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Herein is presented a case of a 3-year-old who was the product of a pregnancy complicated by fetal congenital cervical teratoma. The teratoma was resected day-of-life 6, and he underwent tracheotomy. Radiologic review of his cartilaginous cervical anatomy in utero, pre- and post-tumor excision indicated congenital absence of the hyoid. An initial double-staged laryngotracheal reconstruction improved the subglottic and tracheal airway, but the supraglottic and pharyngeal airway remained collapsed. Using a cadaveric cartilage, a hyoid was fashioned. After the pharynx and straps muscles were sewn to the hyoid construct, the supraglottic and supra-laryngeal airway improved. Subsequent laryngotracheal reconstruction, which included tracheal onlay grafts of cadaveric cartilage, achieved decannulation. Laryngoscope, 134:5207-5209, 2024., (© 2024 The Author(s). The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To report the prevalence of cholesteatoma and related comorbidities in pediatric aerodigestive patients requiring tracheostomy or airway reconstruction procedures. To use study findings to inform clinical management of these complex patients., Methods: A repository of clinical data drawn from our institution's electronic medical records was queried to identify airway reconstruction (airway) and complex hospital control (control) patient cohorts. Retrospective chart review was then performed to investigate the occurrence of cholesteatoma and related pathologies in these patients, as well as clinical management., Results: The prevalence of cholesteatoma in airway and control patients was 6/374 (1.60 %) and 35/30,565 (0.11 %), respectively. The relative risk of cholesteatoma diagnosis in airway patients was 14.01 (95 % CI 6.06-32.14). Airway patients were more likely than control patients to have pressure equalization tube history (relative risk 3.25, 95 % CI 2.73-3.82). Age at cholesteatoma diagnosis and first surgical intervention was younger in airway compared to control patients (5.43 vs. 8.33, p = 0.0182, and 6.07 vs. 8.82, p = 0.0236). However, time from diagnosis to intervention and extent of surgery were similar between the groups., Conclusion: This is the first study to investigate the prevalence of cholesteatoma in the pediatric aerodigestive population. The relative risk of cholesteatoma diagnosis was found to be 14 times higher in patients with tracheostomy or airway reconstruction history. Underlying eustachian tube and palatal dysfunction are likely contributing factors to the elevated risk. Additionally, cholesteatoma in this population was diagnosed and required surgical intervention at a younger age, which may suggest a more aggressive disease course. Providers should maintain a high degree of suspicion for cholesteatoma in this complex population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Posterior glottis impairment alters breathing, voicing, and swallowing. Bilateral vocal fold movement impairment (BVFMI) occurs when the vocal cords are fixed/remain midline. Studies inadequately assessed endoscopic posterior costal cartilage grafting (enPCCG) for BVFMI across broad ages. We aim to assess decannulation and prosthesis free airway in children and adults who have undergone enPCCG., Study Design: Retrospective cohort., Setting: Referral center., Methods: This study included adults and children who received enPCCG for BVFMI (2010-2018) and were followed for 35 months on average. The main outcome was successful decannulation of patients, or airway improvement in those without tracheostomy. Data on comorbidities, surgical complications, and interventions following surgery were collected., Results: Ten children and 11 adults underwent enPCCG for BVFMI. Eighty-one percent of patients had a tracheostomy at surgery; adults were more likely to have a tracheostomy at surgery (P = 0.035), and to undergo double-staged procedure (P = 0.035) and stent (P = 0.008). Average stent duration was 29.7 days. Overall decannulation rate was 76% (90% for children; 70% for adults). Children were more likely to receive postoperative intensive care unit care (P = 0.004). Adults had mean 4.4 post-enPCCG interventions per patient compared to children's mean 3.91 interventions. The most common interventions were steroid injection (17.6%) and balloon dilation (16%). Preliminary analysis suggests postoperative dysphonia was reported in 66.7% of patients; postoperative dysphagia was rare., Conclusion: EnPCCG was more successful at achieving decannulation in children. Adults required additional interventions. A double-staged operation with prolonged stenting is recommended for adult patients. A majority of patients were decannulated at last follow-up., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

The objective of this study was to characterize mucosal microbial shifts in patients with acute laryngeal injury (ALgI) after intubation. This cross-sectional study included 20 patients with ALgI who underwent early endoscopic intervention with tissue culture, 20 patients with idiopathic subglottic stenosis (iSGS) who underwent tissue culture during the routine endoscopic intervention, and 3 control patients who underwent mucosal swab culture. 70% of the ALgI patients had a positive culture compared to 5% of the iSGS patients and none of the controls. The most identified microbes isolated from ALgI patients included Staphylococcus species in 30% and Streptococcus species in 25%. The high rate of pathologic bacterial infiltration into postintubation laryngeal wounds supports efforts to reduce bacterial colonization of endotracheal tubes and highlights the role of culture-directed antibiotic therapy as a part of early intervention to improve outcomes for patients with ALgI., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: To investigate whether revision surgery with the same device results in a change in three key indicators of electrode positioning: scalar location, mean modiolar distance ( M ¯ ), and angular insertion depth (AID)., Methods: Retrospective analysis of a cochlear implant database at a university-based tertiary medical center. Intra-operative CT scans were obtained after initial and revision implantation. Electrode array (EA) position was calculated using auto-segmentation techniques. Initial and revision scalar location, M ¯ , and AID were compared., Results: Mean change in M ¯ for all ears was -0.07 mm (SD 0.24 mm; P  = 0.16). The mean change in AID for all ears was -5° (SD 67°; P  = 0.72). Three initial implantations with pre-curved EAs resulted in a translocation from Scala Tympani (ST) to Scala Vestibuli (SV). Two remained translocated after revision, while one was corrected when revised with a straight EA. An additional five translocations occurred after revision., Conclusions: In this study examining revision cochlear implantation from a single manufacturer, we demonstrated no significant change in key indicators of EA positioning, even when revising with a different style of electrode. However, the revision EA is not necessarily confined by the initial trajectory and there may be an increased risk of translocation.

