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Vocal fold (VF) immobility is a common complication after pediatric cardiothoracic surgeries involving the aortic arch and conotruncal region. Nasolaryngoscopy is considered the standard for diagnosis but is invasive and requires expertise and special resources. VF ultrasound (VF US) is an efficient, non-invasive alternative for VF evaluation in the post-cardiac surgical setting. Our aim was to improve screening rates for vocal fold motion impairment (VFMI) by implementing VF US in a group of pre-identified high-risk patients after index cardiac surgeries using Quality Improvement (QI) methodology. The QI project included formation of a widely representative stakeholder team, collaborative development of a screening protocol for the cohort of patients in our tertiary center. Baseline data were derived by retrospective review of screening and incidence of VFMI in a similar post-surgical cohort in 2 years prior to this intervention. We implemented an US screening algorithm with multidisciplinary care coordination. We evaluated feeding practices and length of stay (LOS) related to our screening interventions and documented follow up practices. Screening for VFMI by ultrasound increased from 59 to 92% after implementation of the VF screening protocol. Additionally, time between extubation and VF US decreased from 7.7 to 2.3 days. The positive predictive value of VF US was 96%. Patients with VFMI had a longer LOS and greater dependence on tube feeds at discharge after index surgery. We successfully implemented an ultrasound-based screening protocol for VFMI and demonstrated improved screening, timeliness and high positive predictive value of ultrasound.

Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described.A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores.The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high.This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.

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

To assess the efficacy of interarytenoid injection augmentation (IAIA) and the ability of IAIA to predict response to interarytenoid suture augmentation (IASA) based on diet advancement on video fluoroscopic swallow studies (VFSS).Retrospective cohort analysis of patients with persistent pharyngeal dysphagia at a tertiary children's hospital with VFSS pre- and post-IAIA were included between March 2011 and June 2019.Median age of the 229 patients was 2.2 years (5.8 months-19 years). Interarytenoid mucosal height (IAMH) was found to be above the false vocal folds in 112 patients (53.4%) and at true vocal folds in 10 (4.9%) patients. On VFSS post-IAIA, 95 (41.5%) patients were successfully advanced in recommended diet consistency, 115 (50.2%) were stable, and 19 (8.3%) needed thicker consistency. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of0.0001, 95% confidence interval (CI; 0.50-0.85). Poisson regression found no covariates with significant association with improvement on IAIA. For IASA patients, 35/60 (58.3%) improved on post-op VFSS. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of0.0001, 95% CI (0.63-1.33). Positive predictive value for IAIA predicting response to IASA was 77% with positive likelihood ratio of 2.3. The response to IAIA versus no response to IAIA likelihood ratios were found to have a statistically significant difference (p 0.05).Our study suggests IAIA yields objective improvement in swallow function on VFSS in nearly half of our patients and may be a reliable diagnostic tool to predict response to IASA in patients with persistent pharyngeal dysphagia with or without a laryngeal cleft.Level 3 Laryngoscope, 2022.

I. Executive summary BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. Methods ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. Conclusion This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Obstructive sleep apnea affects approximately 1-4% of all children, with increased prevalence amongst overweight and obese children.To assess the effects of drug-induced sleep endoscopy (DISE)-directed surgery on polysomnography parameters in obese and overweight children.A retrospective case-series was performed on obese and overweight pediatric patients who underwent clinically indicated DISE-directed surgery. Forty children met the inclusion criteria, including: body mass index ≥85%, DISE-study, and pre- and post-DISE polysomnography. Patients were divided into surgically naïve (Of 40 children with mean BMI 94% and mean age 8 ± 6 years old, 17 (43%) underwent a previous adenotonsillectomy. Overall, significant improvements were observed in the apnea-hypopnea index (AHI; 25.0 to 9.9 events/hour,Polysomnography parameters significantly improved following DISE-directed interventions in obese and overweight children with obstructive sleep apnea.

Robotic surgery has been shown to be feasible and successful in several areas of pediatric head and neck surgery. However, adoption has been limited. Robotic surgery may be better integrated into practice with advanced preoperative surgical planning and the design of new robotic platforms with instrumentation specific for the application. With continued investigations, computer-aided surgical planning techniques including three-dimensional printing, virtual reality, multiobjective cost function for optimization of approach, mirror image overlay, and flexible robotic instruments may demonstrate value and utility over current practice.

