2%), tracheobroncomalacia in 8 (16.3%), and vocal cord paralysis in 6 (12.2%) cases. Bronchoalveolar lavage was performed in 39 cases. Eight cases were diagnosed by bronchoscopy and then treated with surgery in the Thoracic Surgery/Otolaryngology Department; all of them were cured and discharged from the hospital after surgery. No serious complications, such as pneumothorax or shock, occurred in any of the children, of whom none died. Conclusions: Flexible bronchoscopy could play an important role in diagnosing and identifying respiratory disorders in neonates and be safely used with few serious complications. [ABSTRACT FROM AUTHOR]

Abstract Background Respiratory disease is a predominantly observed problem in neonates. Moreover, the application of flexible bronchoscopy in newborns is gradually increasing. This study aimed to investigate the value of bronchoscopy in neonates respiratory abnormalities and evaluate the safety of bronchoscopy application. Methods Clinical data and outcomes of 56 neonates who underwent flexible bronchoscopy were retrospectively analyzed. Correlations among indications for bronchoscopy, findings, and clinical diseases were assessed. Results A total of 56 neonates had a minimum weight of 1200 g at the time of bronchoscopy, while the minimum gestational age at birth was 26 + 1 weeks. A total of 22 cases (39.3%) had two or more clinical indications; the five most common indications were respiratory distress in 24 (42.9%), stridor in 22 (39.3%), pulmonary atelectasis in 10 (17.6%), feeding difficulty in 10 (17.6%), and difficult weaning from mechanical ventilation in 6 (10.7%) cases. A total of 13 types of abnormalities were detected in the respiratory tract. The most common abnormalities were laryngomalacia in 29 (59.2%), tracheobroncomalacia in 8 (16.3%), and vocal cord paralysis in 6 (12.2%) cases. Bronchoalveolar lavage was performed in 39 cases. Eight cases were diagnosed by bronchoscopy and then treated with surgery in the Thoracic Surgery/Otolaryngology Department; all of them were cured and discharged from the hospital after surgery. No serious complications, such as pneumothorax or shock, occurred in any of the children, of whom none died. Conclusions Flexible bronchoscopy could play an important role in diagnosing and identifying respiratory disorders in neonates and be safely used with few serious complications.

This article explores the use of bipolar cautery as a treatment for laryngomalacia, a common cause of infantile stridor. The technique involves applying heat to the epiglottis to reposition it. The article presents the results of a study showing that 93% of patients did not require further surgery after the procedure. The article also discusses other techniques, such as using lasers or sutures, which may not be practical in developing countries. The bipolar cautery technique is considered safe, effective, and more affordable. [Extracted from the article]

Objective: In neonatal stridor, various conditions can be responsible as well as laryngomalacia. These conditions can be quite rare and the treatment of these diseases could be complicated. The purpose of this study is to identify the laryngeal pathologies and to discuss our approach in infants with chronic stridor. Methods: The hospital charts of infants with stridor undergoing rigid laryngotracheobronchoscopy in our hospital in 2018-2022 were retrospectively reviewed. Results: 107 children were enrolled to the study. The most frequent diagnosis was laryngomalacia (isolated and seen with secondary airway lesions (SALs)) (74 patients, 69.1%). 10 patients (9.3 %) had subglottic stenosis which caused stridor or dyspnea. Regarding other laryngeal lesions, in 8 patients (7.47 %) the diagnosis was laryngeal edema and 8 patients (7.47 %) had tracheomalacia. SALs which occurred with laryngomalacia were seen in 16 patients of our series (14.9 % of all cases). Surgery was performed in 11 of patients. Stridor was resolved in % 80 of laryngomalacia patients at about 2 years of age with only follow up. Conclusions: In neonatal stridor, various conditions can be responsible as well as laryngomalacia. Referral of infant to otorhinolaryngologists and examination with flexible and rigid endoscopy is necessary for the assessment of stridor. The examination of the airway with the rigid endoscopy under general anesthesia without intubation on operating room with the cooperation of the anesthesiologist may provide the surgical intervention together with simultaneous inspection especially in the patients with severe stridor and systemic diseases. [ABSTRACT FROM AUTHOR]

Laryngomalacia is the most common cause of stridor in newborns. Pediatric difficult airway is a major challenge for anesthetists and one of the main causes of perioperative respiratory complications. In order to prevent respiratory complications of general anesthesia, especially apnea, in newborns, regional anesthesia techniques such as caudal or spinal anesthesia may be preferred. Caudal anesthesia can be used as the sole anesthesia method, especially for subumbilical surgeries, or as an adjunct to general anesthesia and is an effective way to provide perioperative analgesia. In this article, we presented our experience with caudal anesthesia for bilateral inguinal hernia surgery in a newborn with laryngomalacia. [ABSTRACT FROM AUTHOR]