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: To analyze the association of mast cells found on supraglottic biopsy of pediatric patients with common aerodigestive diseases., Study Design: Cross-sectional study., Setting: Tertiary care children's hospital., Methods: A total of 461 pediatric patients undergoing otolaryngology aerodigestive procedures provided consent between 2014 and 2019, and biopsies of the supraglottic larynx were collected at the time of their surgery. Pathologists reviewed biopsies for the presence and number of mast cells per high-power field. The patients' electronic health records were reviewed for relevant demographic data and clinical diagnoses present at the time of biopsy. Multivariate logistic regression was used to assess the relationship of mast cells with odds of aerodigestive disease., Results: Patients with mast cells in their biopsy had significantly higher odds of asthma (odds ratio [OR], 2.02; 95% CI, 1.17-3.46), gastroesophageal reflux disease (OR, 2.36; 95% CI, 1.47-3.77), laryngomalacia (OR, 2.98; 95% CI, 1.80-4.94), laryngeal anomalies (OR, 2.32; 95% CI, 1.52-3.55), and obstructive sleep apnea (OR, 2.16; 95% CI, 1.35-3.45). When mast cells were evaluated as a continuous variable, there was a nonlinear relationship between increasing mast cell count and odds of disease., Conclusions: Mast cells are known to be associated with inflammatory conditions, though little is known about their presence in laryngeal inflammation. Results from our study demonstrate an association between mast cells in the pediatric larynx and asthma, gastroesophageal reflux disease, laryngomalacia, laryngeal anomalies, and obstructive sleep apnea. Our study also showed a nonlinear relationship between number of mast cells and odds of disease diagnosis.

Purpose: Endoscopic arytenoid abduction lateropexy (EAAL) is a reliable surgical solution for the minimally invasive treatment of bilateral vocal fold palsy (BVFP), providing a stable airway by the lateralization of the arytenoid cartilages with a simple suture. The nondestructive manner of the intervention theoretically leads to higher regeneration potential, thus better voice quality. The study aimed to investigate the respiratory and phonatory outcomes of this treatment concept., Methods: 61 BVFP patients with significant dyspnea associated with thyroid/parathyroid surgery were treated by unilateral EAAL. Jitter, Shimmer, Harmonics to Noise Ratio, Maximum Phonation Time, Fundamental frequency, Voice Handicap Index, Dysphonia Severity Index, Friedrich's Dysphonia Index, Global-Roughness-Breathiness scale, Quality of Life, and Peak Inspiratory Flow were evaluated 18 months after EAAL., Results: All patients had a stable and adequate airway during the follow-up. Ten patients (16.4%) experienced complete bilateral motion recovery with objective acoustic parameters in the physiological ranges. Most functional results of the 13 patients (21.3%) with unilateral recovery also reached the normal values. Fifteen patients (24.6%) had unilateral adduction recovery only, with slightly impaired voice quality. Eleven patients (18.0%) had false vocal fold phonation with socially acceptable voice. In 12 patients (19.7%) no significant motion recovery was detected on the glottic level., Conclusion: EAAL does not interfere with the potential regeneration process and meets the most important phoniatric requirements while guaranteeing the reversibility of the procedure-therefore serving patients with transient palsy. Further, a socially acceptable voice quality and an adequate airway are ensured even in cases of permanent bilateral vocal fold paralysis., (© 2021. The Author(s).)

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients., Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence., Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression., Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Background: Since the start of the COVID-19 pandemic outpatient medicine has drastically been altered how it is delivered. This time period likely represents the largest volume of telehealth visits in the United States health care history. Telehealth presents unique challenges within each subspecialty, and pediatric otolaryngology is no different. This retrospective review was designed to evaluate our division of pediatric otolaryngology's experience with telehealth during the COVID19 pandemic., Methods: This study was approved by the Institutional Review Board at Vanderbilt University Medical Center. All telehealth and face-to-face visits for the month of April 2020 completed by the Pediatric Otolaryngology Division were reviewed. A survey, utilizing both open-ended questions and Likert scaled questions was distributed to the 16 pediatric otolaryngology providers in our group to reflect their experience with telehealth during the 1-month study period., Results: In April, 2020 our outpatient clinic performed a total of 877 clinic visits compared to 2260 clinic visits in April 2019. A total of 769 (88%) were telehealth visits. Telemedicine with video comprised 523 (68%) and telephone only comprised 246 (32%). There were 0 telehealth visits in April 2019. Interpretive services were required in 9.3% (N = 211) clinic visits in April 2019 and 7.5% (N = 66) of clinic visits in April 2020. The survey demonstrated a significant difference ( P  < .00002) in provider's anticipated telehealth experience (mean 3.94, 95% CI [3.0632, 4.8118] compared to their actual experience after the study period (mean 7.5, 95% CI [7.113, 7.887]., Conclusions: Despite low initial expectations for telehealth, the majority of our providers felt after 1 month of use that telehealth would continue to be a valuable platform post-pandemic clinical practice. Limited physical exam, particularly otoscopy, nasal endoscopy, and nasolaryngoscopy present challenges. However, with adequate information and preparation for the parents and for the physician some of the obstacles can be overcome.