To identify and seek consensus on issues and controversies related to ankyloglossia and upper lip tie in children by using established methodology for American Academy of Otolaryngology-Head and Neck Surgery clinical consensus statements.An expert panel of pediatric otolaryngologists was assembled with nominated representatives of otolaryngology organizations. The target population was children aged 0 to 18 years, including breastfeeding infants. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus, per established methodology published by the American Academy of Otolaryngology-Head and Neck Surgery.After 3 iterative Delphi method surveys of 89 total statements, 41 met the predefined criteria for consensus, 17 were near consensus, and 28 did not reach consensus. The clinical statements were grouped into several categories for the purposes of presentation and discussion: ankyloglossia (general), buccal tie, ankyloglossia and sleep apnea, ankyloglossia and breastfeeding, frenotomy indications and informed consent, frenotomy procedure, ankyloglossia in older children, and maxillary labial frenulum.This expert panel reached consensus on several statements that clarify the diagnosis, management, and treatment of ankyloglossia in children 0 to 18 years of age. Lack of consensus on other statements likely reflects knowledge gaps and lack of evidence regarding the diagnosis, management, and treatment of ankyloglossia. Expert panel consensus may provide helpful information for otolaryngologists treating patients with ankyloglossia.

Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism.Retrospective multi-institutional cohort study.Tertiary care pediatric hospital systems throughout North America.Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models.In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism.These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.

OBJECTIVES/HYPOTHESIS The diffuse sclerosing variant of papillary thyroid carcinoma (DSV) may be more aggressive than conventional well-differentiated non-DSV related papillary thyroid carcinomas (N-PTC). STUDY DESIGN Retrospective chart review. METHODS Retrospective review of clinical outcomes for patients 21 years of age or younger who underwent initial surgery for PTC at a single institution from January 1, 2005 to April 1, 2020. Genomic analysis was performed using targeted next-generation sequencing. Data were analyzed using Fischer's exact test and Kaplan-Meier curve log-rank test. RESULTS Our cohort consisted of 72 patients, nine with DSV and 63 with N-PTC. Age at diagnosis was comparable (15.4 vs. 16.2 years, respectively, P = .46). DSV were more likely to be in the high-risk American Thyroid Academy pediatric risk group (100% vs. 41.3%, P = .004), to present with regional cervical lymph node metastases (100% vs. 60.3%, P = .036), and to present with distant metastases (67% vs. 22%, P = .005). No mortality seen in either group over 27.5 (interquartile range 14.8, 46.00) months average follow-up. Throughout the follow-up period, DSV were more likely to experience progression than N-PTC (hazard ratio = 5.7 [95% confidence interval 1.7-20.0; P = .0056]). In a subset of 19 patients with aggressive disease who had molecular testing as part of clinical care we detected RET fusions in nearly all DSV compared to a minority of N-PTC (83% vs. 15.4%, P = .0095). CONCLUSIONS Pediatric patients with DSV have more advanced disease at diagnosis and are more likely to experience progression of disease compared to patients with N-PTC. The prevalence of RET fusions in our cohort recapitulates the frequency of this alteration described in prior studies. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.

Drug-induced sleep endoscopy (DISE) is useful in children with obstructive sleep apnea (OSA) that persists after adenotonsillectomy (AT), but its utility in surgically naive children is unclear. We report polysomnography outcomes of surgically naive children who underwent DISE-directed intervention because they were considered high risk for persistent OSA after adenotonsillectomy. This study is a case series of 62 surgically naive children with OSA who were considered high risk for persistence after AT and underwent DISE-directed intervention with pre- and postoperative polysomnography between 2012 and 2016. Analysis was performed with the paired t test. Children were on average 5.9 (± 5.5, 0.2–18.6) years old at the time of surgery, 68% male, 18% obese, and 60% white. Thirty-eight percent had a syndromic diagnosis: 19% trisomy 21, 11% hypotonic neuromuscular disorder, and 8% craniofacial condition. The remaining 62% were non-syndromic but underwent DISE because they had at least one risk factor for OSA persistence after AT (age > 7 years, black race, 1+ tonsils, obesity, and/or severe OSA). Forty-two percent underwent AT, while 58% underwent treatment other than AT, including 18% who had multilevel surgery. Children improved significantly in 4 out of 5 polysomnography parameters tested, including obstructive apnea-hypopnea index (oAHI; 22.2 to 7.2, p