Objective: To assess the role of laryngo-tracheo-bronchoscopy in children with obstructive sleep apnoea by identifying airway abnormalities at surgery, that occur separately or in addition to adenotonsillar hypertrophy, and examining the correlation with respiratory parameters. Methods: A retrospective study was conducted of children with obstructive sleep apnoea who underwent laryngo-tracheo-bronchoscopy intra-operatively, performed by a single ENT surgeon from February 2016 to July 2019. Pre- and post-operative minimum oxygen saturation, apnoea-hypopnoea index, and oxygen desaturation index were recorded. Results: Sixty-five children were identified; 34 were aged less than three years and 31 were aged three years or more. 77 per cent and 13 per cent respectively had an airway abnormality; the t -test showed a significantly higher mean oxygen desaturation index and lower mean minimum oxygen saturation pre-operatively compared to children without an airway abnormality. Conclusion: An update of the surgical pathway for children aged less than three years with obstructive sleep apnoea is required to include laryngo-tracheo-bronchoscopy intra-operatively. A t -test analysis of the pre-operative respiratory parameters suggests that airway abnormalities contribute to obstructive sleep apnoea severity. [ABSTRACT FROM AUTHOR]

Introduction: Lower airway malacia (LAM) is characterized by a reduction in the cross-sectional luminal area during quiet respiration. There is no gold standard diagnostic test; however, flexible fiberoptic bronchoscopy (FFB) is most frequently utilized. The exact prevalence and incidence of LAM are unknown. This study aimed to determine the prevalence rates of pediatric patients diagnosed with LAM, offer a detailed understanding of their demographic and clinical characteristics, and investigate distinctions between two specific types of LAM, namely, tracheomalacia (TM) and bronchomalacia (BM). Materials and Methods: Patients younger than 18 years diagnosed with LAM using FFB were included in this retrospective case series. Demographic and clinical characteristics and comorbid disorders were compared between patients with isolated BM and those with isolated TM or tracheobronchomalacia (TM/TBM). Results: Among 390 patients who underwent FFB, 65 (16.6%) were diagnosed with LAM, 16 (24.6%) with TM, and 56 (86.2%) with BM. The median age at diagnosis was 15 months. Among them, 59 (90.8%) had other comorbidities; gastrointestinal (GI) disorders were the most common (38.5%). The most common indications for bronchoscopy were recurrent/prolonged lower respiratory tract infections (LRTI) or wheezing (43.1%), while the most frequently observed respiratory physical examination finding was stridor (35.4%). Patients with TM/TBM had significantly higher frequencies of premature births, stridor, retraction, and GI disorders. Conclusion: Patients with stridor without typical laryngomalacia features or recurrent or prolonged LRTI should undergo prompt evaluation for LAM. The potential coexistence of GI disorders such as gastroesophageal reflux disease and swallowing dysfunction should also be considered. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the role infant pulmonary function tests (Tidal Breathing Flow Volume Loops, TBFVL) in children with airway anomalies and to correlate the TBFVL so obtained with bronchoscopy findings. Methods: In this prospective cohort study, we enrolled children aged 0–2 years with airway anomalies and performed TBFVL and bronchoscopy. The primary outcome measure was graphic pattern of TBFVL in laryngomalacia. Secondary outcome measures were types of TBFVL results in various airway anomalies and controls. Results: Out of 53 children enrolled, 28 (52.3%) had laryngomalacia. Pattern 3 (fluttering of inspiratory limb) was commonest TBFVL pattern in laryngomalacia. Among TBFVL parameters, the ratio of inspiratory time to expiratory time (Ti/Te) and tPTEF/tE was significantly high in children with isolated laryngomalacia compared to controls. At six months of follow-up, TBFVL pattern 1 (normal) became the commonest pattern. Conclusion: A particular type of airway anomaly may have a characteristic graphic pattern in TBFVL and TBFVL pattern may indicate improvement in airway anomalies in follow-up. [ABSTRACT FROM AUTHOR]

Background: The Koolen-de Vries syndrome (KdVS) is a relatively new rare disease caused by micro-deletion of 17q21.31 which was first reported by Koolen in 2006. Typical phenotypes for KdVS include hypotonia, developmental delay, moderate intellectual disability, and characteristic facial dysmorphism. Up to now, there was only one case report about anesthesia management of patient diagnosed KdVS. It was a 2-year-old girl who experienced an MRI exam under anesthesia. Case presentation: We described a 21-month-old boy who planned to undergo an orchidopexy under general anesthesia diagnosed with KdVS. He had an intellectual disability, characteristic facial dysmorphism, tracheo/laryngomalacia, patent foramen ovale, and cryptorchidism related to KdVS. Due to the complex condition especially the presence of tracheo/laryngomalacia, we took some special measures, including reducing the amount of long-acting opioid, keeping the spontaneous breath, performing a caudal block, and applying the laryngeal mask. But the laryngeal mask was changed to an endotracheal tube because it failed to provide adequate ventilation. The boy experienced mild laryngeal spasm and hypoxia after extubation, but lateral position and etomidate eased his breathing problem and re-intubation was avoided. It is indicated that anesthesia management for patients with orphan disease is a real challenge for all anesthesia providers. Conclusions: The Koolen-de Vries syndrome is a relatively new orphan disease involving multiple systems. Keeping spontaneous breath, evaluating airway potency to anesthetics, applying endotracheal tube, and post-extubation lateral or prone position may be helpful for airway management for patient with hypotonia and tracheo/laryngomalacia. KdVS patient needs prolonged post-anesthesia monitoring and/or medication for airway complications. [ABSTRACT FROM AUTHOR]

