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Objective: To estimate the incidence and identify predictors of pediatric tracheostomy patients who transition into adulthood with a tracheostomy., Methods: We conducted a retrospective analysis of pediatric tracheostomy patients treated at a single tertiary care pediatric hospital between 2009 and 2022. Patient demographics, comorbidities, tracheostomy outcomes, including decannulation and mortality rates, and the status of those alive with a tracheostomy at adulthood were compared., Results: Of the 663 children who underwent a tracheostomy, 103 (15.5%) would have surpassed 18 years by September 1, 2023. Detailed breakdown: 26 (25%) were alive with a tracheostomy, 35 (34%) had been decannulated, 25 (24%) had passed away, and 17 (16.5%) were lost to follow-up. Patients who retained their tracheostomies into adulthood were more likely to be older at tracheostomy placement (mean age 14.3 vs. 1.7 years, p < 0.001), Hispanic (43.7% vs. 30.5%, p = 0.003), not ventilated at initial discharge (41% vs. 24%, p < 0.001), and have severe neurocognitive disabilities (72% vs. 53%, p < 0.001). Logistic regression identified older age at tracheostomy placement (OR = 1.35, 95% CI [1.24-1.48]) and severe neurocognitive disability (OR = 6.20, 95% CI [2.13-18.09]) as significant predictors of maintaining a tracheostomy into adulthood., Conclusions: Older age at tracheostomy placement and severe neurocognitive disabilities significantly predict the transition of pediatric tracheostomy patients to adult care with their tracheostomies. These findings highlight the need for specialized transition programs tailored to the needs of this unique population., Level of Evidence: IV Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: The objective of this study is to determine the time to ventilator liberation and decannulation after tracheostomy placement in children with bronchopulmonary dysplasia (BPD) and pulmonary hypertension., Methods: A prospective cohort study included all children (<18 years old) who underwent tracheostomy between 2015 and 2021 with or without a diagnosis of BPD. The primary outcomes were time to ventilator liberation, tracheostomy decannulation, or death with tracheostomy in place., Results: A total of 303 children met inclusion with a median (interquartile range [IQR]) age at tracheostomy of 6.9 (IQR: 4.0-49.5) months. A diagnosis of BPD was made for 42% (N = 127) and this group was younger (5.1 vs. 24.5 months, p < .001) and more often had pulmonary hypertension (68% vs. 24%, p < .001). Children with BPD spent a median of 2.9 years (IQR: 1.6-4.0) on ventilation compared to 1.9 years (IQR: 0.9-3.7) for children without BPD (p = .009). The time to decannulation was greater among children with BPD (3.4 vs. 1.8 years, p < .001). However, unadjusted estimates of ventilator liberation (hazard ratio [HR]: 1.05, 95% confidence interval [95% CI]: 0.77-1.44) and decannulation (HR: 1.11, 95% CI: 0.74-1.66) over time were not prolonged by BPD. Pulmonary hypertension was associated with shorter time to death (adjusted HR [aHR] = 1.99, 95% CI: 1.17-3.38, p = .01), while BPD was associated with longer time to death (aHR: 0.38, 95% CI: 0.22-0.67, p = .001)., Conclusion: BPD is associated with increased ventilation and duration of tracheostomy but over time many children with BPD will wean off the ventilator and be decannulated. Pulmonary hypertension and not BPD is associated with increased time to death after tracheostomy., (© 2024 Wiley Periodicals LLC.)

Objective: To determine survival among critically ill children when caregivers decline tracheostomy placement., Study Design: Retrospective cohort., Methods: All children (<18 years) obtaining a pre-tracheostomy consultation at a tertiary children's hospital between 2016 and 2021 were included. Comorbidities and mortality were compared between children of caregivers that declined or agreed to tracheostomy., Results: Tracheostomy was declined for 58 children but was placed for 203 children. After consultation, mortality was 52% (30/58) when declining and 21% (42/230) when agreeing to tracheostomy (p < 0.001) at a mean of 10.7 months (standard deviation [SD]: 16) and 18.1 months (SD: 17.1), respectively (p = 0.07). For those declining, 31% (18/58) died during the hospitalization within a mean of 1.2 months (SD: 1.4) while 21% (12/58) died at a mean of 23.6 months (SD: 17.5) after discharge. Among children of caregivers declining tracheostomy, older age (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.74-0.97, p = 0.01) and chronic lung disease (OR: 0.18, 95% CI: 