Objectives/hypothesis We hypothesized that the use of three-dimensional (3D) printed tracheal models to reproducibly simulate surgical technique variations in slide tracheoplasty would demonstrate the quantitative impact of surgical variables on postoperative tracheal dimensions. Study design Prospective analysis of three-dimensional printed surgical simulation models. Methods Slide tracheoplasty was performed on 3D printed long segment tracheal stenosis models with combinations of tracheal transection incision angle (90°, 45° beveled superior to inferior, 45° beveled inferior to superior) and tracheal transection location relative to the stenosis (at midpoint, 2 mm each superior and inferior to midpoint). Postoperative computed tomography (CT) scans measured changes in tracheal length, volume, and cross-sectional area compared to controls. Statistical analysis was performed using one-way analysis of variance and unpaired two-tailed t-tests. Results Slide tracheoplasty yielded 27 reconstructed tracheas. On average, slide tracheoplasty reduced total tracheal length by 36%. Beveled tracheal incisions yielded 9.5% longer final tracheas than straight transection incisions (P .05). Total tracheal luminal volume increased from 900 mm3 to 1378 mm3 overall and was largest with beveled incisions (P = .03). More material was discarded with straight incisions compared to beveled (89 mg vs. 19 mg, P Conclusions Beveled tracheal transection incisions resulted in increased tracheal length, longer anastomotic segments, increased volume, and reduced tissue waste as compared to straight incisions. Offsetting the incision from the midpoint of stenosis did not significantly affect reconstructed tracheal morphology. Using 3D printed models for surgical simulation can be helpful for the quantitative study of the effect isolated surgical variables on technical outcomes. Level of evidence 3 Laryngoscope, 2021.

Introduction: Our goal was to standardize intraoperative analgesic regimens for pediatric ambulatory tonsillectomy by eliminating local anesthetic use and to determine its impact on postoperative pain measures, while controlling for other factors. Methods: We assembled a quality improvement team at an ambulatory surgery center. They introduced a standardized anesthetic protocol, involving American Society of Anesthesiologists Classification 1 and 2 patients undergoing adenotonsillectomy. Local anesthesia elimination was the project’s single intervention. We collected pre-intervention data (79 cases) from July 5 to September 17, 2019 and post-intervention data (59 cases) from September 25 to December 17, 2019. The intervention requested that surgeons eliminate the use of local anesthetics. The following outcomes measures were evaluated using statistical process control charts and Shewhart’s theory of variation: (1) maximum pain score in the post-anesthesia care unit, (2) total post-anesthesia care unit minutes, and (3) postoperative opioid rescue rate. Results: No special cause variation signal was detected in any of the measures following the intervention. Conclusions: Our data suggest that eliminating intraoperative local anesthetic use does not worsen postoperative pain control at our facility. The intervention eliminated the added expenses and possible risks associated with local anesthetic use. This series is unique in its standardization of anesthetic regimen in a high-volume ambulatory surgery center with the exception of local anesthesia practices. The study results may impact the standardized clinical protocol for pediatric ambulatory adenotonsillectomy at our institution and may hold relevance for other centers.

Childhood thyroid cancer is a rare disease. Providers caring for children with thyroid disease must be knowledgeable about the unique pathology and behavior of pediatric thyroid cancers, including diffuse sclerosing variant papillary thyroid cancer (DSVPTC), as well as the American Thyroid Association (ATA) Guidelines for the treatment of pediatric differentiated thyroid cancer (DTC) and medullary thyroid cancer (MTC). Treatment of most childhood papillary thyroid cancers (PTCs) should entail total or near-total thyroidectomy and appropriate nodal resection (not “berry picking”). Every effort should be made to preserve parathyroid and recurrent laryngeal nerve (RLN) function. Surgery should be performed by high-volume, experienced endocrine, pediatric, and head and neck surgeons familiar with the ATA pediatric thyroid DTC guidelines to minimize surgical and adjuvant treatment morbidity. Radioactive iodine (RAI) benefits children in intermediate and high-risk categories and those with more aggressive tumor variants. More work is needed to better understand pediatric tumor genetics and outcomes to further individualize treatment plans and optimize long-term outcomes.

Objectives/Hypothesis: Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology. Study Design: DELPHI survey. Methods: Twenty-seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained. Results: The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high-definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ-specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre- and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery. Conclusions: International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery. Level of Evidence: 5 Laryngoscope, 131:E732–E737, 2021.

Importance Initial data suggest the effectiveness of oncogene-specific targeted therapies in inducing tumor regression of diverse cancers in children and adults, with minimal adverse effects. Observations In this review, preliminary data suggest that systemic therapy may be effective in inducing tumor regression in pediatric patients with unresectable invasive thyroid cancer. Although most pediatric patients with thyroid cancer initially present with operable disease, some children have extensive disease that poses substantial surgical challenges and exposes them to higher than usual risk of operative complications. Extensive disease includes thyroid cancer that invades the trachea or esophagus or encases vascular or neural structures. Previous efforts to manage extensive thyroid cancer focused on surgery with near-curative intent. With the recent development of oncogene-specific targeted therapies that are effective in inducing tumor regression, with minimal drug-associated adverse effects, there is an opportunity to consider incorporating these agents as neoadjuvant therapy. In patients with morbidly invasive regional metastasis or with hypoxia associated with extensive pulmonary metastasis, neoadjuvant therapy can be incorporated to induce tumor regression before surgery and radioactive iodine therapy. For patients with widely invasive medullary thyroid cancer, in whom the risk of surgical complications is high and the likelihood of surgical remission is low, these agents may replace surgery depending on the response to therapy and long-term tolerance. Conclusions and Relevance With oncogene-specific targeted therapy that is associated with substantial tumor regression and low risk of adverse reactions, there appears to be an opportunity to include children with advanced invasive thyroid cancer in clinical trials exploring neoadjuvant targeted oncogene therapy before or instead of surgery.