Objective: To compare supraglottoplasty versus non-surgical treatment in children with laryngomalacia and mild, moderate and severe obstructive sleep apnoea. Methods: Patients were classified based on their obstructive apnoea hypopnoea index on initial polysomnogram, which was compared to their post-treatment polysomnogram. Results: Eighteen patients underwent supraglottoplasty, and 12 patients had non-surgical treatment. The average obstructive apnoea hypopnoea index after supraglottoplasty fell by 12.68 events per hour (p = 0.0039) in the supraglottoplasty group and 3.3 events per hour (p = 0.3) in the non-surgical treatment group. Comparison of the change in obstructive apnoea hypopnoea index in the surgical versus non-surgical groups did not meet statistical significance (p = 0.09). Conclusion: All patients with laryngomalacia and obstructive sleep apnoea had a statistically significant improvement in obstructive apnoea hypopnoea index after supraglottoplasty irrespective of obstructive sleep apnoea severity, whereas patients who received non-surgical treatment had more variable and unpredictable results. Direct comparison of the change between the two groups did not find supraglottoplasty to be superior to non-surgical treatment. Larger prospective studies are recommended. [ABSTRACT FROM AUTHOR]

The aim of this review is to investigate the state of the art among the association between Obstructive sleep apnea (OSA) and laryngomalacia, analyzing the epidemiology, the diagnostic tools, and the possible treatments available to affected patients. Laryngomalacia, characterized by the malacic consistency of the epiglottis with a tendency to collapse during inspiratory acts, producing a characteristic noise known as stridor, is a common condition in infants and particularly in those affected by prematurity, genetic diseases, craniofacial anomalies, and neurological problems. Congenital laryngomalacia, presenting with stridor within the first 15 days of life, is often self-limiting and tends to resolve by 24 months. OSA is not only a consequence of laryngomalacia but also exacerbates and perpetuates the condition. Currently, the treatments reported in the literature are based (i) on medical therapies (including watchful waiting) and (ii) on surgical treatments. Among the surgical techniques, the most described is supraglottoplasty, performed with the use of cold instruments, CO2 LASER, transoral robotic surgery, or the microdebrider. [ABSTRACT FROM AUTHOR]

This article describes a case study of a 5-month-old patient with severe laryngomalacia, a congenital laryngeal anomaly. The patient underwent a 3D-4K exoscope-assisted CO2 laser supraglottoplasty, a surgical procedure to treat laryngomalacia. The use of the 3D-4K exoscope provided improved visualization and precision during the surgery. The procedure was successful, and the patient experienced complete healing of laryngeal structures without complications. The article highlights the advantages of using the 3D-4K exoscope in pediatric laryngeal surgery and emphasizes its potential for education and training purposes. [Extracted from the article]

Introduction: Laryngomalacia (LGM) is the most common congenital anomaly of the larynx and the most frequent cause of stridor in the newborn. Even though it can be a source of concern and anxiety to parents, a large majority of cases usually resolve spontaneously within 18 months of life. However, in infants with signs of severity, a multidisciplinary approach and surgical intervention might be necessary. Case report: We report the case of a full-term 7-week-old infant girl, previously hospitalized in the Neonatal Intensive Care Unit and diagnosed with type II LGM (Olney’s classification). She presented to the Paediatric Emergency Department with stridor at rest, vigorous chest wall retractions and poor weight gain (increase of 10 g/day, weight under the 3rd percentile). The infant was admitted to monitor respiratory symptoms and investigate her failure to thrive. However, irrespective of feeding modifications, and after exclusion of other causes of failure to thrive, the infant maintained an insufficient weight gain. Additionally, respiratory symptoms remained exuberant and surgical intervention was determined as the optimal treatment. At 3 months old, supraglottoplasty was performed. At 18 months, she has a weight in the 3rd-15th percentile range (WHO curves) and is clinically asymptomatic. Conclusion: LGM is a remarkably frequent cause of stridor in infants, but only a rare number of cases require other interventions beyond symptomatic measures. In this report, surgical intervention was of paramount importance to ensure normal growth, emphasising the impact of a multidisciplinary approach in such cases.