Objectives/hypothesis: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal., Study Design: Blinded modified Delphi consensus process., Setting: Tertiary care center., Methods: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items., Results: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus., Conclusions: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated., Level of Evidence: 5. Laryngoscope, 131:1168-1174, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: Arytenoid adduction (AA) has been indicated for unilateral vocal fold paralysis (UVFP) patients with vertical vocal fold height mismatch and/or large posterior glottic gaps that are unable to be adequately addressed by anterior medialization techniques. Although AA offers several advantages over other methods, it is technically challenging and involves significant laryngeal manipulation of the cricoarytenoid joint. A novel, minimally invasive endoscopic arytenoid medialization technique is presented for the closure of the posterior commissure., Study Design: Prospective case series., Methods: Seventeen consecutive patients were diagnosed and treated with unilateral endoscopic arytenoid medialization (EAM) combined with injection laryngoplasty because of unilateral vocal fold paralysis. Jitter, shimmer, harmonics-to-noise ratio (HNR), maximum phonation time (MPT), fundamental frequency (F 0 ), Voice Handicap Index (VHI), peak inspiratory flow (PIF), and quality of life (QoL) were evaluated preoperatively, 1 month, and 1 year after EAM., Results: Jitter, shimmer, HNR, and MPT significantly improved and remained stable 1 year after the intervention. F 0 and PIF remained unchanged. Significant improvements in VHI and QoL demonstrated patient satisfaction with voicing and respiratory functions., Conclusions: Endoscopic arytenoid medialization is a quick, minimally invasive solution for unilateral vocal fold paralysis. With simultaneous augmentation of the vocal fold, it provides a complete glottic closure along the entire vocal fold in UVFP patients., Level of Evidence: 4 Laryngoscope, 131:E903-E910, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Importance: Patients with laryngeal injury after endotracheal intubation often present long after initial injury with mature fibrosis compromising cricoarytenoid joint mobility and glottic function., Objective: To compare functional outcomes between early and late intervention for intubation-related laryngeal injury., Design, Setting, and Participants: This retrospective cohort study involved 29 patients with laryngeal injury resulting from endotracheal intubation who were evaluated at a tertiary care center between May 1, 2014, and June 1, 2018. Ten patients with intubation injury to the posterior glottis who received early treatment were compared with 19 patients presenting with posterior glottic stenosis who received late treatment. Statistical analysis was performed from May 1 to July 1, 2019., Exposures: Early intervention, defined as a procedure performed 45 days or less after intubation, and late treatment, defined as an intervention performed greater than 45 days after intubation., Main Outcomes and Measures: Patient-specific and intervention-specific covariates were compared between the 2 groups, absolute differences with 95% CIs were calculated, and time to tracheostomy decannulation was compared using log-rank testing., Results: The 2 groups had similar demographic characteristics and a similar burden of comorbid disease. Ten patients who received early intervention (7 women [70%]; median age, 59.7 years [range, 31-72 years]; median, 34.7 days to presentation [IQR, 1.5-44.8 days]) were compared with 19 patients who received late intervention (11 women [58%]; median age, 53.8 years [range, 34-73 years]; median, 341.9 days to presentation [IQR, 132.7-376.3 days]). Nine of 10 patients (90%) who received early intervention and 11 of 19 patients (58%) who received late interventions were decannulated at last follow-up (absolute difference, 32%; 95% CI, -3% to 68%). Patients who received early treatment required fewer total interventions than patients with mature lesions (mean, 2.2 vs 11.5; absolute difference, 9.3; 95% CI, 6.4-12.1). In addition, none of the patients who received early treatment required an open procedure, whereas 17 patients (90%) with mature lesions required open procedures to pursue decannulation., Conclusions and Relevance: This study suggests that early intervention for patients with postintubation laryngeal injury was associated with a decreased duration of tracheostomy dependence, a higher rate of decannulation, and fewer surgical procedures compared with late intervention. Patients who underwent early intervention also avoided open reconstruction. These findings may bear relevance to the management of patients requiring extended durations of endotracheal intubation during recovery for critical illness related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Objectives/hypothesis: Characterization of the localized adaptive immune response in the airway scar of patients with idiopathic subglottic stenosis (iSGS)., Study Design: Basic Science., Methods: Utilizing 36 patients with subglottic stenosis (25 idiopathic subglottic stenosis [iSGS], 10 iatrogenic post-intubation stenosis [iLTS], and one granulomatosis with polyangiitis [GPA]) we applied immunohistochemical and immunologic techniques coupled with RNA sequencing., Results: iSGS, iLTS, and GPA demonstrate a significant immune infiltrate in the subglottic scar consisting of adaptive cell subsets (T cells along with dendritic cells). Interrogation of T cell subtypes showed significantly more CD69 + CD103 + CD8 + tissue resident memory T cells (T RM ) in the iSGS airway scar than iLTS specimens (iSGS vs. iLTS; 50% vs. 28%, P = .0065). Additionally, subglottic CD8 + clones possessed T-cell receptor (TCR) sequences with known antigen specificity for viral and intracellular pathogens., Conclusions: The human subglottis is significantly enriched for CD8 + tissue resident memory T cells in iSGS, which possess TCR sequences proven to recognize viral and intracellular pathogens. These results inform our understanding of iSGS, provide a direction for future discovery, and demonstrate immunologic function in the human proximal airway. Laryngoscope, 131:610-617, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

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

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research., Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease., Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook., Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications., Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk., Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Objectives: Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes., Design: Prospective cohort study., Setting: Tertiary referral critical care center., Patients: Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation., Interventions: Laryngoscopy following endotracheal intubation., Measurements and Main Results: One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48-2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0-6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0-0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0-1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury., Conclusions: Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.

The early efforts of pediatric airway surgeons, gastroenterologists, and pulmonologists to optimize surgical outcomes involved evaluating multiple organ systems for diseases negatively affecting surgery. This resulted in coordinated clinics with multiple services, ancillary testing, and endoscopic procedures, known as aerodigestive programs. These programs have nationally increased the value of care, with multidisciplinary experts delivering organized and efficient care to children with complex needs. This article describes the origin and value of aerodigestive programs within the modern health care landscape, serving as a primer for providers and administrators investigating how to facilitate aerodigestive or similar programs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Mucosal impedance testing measures changes in resistance to alternating electrical current. The purpose of this study is to establish the feasibility of mucosal impedance (MI) measurement in the pediatric larynx., Methods: A flexible plastic catheter, whose tip contains paired 2 mm mucosal impedance, is directly applied to the larynx under suspension microlaryngoscopy. Milliohms of resistance is relayed real-time from the catheter and output onto a PC. Results were obtained safely over the course of 5 min of intraoperative time for all 49 patients undergoing routine microlaryngoscopy at a tertiary care pediatric hospital., Results: The technique was successful in identifying MI values with reliable and reproducible results. The risk was minimal with no adverse events occurring. Impedance noise reduction was improved by the use of an aqueous gel coating on the probe and an emphasis on measurements of the interarytenoid space, which enabled the sensor rings to contact 360° of the mucosa., Conclusion: Laryngeal MI can be safely and reliably performed with reproducible measurements and minimal added procedure time., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: The primary aim of this study is to evaluate the safety, efficacy, and execution of major open laryngotracheal operations for patients in the advanced decades., Study Design: Case series with chart review., Setting: Multidisciplinary clinic at a tertiary care academic hospital., Subjects and Methods: Patient characteristics, operative course, and postoperative outcomes were retrospectively recorded for all airway reconstruction operations performed between 1999 and 2016 on patients aged ≥60 years Long-term success was defined as prosthesis-free survival at last follow-up. Descriptive statistics were performed., Results: Twenty-nine patients met inclusion criteria, and the median age was 71 years (interquartile range, 63-74). Tracheal resection was the most common procedure (13 patients), followed by laryngotracheal reconstruction (7 patients). Fifteen patients began their operation with a tracheostomy, 6 of whom underwent decannulation prior to leaving the operating room. Three additional patients underwent decannulation at follow-up appointments and were prosthesis-free at most recent follow-up. The mean time to decannulation among these patients was 3 months. Of the 14 patients beginning their procedure without a tracheostomy, only 2 required permanent airway prosthesis. The overall long-term rate of prosthesis-free survival was 72.4% (21 of 29 patients). Factors suggestive of long-term success include lower McCaffrey grade and lack of pulmonary disease, hypertension, or diabetes, as well as decreased red blood cell distribution width on preoperative complete blood count., Conclusion: Through careful patient selection, preoperative workup, and meticulous postoperative care, airway reconstruction procedures in patients aged ≥60 years are reasonably successful. Of 29 patients, 21 (72.4%) were successfully breathing long-term without airway prosthesis.