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children15 years of age, based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been7 episodes in the past year,5 episodes per year in the past 2 years, or3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of obstructive sleep-disordered breathing. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. Inclusion of 2 consumer advocates on the guideline update group. Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). Addition of an algorithm outlining KASs. Enhanced emphasis on patient and/or caregiver education and shared decision making.

Coronavirus disease 2019 (COVID-19) is a novel coronavirus resulting in high mortality in the adult population but low mortality in the pediatric population. The role children and adolescents play in COVID-19 transmission is unclear, and it is possible that healthy pediatric patients serve as a reservoir for the virus. This article serves as a summary of a single pediatric institution's response to COVID-19 with the goal of protecting both patients and health care providers while providing ongoing care to critically ill patients who require urgent interventions. A significant limitation of this commentary is that it reflects a single institution's joint effort at a moment in time but does not take into consideration future circumstances that could change practice patterns. We still hope dissemination of our overall response at this moment, approximately 8 weeks after our region's first adult case, may benefit other pediatric institutions preparing for COVID-19.

To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC).An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative.In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality.We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative.Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.

Objectives/hypothesis The optimal surgical treatment to improve sleep apnea in children with small tonsils is not known. Drug-induced sleep endoscopy (DISE) may be useful in selecting effective surgical procedures for this patient population. This study compared polysomnography (PSG) measures before and after DISE-directed surgery in children with small tonsils. We hypothesize that DISE-directed surgery improves PSG measures in children with small tonsils. We also aimed to identify the most common surgery performed in this population. Study design Retrospective chart review. Methods A retrospective review was performed of subjects who underwent DISE at a single pediatric tertiary care center over a 6-year period. Inclusion criteria were 1+ tonsils and PSG performed before and after DISE-directed surgery. Exclusion criteria were previous tonsillectomy and tonsils score 2+ or greater. Pre- and postoperative PSG parameters were compared using paired t tests. Results Average age was 7 ± 4 years old at the time of surgery. The most common DISE-directed intervention was supraglottoplasty (n = 23). DISE-directed surgery significantly improved mean apnea-hypopnea index (AHI) from 14.4 to 8.0 (P = .02). Although improvements were seen in mean obstructive AHI (12.5 to 5.5), O2 nadir (87.0 to 88.3), and ODI (10.6 to 5.8), these measures did not reach statistical significance. Conclusions DISE-directed surgery significantly improves AHI in children with small tonsils. The most common intervention performed on these children was supraglottoplasty. Interestingly, adenotonsillectomy was rarely performed in this cohort. Additionally, supraglottic collapse, prompting supraglottoplasty, is difficult to accurately assess in an awake child, supporting use of a DISE-directed approach in this patient population. Level of evidence 4 Laryngoscope, 129:2771-2774, 2019.

Background Children with Down Syndrome (DS) and obstructive sleep apnea (OSA) are difficult to treat, as first line therapies may not lead to significant improvement. Drug-induced sleep endoscopy (DISE) directed surgery may be particularly beneficial for these patients. Objective To assess change in polysomnography (PSG) measures of patients with DS who underwent DISE-directed surgery. Methods Retrospective chart review was performed on patients with DS who underwent DISE-directed surgery and had pre- and post-surgery PSG. Patients were analyzed in groups defined by previous adenotonsillectomy. Two-sided t-tests with equal variances were used to assess statistical significance. Results Of 24 patients reviewed, 14 were surgically naive and 10 had undergone prior adenotonsillectomy. The primary outcome was change in PSG parameters including apnea hypopnea index, obstructive apnea hypopnea index, oxygen nadir, oxygen desaturation index, and mean carbon dioxide level. While improvement was seen in all PSG parameters, only improvement in oxygen nadir in children who had undergone prior adenotonsillectomy was statistically significant (88.5% to 90.9%, p = .04). Conclusions and significance DISE-directed surgery may be beneficial for children with DS and OSA, with improvement in the means of main PSG measures observed. A larger, prospective study is warranted to further explore DISE utility.