Objective: This study used the European Laryngeal Society (2016) and Ni (2011 and 2019) classifications for narrow-band imaging and correlated the findings with histopathology. Methods: Retrospective analysis was conducted by retrieving data of patients who underwent micro-laryngoscopy for suspicious glottic lesions. The narrow-band imaging findings were classified using both classification systems. Retrieved histopathology report findings were correlated with narrow-band imaging data. Results: Using the European Laryngeal Society and Ni classifications, 37 (69.8 per cent) and 35 (66 per cent) patients, respectively, were suspected to have malignant lesions. Upon histopathology, 37 (69.8 per cent) lesions were malignant. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy using the European Laryngeal Society classification were 91.9 per cent, 81.3 per cent, 91.9 per cent, 81.3 per cent and 88.7 per cent, and using the Ni classification were 91.9 per cent, 93.8 per cent, 97.1 per cent, 83.3 per cent and 92.5 per cent, respectively. Conclusion: The Ni classification had better specificity and accuracy. The European Laryngeal Society classification is simple to use and may serve as a useful screening tool. For optimum results, both European Laryngeal Society and Ni classifications may be used together, in that order. [ABSTRACT FROM AUTHOR]

Objective: Epiglottopexy has been an increasingly utilized intervention in children with epiglottic prolapse and airway obstruction. Given the role of the epiglottis in protecting the airway during swallowing and the potential effect of repositioning the epiglottis on the passage of the bolus, we aimed to compare swallowing outcomes before and after epiglottopexy in children. Study Design: A retrospective cohort study. Setting: Tertiary care children's hospital. Methods: Data were extracted from charts of children who underwent epiglottopexy and had a subsequent instrumental swallowing evaluation between January 2018 and September 2022. Results: A total of 93 patients underwent epiglottopexy. Of these, 38 patients met inclusion requirements. The mean age at surgery was 41 ± 47 months. Most patients (n = 37, 97.4%) had significant comorbidities such as secondary airway lesions (n = 33, 91.7%), a genetic or syndromic disorder (n = 25, 69.4%), and dysphagia (n = 29, 76.3%). All patients had a concurrent procedure at the time of epiglottopexy with supraglottoplasty (n = 24, 63.2%) and lingual tonsillectomy (n = 16, 42.1%) being the most common. No changes in initiation or patterns of swallowing were noted postoperatively. A total of 7 (18.4%) patients had worsening swallow function: 2 had new‐onset dysphagia, and 5 had worsening pre‐existing dysphagia. Liquid or food textures penetrated remained unchanged or improved in most cases. No risk factors for worsening dysphagia were identified in our cohort. Conclusion: Children with medical comorbidities undergoing epiglottopexy with additional airway interventions may experience new or worsening dysphagia. However, the procedure is generally safe without notable patterned changes in the swallowing mechanism. [ABSTRACT FROM AUTHOR]

Objective: Epiglottic prolapse (EP) presents a unique management challenge. The objective of the present case series is to present clinical outcomes using a novel technique of transcervical epiglottopexy (TCE) in etiologically diverse cases of EP and to discuss the evolution of the surgical technique with technical modifications to optimize the surgical procedure. Study Design: A retrospective case series review. Setting: Tertiary care academic setting. Methods: Pediatric cases with EP over a 3‐year period. Demographic data including age, sex, presenting symptoms, operative details, and polysomnographic indices were collected. Results: A total of 18 patients with a mean age of 48.88 ± 37.3 months underwent TCE. Sixty‐seven percent of patients had high‐grade EP (grades 3 and 4). A previous endolaryngeal epiglottopexy had been performed in 5 (28%) patients. Fourteen (78%) patients had a concurrent airway procedure performed including 4 undergoing single‐stage laryngotracheal reconstruction. The mean suspension time only for the TCE part ranged from 8 to 17 minutes with a mean of 11.23 ± 3.4 minutes. A stable EP defined as a healed glossoepiglottic adhesion was achieved in all but 1 case with an overall success rate of 95%. All cases with previous failed endoscopic epiglottopexy had a stable epiglottopexy. No immediate complications were noticed. Among the late complications, the most common was the formation of granulation tissue at the site of silastic disc placement which was seen in 3 patients. Conclusion: TCE using an exo‐endolaryngeal technique can achieve stable epiglottopexy in children with EP and can be adapted for any kind of EP. [ABSTRACT FROM AUTHOR]