Objectives: Bilateral vocal cord paralysis often causes severe dyspnea requiring an early airway intervention in neonates. Endoscopic arytenoid abduction lateropexy (EAAL) with suture is a quick, reversible, minimally-invasive vocal cord lateralizing technique to enlarge the glottis. The arytenoid cartilage is directly lateralized to a normal abducted position. It can be performed even in early childhood with the recently-introduced pediatric endoscopic thread guide instrument. The long-term results and the stability of the lateralization were evaluated., Methods: Three newborns had inspiratory stridor immediately after birth. Laryngo-tracheoscopy revealed bilateral vocal cord paralysis. Unilateral, left-sided endoscopic arytenoid abduction lateropexy was performed with supraglottic jet ventilation. The follow-up period was >3 years., Results: After extubation on the 4-7th postoperative day no dyspnea or swallowing disorder occurred. Laryngo-tracheoscopy, clinical growth charts and voice analysis showed satisfactory functional results., Conclusions: The endoscopic arytenoid abduction lateropexy might be a favorable solution for neonatal bilateral vocal cord paralysis. In one step, airway patency can be achieved without irreversible damage to the glottic structures. Normal swallowing function was preserved. The results are durable, and neither medialization nor dyspnea re-appeared during observation., (Copyright © 2019. Published by Elsevier B.V.)

Importance: Airway reconstruction for adults with laryngotracheal stenosis (LTS) is directed toward improving airway caliber to mitigate the patient's dyspnea and achieve prosthesis-free breathing (ie, without tracheostomy, intraluminal stent, or T-tube). Despite the importance of preoperative risk stratification to minimize postoperative complications, consensus on an objective predictive algorithm for open airway reconstruction is lacking., Objective: To determine whether the ability to achieve a prosthesis-free airway in adults after open airway reconstruction is associated with red blood cell distribution width (RDW) at the time of surgery., Design, Setting, and Participants: Case series study investigating 92 consecutive patients 18 years and older with laryngotracheal stenosis who underwent open airway reconstruction at a US tertiary care hospital from January 1, 2006, to January 1, 2017., Main Outcomes and Measures: The main outcome was a prosthesis-free airway (absence of tracheostomy, intraluminal stent, or T-tubes) at last follow-up. Multivariate logistic regression modeling was used to identify independent factors associated with this outcome., Results: Of the 92 patients who met inclusion criteria, the median (interquartile range) age was 44 (33.0-60.3) years; 50 (53%) were female, and 82 (89%) were white. In all, 74 patients (80%) were prosthesis free at the last follow-up (mean, 833 days; 95% CI, 10-4229 days). In multivariate analyses, airway decannulation was significantly correlated with reduced RDW (odds ratio [OR], 0.40; 95% CI, 0.19-0.84) and the absence of posterior glottic stenosis (OR, 0.12; 95% CI, 0.04-0.37)., Conclusions and Relevance: These data suggest that surgical success in open airway reconstruction is significantly associated with RDW and whether the patient had posterior glottic stenosis. The RDW is a routine laboratory parameter that may provide some insight to the preoperative probability of prosthesis removal, facilitate risk stratification, promote informed patient decision making, and optimize health care resource management.

Objective: To characterize the phenotype and function of fibroblasts derived from airway scar in idiopathic subglottic stenosis (iSGS) and to explore scar fibroblast response to interleukin 17A (IL-17A)., Study Design: Basic science., Setting: Laboratory., Subjects and Methods: Primary fibroblast cell lines from iSGS subjects, idiopathic pulmonary fibrosis subjects, and normal control airways were utilized for analysis. Protein, molecular, and flow cytometric techniques were applied in vitro to assess the phenotype and functional response of disease fibroblasts to IL-17A., Results: Mechanistically, IL-17A drives iSGS scar fibroblast proliferation ( P < .01), synergizes with transforming growth factor ß1 to promote extracellular matrix production (collagen and fibronectin; P = .04), and directly stimulates scar fibroblasts to produce chemokines (chemokine ligand 2) and cytokines (IL-6 and granulocyte-macrophage colony-stimulating factor) critical to the recruitment and differentiation of myeloid cells ( P < .01). Glucocorticoids abrogated IL-17A-dependent iSGS scar fibroblast production of granulocyte-macrophage colony-stimulating factor ( P = .02)., Conclusion: IL-17A directly drives iSGS scar fibroblast proliferation, synergizes with transforming growth factor ß1 to promote extracellular matrix production, and amplifies local inflammatory signaling. Glucocorticoids appear to partially abrogate fibroblast-dependent inflammatory signaling. These results offer mechanistic support for future translational study of clinical reagents for manipulation of the IL-17A pathway in iSGS patients.