Postoperative calcium management is challenging following pediatric thyroidectomy given potential limitations in self-reporting symptoms and compliance with phlebotomy. A protocol was created at our tertiary children's institution utilizing intraoperative parathyroid hormone (PTH) levels to guide electrolyte management during hospitalization. The objective of this study was to determine the effect of a new thyroidectomy postoperative management protocol on two primary outcomes: (1) the number of postoperative calcium blood draws and (2) the length of hospital stay.Institutional review board approved retrospective study (2010-2016).Consecutive pediatric total thyroidectomy and completion thyroidectomy ± neck dissection cases from 1/1/2010 through 8/5/2016 at a single tertiary children's institution were retrospectively reviewed before and after initiation of a new management protocol. All cases after 2/1/2014 comprised the experimental group (post-protocol implementation). The pre-protocol control group consisted of cases prior to 2/1/2014. Multivariable linear and Poisson regression models were used to compare the control and experimental groups for outcome measure of number of calcium lab draws and hospital length of stay.53 patients were included (n = 23, control group; n = 30 experimental group). The median age was 15 years. 41 patients (77.4%) were female. Postoperative calcium draws decreased from a mean of 5.2 to 3.6 per day post-protocol implementation (Rate Ratio = 0.70, p .001), adjusting for covariates. The mean number of total inpatient calcium draws before protocol initiation was 13.3 (±13.20) compared to 7.2 (±4.25) in the post-protocol implementation group. Length of stay was 2.1 days in the control group and 1.8 days post-protocol implementation (p = .29). Patients who underwent concurrent neck dissection had a longer mean length of stay of 2.32 days compared to 1.66 days in those patients who did not undergo a neck dissection (p = .02). Hypocalcemia was also associated with a longer mean length of stay of 2.41 days compared to 1.60 days in patients who did not develop hypocalcemia (p .01).The number of calcium blood draws was significantly reduced after introduction of a standardized protocol based on intraoperative PTH levels. The hospital length of stay did not change. Adoption of a standardized postoperative protocol based on intraoperative PTH levels may reduce the number of blood draws in children undergoing thyroidectomy.

Objectives/Hypothesis Children with bilateral true vocal fold immobility (BTVFI) may present with significant airway distress necessitating tracheostomy. The objective of this study was to review our preliminary experience with the anterior–posterior cricoid split (APCS), an endoscopic intervention used as an alternative to tracheostomy in children with BTVFI. Study Design Multicenter review. Methods A review of patients undergoing endoscopic APCS for BTVFI at four institutions was performed. Patients were evaluated for the ability to ventilate without the requirement for tracheostomy or reintubation. Additional data extracted included the duration of intubation following APCS, the requirement for additional procedures, and demographics. Surgical success was defined as the ability to avoid tracheostomy and to cap or decannulate without respiratory symptoms if a tracheostomy was present prior to APCS. Results Nineteen APCS procedures were performed between October 2010 and June 2016. There were 12 male patients, the mean age at APCS was 4.7 months. BTVFI was primarily idiopathic (58%) and associated with other comorbidities (74%). All patients were candidates for tracheostomy prior to APCS. Fourteen patients (74%) were considered surgical successes. Of the unsuccessful patients, three (66%) required tracheostomy following APCS, and one was treated with a posterior cartilage graft. There was one nonsurgical mortality greater than 2 months after APCS and thought to be unrelated to the airway. Conclusions Endoscopic APCS appears to be a safe and effective intervention for pediatric BTVFI. Under the correct circumstances, this can be performed as a single procedure, obviating tracheostomy. Further study is warranted. Level of Evidence 4. Laryngoscope, 128:257–263, 2018

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.

Objectives/hypothesis The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions. Study design Retrospective case series. Methods This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ2 tests and logistic regression were used to identify risk factors for the development of abnormal changes. Results There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%). Conclusions The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation. Level of evidence 4 Laryngoscope, 130:1327-1332, 2020.

OBJECTIVE Create and validate an objective structured assessment of technical skills (OSATS) for otolaryngology residents learning how to perform a tonsillectomy. STUDY DESIGN Multicenter prospective longitudinal validation study. METHODS A multi-institutional study at six tertiary academic otolaryngology residency programs from July 2009 to May 2012. Using the modified Delphi technique, a panel of pediatric otolaryngologists created a tonsillectomy task-based checklist (TBC) for a tonsil OSATS using a 5-point Likert-type scale. Residents were assessed by pediatric otolaryngology staff at the time of surgery with the TBC and a global rating scale. Procedure time, patient age, number of previously performed tonsillectomies, and surgical technique were also collected. RESULTS One hundred sixty-seven tonsil OSATS were completed for 38 residents, and competency was recorded for 99 (59.2%). Residents scored as competent had performed significantly more previous tonsillectomies than those deemed noncompetent, 44.4 ± 35.6 and 13.5 ± 11.6, respectively (P