Introduction Laryngomalacia is the most common congenital laryngeal alteration, with spontaneous resolution in most cases. However, in the face of more severe presentations of the disease, it is necessary to perform supraglottoplasty surgery. Studies have been dedicated to researching changes in swallowing in children with laryngomalacia before and after surgical intervention. Objectives To identify the prevalence of oropharyngeal dysphagia in children with pre and postsupraglottoplasty laryngomalacia. Data Synthesis A search strategy was developed with terms and entreterms to designate a population pediatric with laryngomalacia , exposure supraglottoplasty , and outcome frequency of dysphagia , adapted to the requirements of the main databases in the health area. The analysis of the records found was performed by two independent examiners and, in the end, 6 articles were included in the study. The articles found enabled a sample of 330 children with laryngomalacia, 311 of whom underwent supraglottoplasty. Among the included studies, 5 were grouped and meta-analyzed. After supraglottoplasty surgery, a 59% reduction in the prevalence of oropharyngeal dysphagia was identified, with high heterogeneity I 2 = 93%. Conclusion Despite the heterogeneity of the sample, the supraglottoplasty procedure significantly reduces the prevalence of dysphagia in children with laryngomalacia. [ABSTRACT FROM AUTHOR]

Objective: To analyze the clinical characteristics of laryngomalacia in Chinese children and explore the surgical efficacy and factors influencing severe laryngomalacia. Methods: Children (0–18 years) diagnosed with laryngomalacia in our hospital from January 2016 to January 2022 were enrolled in this study. Clinical data of patients, including general conditions, clinical symptoms, grading and classification, medical comorbidities, surgical efficacy, and the risk factors influencing severe laryngomalacia were retrospectively analyzed. Results: A total of 1810 children were enrolled (male:female; 2.02:1), among which most were infants under 1 year (77.18%). Inspiratory laryngeal stridor (69.56%) was the most common symptom. Most patients had mild laryngomalacia (79.28%), with type IV laryngomalacia being the most common classification (52.27%). Congenital heart disease (37.85%) was the most common medical comorbidity. A total of 168 severe laryngomalacia cases were treated via supraglottoplasty with an effective rate of 83.93%. Notably, preterm birth (OR = 3.868, 95% CI 1.340 ~ 11.168), low birth weight (OR = 4.517, 95% CI 1.477 ~ 13.819) and medical comorbidities (OR = 7.219, 95% CI 2.534 ~ 20.564) were independent risk factors for poor prognosis (P < 0.05). Conclusion: Laryngomalacia is common among infants under the age of one, and it is mostly characterized by inspiratory laryngeal stridor with various medical comorbidity. Supraglottoplasty is the first treatment choice for severe laryngomalacia cases with high success rates. However, premature delivery, low birth weight, and medical comorbidities significantly affect the efficacy of surgery. [ABSTRACT FROM AUTHOR]

A congenital complete tracheal ring is an infrequent cause of tracheal stenosis. It is usually diagnosed in infants and young children, and adults diagnosed with complete tracheal rings are even rarer entities. There is limited literature regarding the adult complete tracheal ring. Down syndrome patients have a wide array of documented anatomic variations especially airway abnormalities such as laryngomalacia, tracheomalacia, tracheal bronchus and bronchomalacia and rare to have complete tracheal ring. Hence, we described a Down syndrome adult who remained asymptomatic until the recent onset of severe respiratory illness, which requires endotracheal intubation, leading to an unexpectedly difficult airway. A differential diagnosis of a complete tracheal ring should be considered when attending such cases of difficult intubation. [ABSTRACT FROM AUTHOR]

The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea–hypopnoea index >5 events·h−1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams. [ABSTRACT FROM AUTHOR]

Stridor is an important symptom which should not be missed, especially in a child. The etiology could be multifactorial and will require a comprehensive investigation into its management. In this case, we discuss the clinician's dilemma in reaching a diagnosis due to various factors which were present in a single patient. This rare benign laryngeal squamous polyp was eventually diagnosed in an 11-week-old boy who presented with acute stridor. The diagnostic dilemma we discuss in this case was due to multiple maternal and fetal factors. He was a premature baby, intubated at birth, there was a maternal tuberculosis infection and he also had a cutaneous hemangioma which were all part of the diagnostic dilemma faced in his management which eventually led to an acquired subglottic stenosis. Our discussion will focus on how a thorough and proper evaluation is needed especially when there are many deceptive clues or signs present in a patient. [ABSTRACT FROM AUTHOR]