Objectives: Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies., Methods: Standard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site-specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria., Results: Thirty-three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative-/intraoperative-/procedure-related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site-specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable., Conclusion: This consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta-analyses, quality improvement, transfer of information, and surgeon self-assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient., Level of Evidence: 5 Laryngoscope, 129:244-255, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Intubation is an essential component of intensive care, yet it does have potential complications. Posterior glottic stenosis (PGS) is among the most severe sequela. Risk factors are poorly understood. One hypothesis is that large endotracheal tubes (ETTs) in smaller airways may increase risk. Because tracheal diameter is proportional to height, we designed a case-control study to evaluate the association between intensive care unit (ICU)-patient height (proxy for tracheal diameter) and their risk of postintubation PGS., Study Design: Retrospective case-control study METHODS: Among patients who underwent intubation in an ICU at a single tertiary care medical center between 2001 and 2015, a convenience sample of all patients with confirmed PGS (cases) were enrolled. Cases were matched 1:1 by age, sex, and race with intubated non-PGS controls chosen from the same population of ventilated patients. Data on height, weight, comorbidities, size of ETT, and duration of intubation were abstracted from the medical record. Multivariate models were used to test the association between patient height and risk of PGS development., Results: In all, 106 PGS cases (mean age 48.9 years, 50.7% female, 79.2% Caucasian) were identified; 77 met inclusion criteria. Compared to matched controls, cases were significantly shorter (mean 166 cm vs. 173 cm, P = .001). Height and PGS showed an inverse relationship in multivariate models. Specifically, odds of PGS decreased 9% (95% confidence interval: 0.01%-16%) for each centimeter increase in height., Conclusions: Shorter height is independently associated with increased odds of having PGS. Further work should consider whether height should be incorporated into ETT selection algorithms., Level of Evidence: 3b Laryngoscope, 128:2811-2814, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: (1) To examine relationships between socioeconomic status (SES) and successful treatment of pediatric obstructive sleep apnea (OSA) with adenotonsillectomy (T&A). (2) To explore sociodemographic factors and medical comorbidities that separate OSA and refractory OSA populations in children., Methods: We retrospectively reviewed pediatric OSA patients (ages 0-18). Patients evaluated for OSA by pediatric otolaryngology between January 2014 and December 2015 were included. OSA was defined as requiring T&A. Refractory OSA (ROSA) was defined as recurring, polysomnography-proven, OSA after T&A, ultimately requiring another intervention, such as a multi-level airway operation. Clinical data were complemented with sociodemographic data. ZIP codes were used to approximate median household income., Results: Our cohort included 105 ROSA and 53 OSA patients. These patients came from similar rates of single parent households and coverage by public insurance. Median household income for OSA patients was $47,086 (IQR $36,395-$60,196), compared to $45,696 (IQR $37,669-$56,203) for ROSA patients. Over 60% of all patients fell below the national household income average. Nearly half of the cohort resided in the three largest metro counties closest to our institution. These patients represented higher rates of single-parent households (p = 0.045) and public insurance (p = 0.002), and trends towards lower rates of ROSA (p = 0.138)., Conclusion: Our results identified sociodemographic factors that may influence healthcare compliance and subsequently overall health outcomes. We identified no statistically significant difference in measures of SES between patients with refractory vs non-refractory OSA. Patients living closest to our medical center had lowest rates of ROSA, suggesting that access to care may affect outcomes of pediatric OSA., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Mucoepidermoid carcinoma of the trachea is a rare pediatric malignancy that presents unique challenges in diagnosis, operative management, and surveillance., Methods and Results: We present a 17-year-old girl with primary tracheal mucoepidermoid carcinoma presenting in acute respiratory distress due to near-total occlusion of the tracheal airway. An algorithmic approach to preoperative planning was developed to evaluate and remove the tumor endoscopically without compromising oxygenation. After initial palliative resection, endobronchial ultrasound was uniquely applied to evaluate depth of tumor invasion, and subsequent tracheal resection with primary anastomosis was performed as curative treatment., Conclusion: Removal of distal tracheal masses can be performed safely with the implementation of an algorithmic approach to tumor visualization and resection. Endobronchial ultrasound can be used to evaluate the extent of tumor invasion and plan for definitive resection., (© 2018 Wiley Periodicals, Inc.)

Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Drs Deboer, Prager, Friedlander, and Deterding are co-founders (Secretary, Treasurer, President, and Vice-President, respectively) and board members of Triple Endoscopy, Inc. They are also co-inventors with University of Colorado on Patent Cooperation Treaty application “Pediatric Nasal Endoscope PCT/US16/39352.” They have not received funding from these entities for this project or at the time of the writing of this manuscript; Dr Rutter serves as consultant to Bryan Medical, which produces and markets an airway balloon of his patent. This is unrelated to the current study and he receives no revenue from this stent; Dr Gold has received grants and funding from Johnson and Johnson, Takeda Pharmaceuticals, Nestle Nutrition, Nutricia Nutrition, and Mead Johnson (unrelated to the current study); Dr Putnam has received payment for lectures including service on speaker bureaus for Abbott Nutrition (unrelated to the current study); the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objectives/hypothesis: Idiopathic subglottic stenosis (iSGS) is an unexplained obstruction involving the lower laryngeal and upper tracheal airway. Persistent mucosal inflammation is a hallmark of the disease. Epithelial microbiota dysbiosis is found in other chronic inflammatory mucosal diseases; however, the relationship between tracheal microbiota composition and iSGS is unknown. Given the critical role for host defense at mucosal barriers, we analyzed tissue specimens from iSGS patients for the presence of microbial pathogens., Methods: Utilizing 30 human iSGS, 20 intubation-related tracheal stenosis (iLTS), and 20 healthy control specimens, we applied molecular, immunohistochemical, electron microscopic, immunologic, and Sanger-sequencing techniques., Results: With unbiased culture-independent nucleic acid, protein, and immunologic approaches, we demonstrate that Mycobacterium species are uniquely associated with iSGS. Phylogenetic analysis of the mycobacterial virulence factor rpoB suggests that, rather than Mycobacterium tuberculosis, a variant member of the Mycobacterium tuberculosis complex or a closely related novel mycobacterium is present in iSGS specimens., Conclusion: These studies identify a novel pathogenic role for established large airway bacteria and provide new targets for future therapeutic intervention., Level of Evidence: NA Laryngoscope, 127:179-185, 2017., Competing Interests: None to disclose, (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