Differentiated thyroid cancer in children is a rare disease, accounting for only 1.4% of all pediatric malignancies. The diagnosis, biological behavior and treatment of differentiated thyroid cancer in children is different from that in adults. While there are many unresolved issues regarding approaches to management of differentiated thyroid cancer in the pediatric population, there is near universal consensus that treatment of this disease, which includes total thyroidectomy, central lymph node dissection at the time of initial surgery in those with nodal metastases, and the possible use of iodine-131 radiotherapy, is best performed by specialists including high-volume endocrine surgeons and experts with experience in calculating and administering radioactive iodine in children, when deemed appropriate.

Partial intracapsular tonsillectomy (PIT) was revisited in 2003 as an alternate surgical option to total tonsillectomy for the treatment of tonsillar hypertrophy. However, evaluation of the existing literature on PIT reveals that it is largely focused on comparing perioperative outcomes after PIT and total tonsillectomy, with few data regarding long-term outcomes. The goal of this commentary is to explain why PIT was not incorporated into the 2019 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline for tonsillectomy, while acknowledging its use and potential advantages and disadvantages and outlining future research opportunities.

Objective To determine whether the degree of lateral pharyngeal wall (LPW) obstruction on pediatric drug-induced sleep endoscopy (DISE) correlates with preprocedure tonsillar hypertrophy score on physical examination, and to determine if clinically small tonsils are obstructive. Methods Retrospective review of 154 patients who underwent DISE at a single pediatric tertiary care center over a 4-year period. Inclusion criteria were documentation of Brodsky tonsil score on preoperative physical examination. Exclusion criteria were previous tonsillectomy, adenoidectomy, or adenotonsillectomy. Lateral pharyngeal wall obstruction was graded for each patient from 0 (no obstruction) to 3 (severe obstruction) using a validated pediatric DISE scoring system known as the Chan-Parikh scoring system (C-P). Data were analyzed using multivariate linear regression controlling for age at time of DISE and presence of comorbid conditions. Results One hundred fifteen patients met criteria for analysis. Median age at DISE was 5.1 years. A moderate positive correlation was calculated between Brodsky score and DISE score, Spearman correlation coefficient 0.55, P = 50% obstruction); and six (9%) had a score of 3 (100% obstruction). Conclusion There is a positive correlation between Brodsky Score and DISE LPW score. The majority of children with sleep-disordered breathing with a Brodsky score of 1 did not demonstrate LPW obstruction. These children may benefit from DISE for identification of alternative sites of upper airway obstruction. Level of Evidence 4. Laryngoscope, 127:1943–1949, 2017

Pediatric septoplasty may be associated with short-term symptomatic benefit. This benefit may be greater in female patients and equally achievable in young patients and using less invasive surgical approaches.To determine the short-term effect of pediatric septoplasty, which is not routinely performed, on sinus and nasal-specific quality-of-life.This study is a retrospective case series of 28 pediatric patients that underwent septoplasty. Pre- and post-septoplasty SN-5 overall (mean of all five items, range = 1-7) and visual analog scale (VAS; range = 0-10) scores were obtained and compared using a Wilcoxon signed-rank test. Comparisons of pre- to post-septoplasty changes by sex (female vs male), age (13 vs ≥13 years), and surgical approach (open vs closed) were performed using a Mann-Whitney U-test. Median and interquartile range are reported.Overall and VAS scores significantly improved from pre- to post-septoplasty (3.5 [2.8, 4.3] to 2.0 [1.4, 2.8], p .001; 5.0 [4.0, 6.3] to 8.0 [8.0, 10.0], p .001). Females reported significantly greater overall and VAS score improvements compared to males (-1.8 [-2.6, -1.6] compared to -1.0 [-1.6, -0.2], p = .01; 5.0 [4.0, 5.0] compared to 3.0 [1.5, 4.0], p = .007). Comparisons of changes by age and surgical approach were not significantly different.