Objective: Postoperative airway concerns persist despite a low rate of post‐supraglottoplasty complications for children with laryngomalacia. The objective of this study is to determine the factors associated with the need for intensive care unit (ICU) admission following supraglottoplasty. Methods: A 7‐year retrospective cohort analysis was conducted between 2014 and 2021. A patient requiring ICU level of care was defined as the use of respiratory support such as intubation, positive pressure ventilation, high‐flow nasal cannula, or multiple doses of nebulized epinephrine. Results: About 134 medical charts were reviewed; 12 patients were excluded because of concurrent surgery. Age at the time of surgery was 2.8 (4.3) months (median [interquartile range]). About 33 (27.0%) ultimately required ICU‐level care. Prematurity (odds ratio [OR] 13.8), neurological condition (OR ∞), American Society of Anesthesiology class 3–4 (OR 6.5), and younger age (OR 1.8) were more likely to require ICU admission. No patient above 10 months of age needed ICU monitoring. The use of respiratory support justifying ICU was known within the first 4 h after surgery for almost all (32/33, 97%) of these patients. 4/33 (12.1%) were kept intubated and the remaining needed non‐invasive ventilation. Only one patient (1/122, 0.8%) was reintubated 12 h after surgery for progressive respiratory distress. Conclusion: Approximately a quarter of patients required ICU‐level care after supraglottoplasty. For nearly all patients without comorbidities requiring ICU, this can be safely predicted within the first 4 h after surgery. Our data suggest that selected patients undergoing supraglottoplasty may be safely monitored outside of an ICU setting after an observation period in the post‐anesthesia care unit. Level of Evidence: 4 Laryngoscope, 134:466–470, 2024 [ABSTRACT FROM AUTHOR]

Noisy breathing in children is a common clinical sign. Parents often present to health care professionals with concerns about the pattern and nature of their child's breathing. In this article, we will discuss causes of chronic noisy breathing in children and our approach to their management. Evaluation begins with careful assessment of the child and video or audio recordings are particularly helpful. The characteristic findings will depend on the affected level of the airway. The most common cause of noisy breathing in an infant is laryngomalacia, although there are several other differential diagnoses for stridor to be considered. Visualization of the airway by either a rigid or a flexible bronchoscope, is the gold standard procedure for identifying any pathology. Red flags include severe respiratory distress, recurrent stridor in early months, feeding difficulties and/or failure to gain weight in neonates and infants. Older children can present with chronic wet cough or wheeze. In this age group trials of treatment and careful documentation of the responses can be helpful in clarifying the diagnosis. [ABSTRACT FROM AUTHOR]

Introduction Laryngomalacia is the most common congenital laryngeal alteration, with spontaneous resolution in most cases. However, in the face of more severe presentations of the disease, it is necessary to perform supraglottoplasty surgery. Studies have been dedicated to researching changes in swallowing in children with laryngomalacia before and after surgical intervention.

Background: Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia. Methods: A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children's hospital. Results: 13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities. Conclusion: Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities. [ABSTRACT FROM AUTHOR]

The article presents the case study of 6-week-old African American female concerning for laryngomalacia. Topics include past medical history was remarkable for stridor since birth, which was suspected by her Pediatrician to be laryngomalacia; and inspiratory stridor with associated increased work of breathing.

Objective: To characterize the prevalence and presentation of laryngomalacia and efficacy of supraglottoplasty (SGP) in a cohort of patients with Pierre Robin Sequence (PRS). Design: Retrospective cohort study. Setting: Tertiary-care children's hospital. Patients, Participants: Consecutive patients with PRS born between January 2010 and June 2018. Main Outcome Measures: Chart review included demographics, comorbid airway obstruction including laryngomalacia, timing of surgical interventions, clinical symptoms, sleep study data, and modified barium swallow study data. Results : 126 patients with PRS were included; 54% had an associated syndrome, 64% had an overt cleft palate, and 22% had a submucous cleft palate. 64/126 were noted to have laryngomalacia (51%). Patients with concurrent PRS and laryngomalacia were significantly more likely to have submucous cleft palate (P =.005) and present with aspiration with cough (P =.01) compared to patients with PRS without laryngomalacia. Patients with concurrent laryngomalacia and PRS showed a significant decrease in apnea–hypopnea index (AHI) and obstructive AHI (OAHI) after mandibular distraction, with a median AHI and OAHI improvement of 22.3 (P =.001) and 19.8 (P =.002), respectively. Patients who underwent only SGP did not show significant improvement in these parameters (P =.112 for AHI, P =.064 for OAHI). Conclusions : The prevalence of laryngomalacia in our PRS cohort was 51%. Patients with PRS and laryngomalacia are more likely to present with overt aspiration compared to patients with PRS without laryngomalacia. These data support that laryngomalacia does not appear to be a contraindication to pursuing MDO. [ABSTRACT FROM AUTHOR]

Laryngomalacia (LM) is the most common airway congenital anomaly and the main cause of stridor in infants. Some patients with severe airway symptoms or with feeding difficulties require surgical intervention. Synchronous airway lesions (SALs) may influence the severity and course of the disease. This study aimed to determine the prevalence of various types of LM and SALs and their influence on surgical intervention decisions and feeding difficulties. Moreover, the study focused on the interrelations between SALs and the type of LM or the presence of feeding difficulties. A retrospective analysis of 106 pediatric patients revealed a significant relationship between type 2 LM and the necessity of surgical treatment. We also found a significant effect of LM type 2 on feeding difficulty. Type 1 LM is significantly more characteristic in premature children. Among different comorbidities, SALs are suspected of modification of the course and severity of LM. This study did not find a significant effect of SALs on the incidence of supraglottoplasty or feeding difficulty. [ABSTRACT FROM AUTHOR]