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., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Idiopathic subglottic stenosis (iSGS) is a rare and devastating extrathoracic obstruction involving the lower laryngeal and upper tracheal airway. It arises without known antecedent injury or associated disease process. Persistent mucosal inflammation and a localized fibrotic response are hallmarks of the disease. Despite the initial clinical description of iSGS more than 40 year ago, there have been no substantive investigations into the pathogenesis of this enigmatic and progressive airway obstruction. In these studies, we present the initial characterization of the molecular pathogenesis underlying the fibrosing phenotype of iSGS., Methods: Utilizing 20 human iSGS and healthy control specimens, we applied histologic, immunohistochemical, molecular, and immunologic techniques., Results: We demonstrate significant activation of the canonical IL-23/IL-17A pathway in the tracheal mucosa of iSGS patients, as well as identify γδ T cells as the primary cellular source of IL-17A., Conclusion: Our results suggest that aberrant mucosal immune activation is a component in of the pathogenesis of iSGS. Most critically, our work offers new targets for future therapeutic intervention., Level of Evidence: NA Laryngoscope, 126:E356-E361, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The purpose of this study was to identify prognostic factors associated with improved speech outcomes following surgical correction for velopharyngeal insufficiency (VPI) in pediatric patients with 22q11.2 deletion syndrome (22q11DS)., Methods: Eighteen patients were identified via retrospective chart review of patients with 22q11DS between 2005 and 2014. Patient characteristics, medical histories, associated comorbidities, surgical procedures, and pre- and postoperative perceptual hypernasality (subjectively rated 1-5 with 5 being the most severe) were gathered for each patient., Results: 12 patients (67%) experienced improvement in hypernasality following corrective surgery for VPI. Higher severity of hypernasality preoperatively was found to be indicative of a lower chance of improvement with VPI surgery. Of 8 patients with a preoperative hypernasality score of 5, 3 (38%) showed improvement in hypernasality postoperatively, while 9 out of 10 (90%) of patients with a preoperative hypernasality score less than 5 showed postoperative improvement. Females were also found to have worse speech outcomes compared to males., Conclusion: 22q11DS patients presenting with severely hypernasal speech preoperatively are less likely to show improvement in hypernasality following corrective surgery for VPI. Those patients with moderate hypernasality are most likely to benefit from surgery., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study was to determine the prevalence and characterize the types of hearing loss in pediatric patients with 22q11.2 deletion syndrome (22q11DS)., Methods: Fifty-eight patients were identified via retrospective chart review performed of patients with 22q11DS between 1996 and 2014. Patient demographics, pertinent family history, associated comorbidities, and degree and type of hearing loss were gathered for each patient. A literature review of the National Library of Medicine's database with a focus on hearing loss and 22q11DS was performed., Results: 22 patients (38%) were found to have hearing impairment: 68% with conductive hearing loss, 14% with sensorineural hearing loss, and 18% with mixed hearing loss. Patients with hearing loss regardless of type had a higher prevalence of developmental delay (55%), cleft palate (23%), articulation disorders (77%), and a greater need for tympanostomy tubes (73%) compared to patients with normal hearing. Temporal bone computed tomography scans of 5 patients revealed a variety of abnormalities in the middle and/or inner ears., Conclusion: Hearing impairment occurs in up to 38% of 22q11DS patients of both conductive and sensorineural types, with the conductive type being the most common. These patients have a greater need for tympanostomy tubes and a higher prevalence of developmental delay and speech articulation disorders. Early hearing screening and treatment is warranted in this population., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives/hypothesis: Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes., Study Design: Medical record abstraction., Methods: Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up., Results: Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1-99.6), Caucasian (95%, 95% CI, 92.2-98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44-1.69). The patients presented at a mean age of 50 years (95% CI, 48.8-51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi(2) = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5-99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches., Conclusion: Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care., Level of Evidence: 4. Laryngoscope, 126:1390-1396, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: (1) To describe and review a single center's pediatric endoscopic cholesteatoma experience, including surgical and audiologic outcomes. (2) To assess the most common locations of residual cholesteatoma following endoscopic removal., Study Design: Case series with chart review., Setting: Tertiary otologic referral center., Subjects: Patients <19 years of age who underwent cholesteatoma removal with either endoscopic or microscopic visualization., Methods: In a comparison of patients who underwent total endoscopic ear surgery (TEES), combined endoscopic-microscopic surgery, or microscopic surgery, analyzed outcomes included locations and incidence of recurrent and residual cholesteatoma, complications, and audiometric testing., Results: Sixty-six patients (mean age, 10.9 years; range, 4-18 years; 43.4% female) with 76 ears met inclusion criteria. The average overall follow-up was 18.8 months (range, 6.7-48.3). Forty-seven (61.8%) ears underwent microscopic removal of cholesteatoma; 29 (38.1%) ears underwent combined endoscopic-microscopic removal; and 8 (10.5%) ears underwent TEES removal. Significantly more mastoidectomies were completed in microscopic cases as compared with endoscopic cases (P = .049). Though second-look procedures occurred in 15 (51.7%) endoscopic cases and 10 (21.3%) microscopic cases (P = .006), the rate of residual disease was 20.0% and 40.0% in endoscopic and microscopic cases, respectively (P = .38). When controlling for preoperative hearing, only the air-bone gap for TEES demonstrated significant improvement (P = .009). No complications were noted., Conclusion: The present report describes our experience with pediatric endoscopic cholesteatoma surgery, demonstrating similar hearing outcomes, rates of recurrence and residual disease, and complication rates as compared with traditional microscopic techniques., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Importance: Patients who undergo open airway reconstruction procedures are likely to experience some degree of postoperative dysphagia symptoms and delayed return to oral intake., Objective: To review the duration of postoperative dysphagia symptoms and outcomes in a group of adult patients., Design, Setting, and Participants: Retrospective review of the medical records of adult patients undergoing laryngotracheoplasty, posterior cricoid split laryngoplasty, tracheal resection, and cricotracheal resection in a tertiary hospital between July 2009 and September 2014., Exposures: Laryngotracheoplasty, posterior cricoid split laryngoplasty, tracheal resection, and cricotracheal resection., Main Outcomes and Measures: Demographic characteristics, etiology of airway stenosis, surgical procedure, stent type, and duration of dysphagia symptoms., Results: Thirty-eight patients (14 men, 24 women; mean [SD; range] age, 48 [14.4; 20-80] years) fitting the inclusion criteria were identified. Twenty-four (63%) patients had laryngotracheal stenosis secondary to prolonged intubation, with 3 (8%), 5 (13%), and 6 (16%) cases being due to autoimmune, idiopathic, or other etiology, respectively. Twenty-five (66%) patients underwent tracheal or cricotracheal resection, and 13 (34%) underwent laryngotracheoplasty or posterior cricoid split laryngoplasty. Of the 17 patients with stents placed, 6 (35%) patients had a suprastomal stent sewn at the top with a polypropylene suture using a horizontal mattress technique, 6 (35%) patients had a suprastomal stent capped with an extended Silastic thoracic T-tube segment, and 5 (29%) patients had either a T-tube or hood bronchial stent. Eight of 17 patients used a nasogastric feeding tube while the stent was in place (up to 5 weeks). All patients returned to their preoperative diet. The mean (SD) duration of dysphagia symptoms in all patients (both those without a stent and following stent removal) was 8 (27.2) days (median, 1.5 days). The mean (SD) duration of dysphagia symptoms in patients who did not have a stent placed was 4.8 (5.3) days (median, 4 days)., Conclusions and Relevance: In this study of adults who underwent open airway reconstruction, all returned to their preoperative diet, but those without stents had a shorter duration of dysphagia symptoms than those with stents. Approximately half as many patients with a stent had a prolonged course with dysphagia symptoms compared with those without a stent.