Objective To evaluate outcomes of the endoscopic posterior cricoid split with rib graft (EPCS/RG) procedure in the treatment of subglottic stenosis (SGS), posterior glottic stenosis (PGS), and bilateral vocal fold immobility (BVFI). Study Design Retrospective chart review. Methods Chart review of all patients who underwent EPCS/RG at a single tertiary-care facility between 1999 and 2014. Patients were grouped based on the primary indication for the procedure. Decannulation was the primary endpoint. Secondary endpoints were the number of subsequent airway procedures and length of hospitalization. Results Thirty-three patients were identified; 32 had tracheotomy. Overall decannulation rate was 65.6%. Subgroup analysis demonstrated the following decannulation rates: 53.8% for SGS, 100% for PGS, and 28.6% for BVFI. Fisher exact test found a significant difference in overall decannulation rates between groups (P = 0.002). Operation-specific decannulation rates for patients who never required an open procedure were 23% for SGS, 91.6% for PGS, and 28.6% for BVFI. This difference was also statistically significant (P = 0.001). Multivariate logistic regression analysis found prematurity had a positive correlation with decannulation that approached statistical significance (P < 0.051; odds ratio 6.1; 95% confidence interval 0.99, 37.6). The percentage of patients who underwent repeat airway procedures for the groups was 61.5% for SGS, 16.6 % for PGS, and 14.3% for BVFI. The median length of hospitalization after EPCS/RG was 3 days. Conclusion This represents the largest series of patients who have undergone EPCS/RG and demonstrates that the majority of patients can be decannulated after this procedure. Patients with PGS had the highest operation-specific decannulation rates. Level of Evidence 4. Laryngoscope, 2016

Objectives/Hypothesis The purpose of this investigation was to assess current drug-induced sleep endoscopy (DISE) practice patterns at centers that have published on the technique, to identify areas of agreement, and to identify areas of disagreement that may represent opportunities for improvement and standardization. Study Design Multi-institutional survey. Methods A survey was designed in two phases to evaluate preoperative assessment, intraoperative performance, and postoperative management of patients undergoing DISE. The survey was constructed iteratively in consultation with the all of the coauthors, each selected as an expert owing to their previous publication of one or more articles pertaining to pediatric DISE. In the first phase of survey creation, each expert was asked to provide narrative answers to questions pertaining to DISE. These responses served as the basis for a second survey. This second survey was then administered to all pediatric otolaryngologists at each respective institution. Results Overall, there was a low rate of agreement (33%) among the respondents; however, there was substantial agreement within institution, particularly for the use of anesthetic medications, the use of cine magnetic resonance imaging, and performance of bronchoscopy along with DISE. There was strong agreement among all respondents for performing DISE in a child with severe obstructive sleep apnea following adenotonsillectomy, regardless of comorbidities. Conclusion This multi-institutional survey demonstrated a lack of consensus between experts and multiple opportunities for improvement. In general, there was agreement regarding the workup prior to DISE performance and the endoscopic protocol but disagreement regarding anesthetic protocol and management decisions. Level of Evidence 4. Laryngoscope, 127:266–272, 2017

Tonsillectomy is a commonly performed procedure with an accepted risk of posttonsillectomy hemorrhage (PTH) approaching 5%, but catastrophic effects of hemorrhage are exceedingly rare. A variety of surgical techniques and hemostatic agents have been used to reduce the rate of hemorrhage, although none eliminate the risk. Numerous patient, surgical, and postoperative care factors have been studied for an association with PTH. The most consistent risk factors for PTH seem to be patient age and coagulopathies. Surgeon skill and surgical technique are most consistently associated with primary PTH.

Washington was the first US state to have a patient test positive for COVID-19. Before this, our children's hospital proactively implemented an incident command structure that allowed for collaborative creation of safety measures, policies, and procedures for patients, families, staff, and providers. Although the treatment and protective standards are continuously evolving, this commentary shares our thoughts on how an institution, and specifically, surgical services, may develop collaborative process improvement to accommodate for rapid and ongoing change. Specific changes outlined include early establishment of incident command; personal protective equipment conservation; workforce safety; surgical and ambulatory patient triage; and optimization of trainee education. Please note that the contents of this manuscript are shared in the interest of providing collaborative information and are under continuous development as our regional situation changes. We recognize the limitations of this commentary and do not suggest that our approaches represent validated best practices.

Objectives The clinical significance of the interarytenoid mucosal height (IAMH) in pediatric dysphagia, ranging from normal anatomy to a laryngeal cleft, is unknown. This study seeks to evaluate a cohort of patients who underwent evaluation of their IAMH during microdirect laryngoscopy (MDL) for associations between IAMH and dysphagia as diagnosed on preoperative videofluoroscopic swallow study (VFSS). Methods A retrospective case series of 1,351 patients who underwent MDL between 2011 and 2016 were reviewed for intraoperative evaluation of IAMH using our interarytenoid assessment protocol. After exclusions, 182 patients were divided into three groups: 1) thickened diet: VFSS with recommendation for thickened liquids (n = 82 of 182; 45.1%), 2) normal diet: VFSS with allowance of thin liquids (n = 19 of 182; 10.4%), and 3) control: no VFSS performed (n = 81 of 182; 44.5%). Results There was no difference in IAMH between groups (P = 0.35). Power analysis was able to achieve > 80% power to detect an effect size of ≥ 0.5 (1-5 mucosal height scale). The majority of patients in each group had an IAMH above the false vocal folds (thickened diet: 57.3%, normal diet: 57.9%, control: 64.2%). There were similar percentages of patients in each group with an IAMH at or below the true vocal folds (thickened diet: 4.9%, normal diet: 5.3%, control: 6.1%). Conclusion There was no significant association between IAMH and preoperative thickened liquid recommendation in this cohort. This data fails to support the hypothesis that the IAMH is an independent etiological factor for pediatric pharyngeal dysphagia. Further studies comparing IAMH with outcomes after feeding therapy and surgery may better clarify this relationship between anatomy and physiology. Level of evidence 4. Laryngoscope, 129:2588-2593, 2019.