Background/aim: The pathology of laryngomalacia is still not clear. The aim of this study was to investigate the relationship between vitamin D levels and laryngomalacia, and to evaluate vitamin D levels according to the classification of laryngomalacia. Materials and methods: This retrospective study was conducted in the Kahramanmaraş Sütçü İmam University Medicine Faculty's Otorhinolaryngology Clinic between June 2014 and January 2021. Laryngomalacia was classified. Laboratory tests for all patients included calcium (Ca), phosphorus (P), parathormone (PTH), blood urea nitrogen (BUN), creatinine (Cre), alanine transaminase (ALT), and 25-hydroxy vitamin D (25-OH-D). Results: Evaluations were performed for 64 infants with laryngomalacia, including 41 male and 23 female infants with a mean age of 4.6 ± 3.0 months, and a control group of 64 healthy infants with a mean age of 4.5 ± 2.8 months. A statistically significant difference was determined between the laryngomalacia group and the control group with respect to 25-OH-D and PTH levels (p < 0.001). When data were examined according to laryngomalacia types, a statistically significant difference was determined between the groups for 25-OH-D, Ca, P, PTH, and ALT values. The 25-OH-D level was statistically significantly lower in the severe laryngomalacia group than in the mild and control groups (p < 0.001). A statistically significant difference was determined between the moderate and severe laryngomalacia groups and the control group regarding PTH levels (p < 0.001). Conclusion: Vitamin D deficiency may have a role in the etiology of laryngomalacia, and this view is supported by the finding that there was a decrease in vitamin D levels associated with laryngomalacia classification. In addition, the reduction in PTH levels in infants with laryngomalacia may be explained by the change in Ca metabolism. It would be appropriate for further studies to investigate the response to vitamin D replacement therapy in patients with moderate and severe laryngomalacia. [ABSTRACT FROM AUTHOR]

Tracheobronchial anomalies (TBA) are abnormal airway pathologies that originate from the primary branching site of the tracheobronchial tree, and their prevalence is 0.1-0.2%. The tracheal bronchus and accessory cardiac bronchus are among the most common TBAs. Although these anomalies are usually asymptomatic, they manifest as respiratory tract infections, hemoptysis, atelectasis, and respiratory distress. Appropriate identification and detection of these anomalies are vital in anesthesia management. Accidental canulation of a tracheal bronchus with an anomaly can prevent ventilation of all other bronchopulmonary segments, and due to potential hyperinflation, pneumothorax secondary to alveolar rupture may develop. In this case presentation, we shared our anesthesia method applied to a child with a tracheobronchial anomaly that was coincidentally detected during a tracheotomy. [ABSTRACT FROM AUTHOR]

Objectives: Laryngomalacia is the most common congenital cause of stridor; the natural history of the disease runs through to complete resolution by the age of two. Severe cases are characterized by cyanosis, hypoxia, apnea, furcular and/or subcostal retractions, aspirations, pulmonary hypertension, and failure to thrive and must undergo surgery. This study aimed to evaluate the success rates of supraglottoplasty in our hospital and evaluate the predictive factors for surgical success. Methods: Cohort study, prospectively planned. 75 patients undergoing endoscopic surgery from July 2007 to July 2016 were analyzed at the Santo Antônio Children’s Hospital. The primary outcome was percentage of surgical success, defined as the absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative month (late success). The secondary outcomes were the early surgical success (absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative day). Results: 39 (58.2%) were male, with an average of 4.9 months. Surgical success on the first day was 80.6% (n = 54). At the end of the 1st month, surgical success was 88.6%, considering only those who completed assessment. Twenty-one (34%) presented comorbidities. Presence of comorbidities, pharyngomalacia and GERD were associated with a worse result on the 1st postoperative day, whereas, at the end of the first month, presence of comorbidities, concomitant injuries (tracheo and bronchomalacia) and pharyngomalacia were the predictive variables of surgery failure. Conclusion: Supraglottoplasty has high rates of efficacy and low morbidity. The presence of comorbidities and pharyngomalacia has shown association with a worse early and late surgical outcome. Synchronous airway lesions predict a worse surgical result at the end of the first month. GERD was associated with obstructive symptomatology only in the 1st post-operative day. Level of evidence: Level 3 of evidence, according to the “The Oxford 2011 Levels of Evidence” from Oxford Centre for Evidence-Based Medicine.