Introduction: Bronchoalveolar lavage (BAL)-nucleated cell counts and the lipid-laden alveolar macrophage index (LLMI) have been investigated in predicting chronic aspiration as well as reflux esophagitis with variable results. To date, BAL neutrophil percentages and the LLMI have not been described in patients with eosinophilic esophagitis (EoE)., Objectives: To evaluate BAL neutrophil percentages and LLMI levels in patients with EoE and compare these levels in patients with aerodigestive concerns without biopsy-proven EoE., Methods: Retrospective review of patients referred to an aerodigestive evaluation team for overlapping aerodigestive complaints (dysphagia, stridor, subglottic stenosis, feeding intolerance, and chronic aspiration). Patients underwent microlaryngoscopy, esophagogastroduodenoscopy with biopsy, and bronchoscopy and BAL were indicated by symptoms. BAL neutrophil percentages, LLMI levels, esophageal biopsy results, and esophageal dual-probe pH/impedance were recorded and compared., Results: Fifty-one patients were included in the study that underwent comprehensive workup for aerodigestive complaints. Patients were subdivided into two groups: (1) negative esophageal biopsy (for EoE) and (2) positive esophageal biopsy. There were no significant differences between the groups in percentage neutrophils (p=0.55, unpaired t-test) or LLMI levels (p=0.14, unpaired t-test)., Discussion: BAL neutrophil percentages and the LLMI are unreliable in identifying patients with silent aspiration and gastroesophageal reflux. To date, there is no report of the utility of BAL neutrophil percentages and the LLMI in diagnosing patients with EoE. Our series indicates no correlation in neutrophil percentages or LLMI in patients with EoE versus patients without EoE that are referred to tertiary centers with aerodigestive concerns., Conclusion: BAL neutrophil percentages and LLMI levels are not a reliable predictor of eosinophilic esophagitis in children with complex aerodigestive concerns. Esophageal biopsy remains the gold standard for diagnosis of EoE and the challenge remains to find other markers that raise suspicion for EoE for the non-gastroenterologist or that stage the extent of disease beyond the esophagus., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: To describe the presence of laryngeal eosinophils and associated symptomatology in patients with aerodigestive dysfunction., Study Design: Case series with chart review., Setting: Single tertiary pediatric referral center., Subjects: Eighty-one consecutive pediatric patients referred to a multidisciplinary aerodigestive clinic with upper airway concerns., Methods: Microlaryngoscopy and posterior arytenoid biopsy, flexible bronchoscopy, esophagogastroduodenoscopy and esophageal biopsy, and impedance probe testing were performed as indicated by clinical symptoms. Positive versus negative posterior arytenoid biopsy for eosinophils and the presence or absence of concomitant histopathological laryngitis and/or esophagitis were measured., Results: Nine of 81 (11%) patients had positive laryngeal biopsy for eosinophils (range, 1-29 eosinophils/high-powered field [HPF]). Three of these 9 patients also had concurrent biopsy-proven eosinophilic esophagitis, while 8 of 81 total patients had biopsy-proven eosinophilic esophagitis. The frequency of biopsy-proven eosinophilic esophagitis was higher in patients with posterior arytenoid eosinophils versus patients without laryngeal eosinophils (33% versus 6.9%, P = .0408)., Conclusions: Eosinophilic inflammation in the larynx has not been described in children with complex aerodigestive complaints. Posterior arytenoid eosinophils may serve as a marker of chronic laryngeal inflammation in children with aerodigestive dysfunction, although their exact role in this inflammation remains unclear. In our population, >15 eosinophils/HPF within posterior arytenoid biopsies was associated with concomitant eosinophilic esophagitis., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Objective: To determine the optimum positioning of a 70-degree telescope to provide a maximum view of the palate and posterior pharynx for observers while minimally obstructing the direct view of a surgeon., Design: Simulator testing of clinical protocol., Setting: Simulation center of an academic tertiary care children's hospital., Interventions: The palate and pharynx of an infant airway mannequin was exposed with a Dingman mouthgag. A 4 mm, 70-degree endoscope was secured to the Mayo stand to provide a projected image of the simulated operative procedure. Various positions of the 70-degree telescope were photodocumented by manipulating the angle of the scope, the extension past the lower lip, and the distance of the scope tip away from the midline. Using a 4-point Likert scale, three surgeons rated the randomized photos from both the direct operative view and the projected endoscopic view., Results: Average rating for the adequacy of the view for pharyngeal surgery was 2.4/4.0 and for palate surgery was 3.1/4.0 (p=.001). Only 4 of 22 scope positions were rated as minimally obstructive to direct view by all three surgeons. Only 1 position--scope parallel and just lateral to the tongue blade--was rated as minimally obstructive and adequate for both pharyngeal and palatal surgery by all three surgeons., Conclusions: In training centers, a 70-degree telescope attached to a Mayo stand may be useful for teaching and assessing cleft palate and pharyngoplasty surgery, while providing minimal obstruction to direct view by the surgeon., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Prader-Willi syndrome (PWS) is a rare genetic disorder with an incidence rate of 1 in 10,000-30,000. Patients with PWS typically have symptoms related to hypotonia, obesity, and hypothalamic dysfunction. A high rate of obstructive sleep apnea (OSA) is found among this population of patients. Adenotonsillectomy has been advocated as a first line approach for treatment of OSA in patients with PWS. Velopharyngeal dysfunction (VPD) is a known complication of adenotonsillectomy. VPD can also be present in patients with global hypotonia, such as those with PWS. The objective of this study is to review the occurrence of VPD in patients with PWS after adenotonsillectomy for OSA., Methods: A retrospective review was performed of all patients with PWS and OSA from a tertiary pediatric hospital between the years of 2002 and 2012. Pre- and post-operative sleep studies and sleep disordered breathing symptoms, post-operative VPD assessment by the speech-language pathologist (SLP), and VPD treatments were evaluated., Results: Eleven patients (five males and six females), fitting the inclusion criteria, were identified. The age of the patient at the initial otolaryngologic evaluation ranged from 2 to 9 years. All patients underwent adenotonsillectomy for sleep disordered breathing. Four patients were diagnosed with post-operative hypernasality after assessment by a speech-language pathologist. The hypernasality ranged from mild to moderately severe. Of the four patients with hypernasality, two were found to have structural issues requiring surgery (pharyngeal flap). Both of the surgical patients experienced significant improvement in their VPD after surgery. The remaining two patients were found to have articulation error patterns that were considered more developmental in nature and both responded to speech therapy. All patients, except one, had improvement in their polysomnogram or sleep symptoms after adenotonsillectomy. However, three patients continue to require continuous positive airway pressure at night., Conclusion: Velopharyngeal dysfunction may occur after adenotonsillectomy in patients with Prader-Willi Syndrome. Families should be counseled of this risk and the potential need for operative intervention to correct it., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Surgical treatment of velopharyngeal insufficiency (VPI) in 22q11.2 deletion syndrome is often warranted. In this patient population, VPI is characterized by poor palatal elevation and muscular hypotonia with an intact palate. We hypothesize that 22q11.2 deletion patients are at greater risk of obstructive sleep apnea (OSA) after surgical correction of VPI, due, in part, to their functional hypotonia, large velopharyngeal gap size, and the need to surgically obstruct the velopharynx., Methods: We performed a retrospective analysis of patients with 22q11.2 deletion syndrome treated at a tertiary pediatric hospital between the years of 2002 and 2012. The incidence of VPI, need for surgery, post-operative polysomnogram, post-operative VPI assessment, and OSA treatments were evaluated., Results: Forty-three patients (18 males, 25 females, ages 1-14 years) fitting the inclusion criteria were identified. Twenty-eight patients were evaluated by speech pathology due to hypernasality. Twenty-one patients had insufficient velopharyngeal function and required surgery. Fifteen underwent pharyngeal flap surgery, three underwent sphincter pharyngoplasty, two underwent Furlow palatoplasty, and one underwent combined sphincter pharyngoplasty with Furlow palatoplasty. Of these, eight had post-operative snoring. Six of these underwent polysomnography (five underwent pharyngeal flap surgeries and one underwent sphincter pharyngoplasty). Four patients were found to have OSA based on the results of the polysomnography (average apnea/hypopnea index of 4.9 events/h, median = 5.1, SD = 2.1). Two required continuous positive airway pressure (CPAP) due to moderate OSA., Conclusion: Surgery is often necessary to correct VPI in patients with 22q11.2 deletion syndrome. Monitoring for OSA should be considered after surgical correction of VPI due to a high occurrence in this population. Furthermore, families should be counseled of the risk of OSA after surgery and the potential need for treatment with CPAP.