Background The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). Methods Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus. Results The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS. Conclusion As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.

Objective Bilateral vocal-fold immobility (BFVI) is a rare but significant cause of severe respiratory distress in neonates. The primary aim of treatment is to provide an adequate airway while minimizing adverse effects such as aspiration and dysphonia. Our objective here is to describe the outcomes of a series of neonates undergoing percutaneous endoscopic suture lateralization for BVFI using a novel technique. Methods In this retrospective case series, we present 6 neonates (mean age: 18 days) with BVFI from three tertiary academic medical centers. The etiologies included 4 idiopathic, 1 unspecified neurodegenerative disorder, and 1 acquired from cardiac surgery. All had stridor and respiratory distress with hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal-fold lateralization was performed under spontaneous-breathing suspension laryngoscopy using a novel technique of percutaneous needle-directed placement of 4–0 prolene suture without use of specialized equipment. Results All patients had clinical improvement in stridor and respiratory support requirements and avoided tracheostomy. One patient had persistent aspiration after lateralization that resolved after suture removal. One patient required bilateral lateralization procedures. One patient expired of epilepsy due to neurodegenerative disease unrelated to airway pathology. At last follow-up (mean 12.6 months), 5/5 remaining patients were on room air without tracheostomy and feeding orally without aspiration; 4/5 had partial or complete return of vocal-fold function. Conclusion Endoscopic percutaneous suture lateralization may be a safe and effective non-destructive primary treatment modality for neonatal BVFI. All neonates undergoing this procedure avoided tracheotomy.

Sustained accumulation of interstitial fluid, or lymphedema, can occur in animals and humans when the development of the lymphatic vascular network is disturbed (Cueni, Detmar, Lymphat Res Biol 6:109–122, 2008) The study of animal models as well as of several syndromic conditions in which lymphedema is a component has furthered our understanding of the genetic regulation of lymphatic development, maintenance, and function (Tammela, Alitalo, Cell 140:460–476, 2010; Fang et al, Am J Hum Genet 67:1382–1388, 2000; Doffinger et al, Nat Genet 27:277–285, 2001; Alders et al, Nat Genet 41:272–1274, 2009; Irrthum et al, Am J Hum Genet 72:1470–1478, 2003). The unusual concurrence of lower extremity lymphedema and anatomical closure of the posterior choanae in the nasal cavity (posterior choanal atresia or PCA) has been reported, and analysis of this concurrence advanced our knowledge of lymphatic development.

OBJECTIVES. In this study, we used computed tomography measurements to investigate the feasibility of nasoseptal flap reconstruction of sellar defects in children, and we reviewed our institutional experience with the procedure. STUDY DESIGN. Cross-sectional and case series. SETTING: Pediatric tertiary care facility. METHODS. We obtained 10 normal maxillofacial scans for each year of age from birth to 18. Computer-assisted nasal and skull-base measurements were performed. Patients with incomplete pneumatization were excluded from analysis. Reconstruction was presumed feasible if the ratio of nasoseptal flap length to associated sellar defect length was greater than 1. Chart review identified surgical patients. RESULTS. Of 190 scans, 125 had complete pneumatization. Of these, 120 (96%) displayed a ratio of nasoseptal flap length to sellar defect length greater than 1, suggesting that reconstruction would be feasible. Mean ratio of flap length to defect length for all subjects was 1.47 (SD 0.33; 95% CI, 1.41–1.53). Only 5 of 125 patients (4%) had a ratio less than 1; the median age for these patients was 15 years, which is older than the median age of 12 years for subjects with a ratio greater than 1 (P = .02). An inverse relationship was identified between age and ratio of flap length to defect length (r = −0.49, P < .001). Case series identified 6 children, ages 5 to 17; flap length was never described as a limitation. CONCLUSIONS. Nasoseptal flap length is not a limiting factor for reconstruction of pediatric sellar defects. When compared with older patients, younger patients tend to have greater nasoseptal flap length relative to sellar defect length.