Objective: To determine the risk factors and their respective magnitudes for developing Obstructive Sleep Apnea (OSA) in Down syndrome (DS) patients. Design: Retrospective cohort study. Patients: The 2016 Kids' Inpatient Database (KID) was queried to identify all patients diagnosed with DS. Main Outcome Measures: The primary predictor variables were tonsillar hypertrophy (TH), adenoidal hypertrophy (AH), Hypertrophy of Tonsils & Adenoids (HTA), Laryngeal Stenosis (LS), Hypotonia, Glossoptosis, Congenital Laryngomalacia (CL), and Overweight & Obesity (OO). The primary outcome variable was OSA. Results: The final sample consisted of 18,181 patients with a diagnosis of DS. Relative to patients aged 0-5, patients aged 6-10 (OR 3.5, P < 0.01), 11-5 (OR 3.4, P < 0.01), and 16 & above (OR 3.6, P < 0.01) were each independently associated with increased odds of OSA. Further, TH (OR 23.2, P < 0.01), AH (OR 20.3, P < 0.01), HTA (OR 64.2, P < 0.01), glossoptosis (OR 5.0, P < 0.01), CL (OR 4.3, P < 0.01), and OO (OR 3.7, P < 0.01) were all independent risk factors for OSA. Conclusions: The presence of hypertrophied tonsils and adenoids together was the strongest risk factor for OSA. DS patients aged six and above were at risk for OSA development relative to younger patients. Patients with DS should be tested for OSA, which otherwise will deteriorate their existing comorbidities. [ABSTRACT FROM AUTHOR]

Objective: To analyze the judgment efficiency of a computer stress model and severity score in severity evaluation and treatment plan selection of laryngomalacia patients. Methods: Twenty-two children (12 cases in the operation group and 10 cases in the follow-up group) with moderate to severe laryngomalacia were assessed by laryngomalacia severity score (LSS) which included visual analogue scale (VAS) and clinical score. A computer stress model of the laryngeal cavity was constructed for all children, with the von Mises stress peak (VMSP) of the model used as another quantitative evaluation method. The ROC curves of two quantitative evaluation methods, the LSS and the VMSP, were analyzed respectively, according to the clinical guideline which is regarded as the gold standard for judging whether surgery is needed. The diagnostic efficiency indexes such as sensitivity, specificity, and accuracy were calculated. The area under ROC curves (AUC) of the two methods were compared by a DeLong model. Spearman correlation analysis and Kappa test were used to test the correlation and consistency of the two quantitative evaluation methods. The independent sample t test was used to compare the difference of LSS and VMSP between operation group and follow-up group. Results: The sensitivity, specificity, and accuracy of LSS in judging whether laryngomalacia was operated or not were 83.33%, 80.00% and 81.82%, respectively, and the area under ROC curve (AUC) was 0.825 (p < 0.05). The sensitivity, specificity, and accuracy of the computer stress model for laryngomalacia were 58.33%, 90.00% and 72.73%, respectively, and the AUC was 0.796 (p < 0.05). The spearman correlation coefficient between LSS and VMSP was 0.833, p < 0.001, which is statistically significant. LSS (t = 3.251, p = 0.004) and VMSP (t = 2.435, p = 0.024) of the two groups were statistically different. Conclusion: VMSP and LSS have high diagnostic efficacy in the quantitative evaluation of the severity of laryngomalacia and the selection of treatment plan. The consistency of the two quantitative evaluation methods is good, which has practical value for the evaluation of the severity of laryngomalacia and has guiding significance for surgery. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) dramatically impacts healthcare delivery. Pulmonary diagnostic procedures have had frequent disruptions during this pandemic. Objectives: This study aimed to discover how the COVID-19 pandemic affected pediatric flexible fiberoptic bronchoscopy. Methods: This retrospective cross-sectional study was carried out on pediatric patients who underwent fiberoptic bronchoscopy at a tertiary pediatric hospital affiliated to Tehran University of Medical Sciences. Procedural analysis was done from 20 March 2019 to 20 February 2020 (the pre-pandemic period) and 20 March 2020 to 20 February 2021 (during the pandemic period). The two groups were compared with regard to bronchoscopic indications and findings. Results: Our results from the data registry showed that within (group 1), 290 patients vs. 241 patients from 20 March 2020 till 20 February 2021 (group 2) were admitted to the operation room at least once for bronchoscopy procedures. Although the findings of foreign body aspiration in bronchoscopy were more frequent in group 2, this difference was not significant in the two groups (P = 0.055). The number of cases without abnormality in group 2 was significantly less than in group 1 (P = 0.006). The prevalence of Laryngomalacia was also significantly higher in group 2 (P = 0.000). Conclusions: Our results confirmed the reduction of bronchoscopy in children after the COVID-19 epidemic. However, there was no change in the immediate indications for bronchoscopy, and this pandemic had the most significant impact on elective bronchoscopy. [ABSTRACT FROM AUTHOR]