Objectives: In this study we determine the subjective and objective outcomes of pediatric patients with refractory OSA undergoing drug-induced sleep endoscopy (DISE)-directed surgical treatment., Methods: 31 consecutive children with OSA following TA underwent DISE. 26 completed DISE-directed operative management of the level(s) of ongoing upper airway obstruction. Pre- and postoperative OSA were assessed through a detailed history (of nighttime symptoms (NS) and daytime symptoms (DS)), physical examination, and polysomnography., Results: Age ranged 5-18 years (mean 9.7 ± 3.4). Fourteen of 26 had trisomy 21 (51%). Operations were performed in the following frequencies: lingual tonsillectomy (LT) (22), midline posterior glossectomy (MPG) (16), revision adenoidectomy (11), inferior turbinate submucosal resection (7), uvulopalatoplasty (2), and supraglottoplasty (2). Overall, 92% reported subjective improvement. NS improved from 5.8 ± 2.9 preoperatively to 2.1 ± 2.5 postoperatively (p<0.05), while DS improved from 2.1 ± 1.3 preoperatively to 0.6 ± 1.1 postoperatively (p<0.05). Seventeen patients completed preoperative polysomnography, while only 11 of them also completed postoperative polysomnography. Mean OAHI fell from 7.0 (±5.8) events/hr to 3.6 (±1.8) events/hr (t-test, p=0.09)., Conclusions: Individualized, multilevel, DISE-directed operative therapy was associated with substantial improvement in subjective measures of sleep., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)