0.04-0.82, P = .03) were associated with lower odds of mortality but sepsis (OR: 9.62, 95% CI: 1.161-57.43, p = 0.01) and intubation (OR: 4.98, 95% CI: 1.24-20.08, p = 0.02) were associated with higher odds of mortality. Median survival after declining tracheostomy was 31.9 months (interquartile range [IQR]: 2.0-50.7) and declining placement was associated with increased mortality risk (hazard ratio [HR]: 4.04, 95% CI: 2.49-6.55, p < 0.001)., Conclusion: When caregivers declined tracheostomy placement, less than half of critically ill children in this cohort survived with younger age, sepsis, and intubation associated with higher mortality. This information offers valuable insight for families weighing decisions pertaining to pediatric tracheostomy placement., Level of Evidence: 3 Laryngoscope, 133:3602-3607, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To estimate the 1-, 5-, and 10-year survival and decannulation rates of children with a tracheostomy., Study Design: Ambidirectional cohort., Setting: Tertiary children's hospital., Methods: All patients (<18 years) that had a tracheostomy placed between 2009 and 2020 were included and followed until 21 years of age, decannulation, or death. The Kaplan-Meier method estimated cumulative probabilities of death and decannulation., Results: A total of 551 children underwent tracheostomy at a median age of 7.2 months (interquartile range [IQR]: 3.8-49.2). Children were followed for a median of 2.1 years (IQR: 0.7-4.2, range 0-11.5). The cumulative probability of mortality at 1 year was 11.9% (95% confidence interval [CI]: 9.4-15.1), at 5 years was 26.1% (95% CI: 21.6-31.3), and at 10 years was 41.6% (95% CI: 32.7-51.8). Ventilator dependence at index discharge (hazard ratio [HR]: 2.04, 95% CI: 1.10-3.81, p = .03), severe neurologic disability (HR: 2.79, 95% CI: 1.61-4.84, p < .001), and cardiac disease (HR: 1.69, 95% CI: 1.08-2.65, p = .02) were associated with time to death. The cumulative probability of decannulation was 10.4% (95% CI: 8.0-13.5), 44.9% (95% CI: 39.4-50.9), and 54.1% (95% CI: 47.4-61.1) at 1 year, 5 years, and 10 years, respectively. Ventilator dependence (HR: 0.43, 95% CI: 0.31-0.60, p < .001), severe neurologic disability (HR: 0.20, 95% CI: 0.14-0.30, p < .001), and tracheostomy indicated for respiratory failure (HR: 0.68, 95% CI: 0.48-0.96, p = .03) correlated with longer decannulation times., Conclusion: After tracheostomy, estimated mortality approaches 42% by 10 years and decannulation approaches 54%. Children with ventilator support at discharge and severe neurological disability had poorer long-term survival and longer times to decannulation., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Introduction: In pediatric tonsillectomy management, the consistent tracking of surgical outcomes and adherence to guidelines are vital. This study explores how a surgical dashboard can serve as a tool in research analysis, translating AAO-HNSF guidelines into measurable performance improvements., Methods: Using a prospective registry from three pediatric hospitals, a Tableau dashboard was constructed to graphically visualize key demographic and postoperative outcomes (including intensive care unit [ICU] utilization, 30-day emergency department (ED) visits, and postoperative bleed rates) in children undergoing tonsillectomy from 2020 to 2024. From the dashboard data, a retrospective cohort study analyzing 6767 tonsillectomies was conducted from January 2, 2020, to June 20, 2023. Patients were categorized into low-risk, OSA-only (by ICD-10 codes), and high-risk groups based on comorbidities. Logistic regression identified factors influencing ED revisits and unplanned nursing calls. Three quality initiatives were assessed: preoperative school absence notes, perioperative dexamethasone recording, and post-tonsillectomy parental education., Results: A total of 2122 (31%) were low-risk, 2648 (39%) were OSA-only, and 1997 (30%) high risk. Risk factors that increased the likelihood of ED visits were high-risk comorbidities (OR = 1.46; 95% CI = 1.24-1.74; p  < 0.001) and older age (OR = 1.05; 95% CI = 1.03-1.08; p  < 0.001). Risk factors that increased the likelihood of an unplanned nursing communication were high-risk comorbidities (OR = 1.53; 95% CI = 1.34-1.75; p  < 0.001), older age (OR = 1.03, 95% CI = 1.01-1.04; p  = 0.001), and Medicaid insurance (OR = 1.25; 95% CI = 1.09-1.43; p  = 0.002). Postoperative bleed control was generally comparable between the groups, at 2.8% (low risk), 2.7% (OSA), 3.2 (high risk) ( p  = 0.651)., Conclusion: The dashboard aided in data collection, data visualization, and data analysis of quality improvement initiatives, effectively translating guidelines into tangible measures to enhance care., Level of Evidence: NA., Competing Interests: The authors have no other funding or financial relationships to disclose., (© 2024 The Author(s). Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objectives: To determine whether long-term outcomes after pediatric tracheostomy are impacted by neighborhood socioeconomic disadvantage., Methods: A prospective cohort of children with tracheostomies was followed at an academic pediatric hospital between 2015 and 2020. Patients were grouped into low or high socioeconomic disadvantage using their neighborhood area deprivation index (ADI). Survival and logistic regression analyses determined the relationship between ADI group, decannulation, and mortality., Results: A total of 260 children were included with a median age at tracheostomy of 6.6 months (interquartile range [IQR], 3.9-42.3). The cohort was 53% male (N = 138), 55% White race (N = 143), and 35% Black or African American (N = 90). Tracheostomy was most frequently indicated for respiratory failure (N = 189, 73%). High neighborhood socioeconomic disadvantage was noted for 66% of children (N = 172) and 61% (N = 158) had severe neurocognitive disability. ADI was not associated with time to decannulation (HR = 0.90, 95% confidence interval [95% CI]: 0.53-1.53) or time to death (HR = 0.92, 95% CI: 0.49-1.72)., Conclusions: Neighborhood socioeconomic disadvantage was not associated with decannulation or mortality among children with a tracheostomy. These findings suggest that long-term outcomes after pediatric tracheostomy are less dependent on socioeconomic factors in an individual community., Level of Evidence: 3 Laryngoscope, 134:2415-2421, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Identify patient characteristics and polysomnogram (PSG) parameters associated with postoperative respiratory complications after adenotonsillectomy (AT) among children with high-risk obstructive sleep apnea (OSA)., Study Design: Case series with chart review., Setting: Tertiary care children's hospital., Methods: Pediatric patients (<18 years) with high-risk OSA (any 1 of: apnea-hypopnea index [AHI] >30, O 2 nadir <80% and peak CO 2  >60 mm Hg) on overnight PSG from 2019 to 2021 were included. Primary outcomes were major respiratory intervention during the postoperative admission, prolonged hospitalization, and intensive care unit (ICU) stay., Results: A total of 307 patients met inclusion criteria. Median age was 6.5 years and 63% were male. Twenty-five (8.1%) required major respiratory intervention and 29 (9.7%) required ICU admission after AT. Major interventions and ICU admissions were significantly associated with neuromuscular disease (P < .01), higher obstructive apnea-hypopnea index (oAHI), higher CO 2 peak, and lower O 2 nadir. Prolonged admission had similar findings except oAHI was not significantly associated. Younger children were significant more likely to require ICU admission or prolonged admission., Conclusion: Increased oAHI and worsening O 2 and CO 2 parameters on preoperative PSG were associated with postoperative respiratory complications in children with high-risk OSA. Children with neuromuscular disease and age 0 to 2 had higher risk of ICU stay and prolonged hospitalization. Clinicians should recognize the importance of parameters beyond oAHI when anticipating postoperative monitoring., (© 2024 The Author(s). Otolaryngology–Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objectives: To determine the incidence of subglottic stenosis (SGS) in children after tracheostomy and identify risk factors for development., Study Design: Retrospective cohort., Methods: All patients (<18 years) undergoing tracheostomy at a tertiary children's hospital between 2015 and 2020 were included. Patients with a direct laryngoscopy (DL) concurrent with tracheostomy and a subsequent DL were included. Medical records, including operative reports, were reviewed to identify subglottic stenosis and associated risk factors., Results: A total of 140 patients were included with mean age at tracheostomy of 2.4 years (standard deviation [SD]: 4.3) (median: 0.5 years, interquartile range [IQR]: 0.3-1.5 years) and gestational age of 33.8 weeks (SD: 5.9) (median: 36 weeks, IQR: 28-39 weeks). At initial DL, 24% (N = 34) had subglottic injury and 26% (N = 37) developed SGS. The incidence of SGS after tracheostomy was 11.5 cases per 100 patients per year. At tracheostomy, lower birth weight (1.8 vs. 2.3 kg, p = 0.005), shorter gestational age (31.8 vs. 34.6 weeks, p = 0.01), younger age (0.8 vs. 2.9 years, p = 0.01), lower weight (5.8 vs. 14.7 kg, p = 0.01), and subglottic injury (44% vs. 21%, p = 0.01) were associated with the development of SGS. Multivariable logistic regression analysis associated birth weight (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.31-0.75, p = 0.001) and early subglottic injury (OR: 3.22, 95% CI: 1.31-7.88, p = 0.01) with SGS development., Conclusions: The incidence of SGS after pediatric tracheostomy is estimated at 11.5 cases per 100 patients per year. Low birth weight and subglottic injury at the time of tracheostomy were associated with SGS in this vulnerable population of children., Level of Evidence: 3 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy., Methods: A prospective cohort of children (<18 years) with a tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits)., Results: A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory-related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18-3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35-5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47-10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy-related complications, which accounted for 4.8% of all encounters. A sub-analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure., Conclusion: Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy-related visits are uncommon, strategies to anticipate and decrease respiratory-related admissions may have the most impact., Level of Evidence: 3 Laryngoscope, 133:2018-2024, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine the incidence of tracheostomy accidental decannulations (AD) among pediatric inpatients and identify risks for these events., Study Design: Prospective cohort., Methods: All tracheostomy patients (≤18 years) admitted at a tertiary children's hospital between August 2018 and April 2021 were included. AD were recorded and patient harm was classified as no harm/minor, moderate, or severe. Monthly AD incidence was described as events per 1000 tracheostomy-days., Results: One-hundred seventeen AD occurred among 67 children with 33% (22/67) experiencing multiple events (median: 2.5 events, range: 2-10). Mean age at AD was 4.7 years (SD: 4.4). AD resulted from patient movement (32%, 37/117), performing tracheostomy care (27%, 31/117), repositioning or transporting (15%, 17/117), or unclear reasons (27%, 32/117). A parent or guardian was involved in 28% (33/117) of events. Nearly all AD resulted in no more than minor harm (84%, 98/117) but moderate (12%, 14/117) and severe (4%, 5/117) events did occur. There were no deaths. Tracheostomy care or repositioning were frequently responsible in acute versus subacute events (48% vs. 26%, p = 0.04). Mean monthly AD incidence was 4.7 events per 1000 tracheostomy-days (95% CI: 3.7-5.8) and after implementation of safety initiatives, the mean rate decreased from 5.9 events (95% CI: 4.2-7.7) to 3.7 events (95% CI: 2.5-5.0) per 1000 tracheostomy-days (p = 0.04)., Conclusions: AD in children occur at nearly 5 events per 1000 tracheostomy-days and often result in minimal harm. Quality initiatives targeting patient movement, provider education, and tracheostomy care might reduce the frequency of these complications., Level of Evidence: 3 Laryngoscope, 133:963-969, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To determine whether injection laryngoplasty (IL) resolves thin liquid aspiration among children with unilateral vocal cord paralysis (UVCP) after cardiac surgery., Study Design: Retrospective case-control., Setting: Tertiary children's hospital., Methods: Consecutive children (<5 years) between 2012 and 2022 with UVCP after cardiac surgery were included. Resolution of thin liquid aspiration after IL versus observation was determined for children obtaining videofluoroscopic swallow studies (VFSS)., Results: A total of 32 children with left UVCP after cardiac surgery met inclusion. Initial surgeries were N = 9 (28%) patent ductus arteriosus ligations, N = 7 (22%) aortic arch surgeries, N = 9 (28%) surgeries for hypoplastic left heart syndrome, and N = 7 (22%) other cardiac surgeries. The mean age at initial surgery was 1.8 months (SD: 3.7). All children had a VFSS obtained after surgery that confirmed aspiration. There were 17 children that obtained an IL at 33.6 months (SD: 20.9) after cardiac surgery and 15 children observed without IL procedure. No surgical complications after IL were noted. The rate of aspiration resolution based on postoperative VFSS was N = 14 (82%) for the IL group and N = 9 (60%) for the control group P  = .24. Documented VFSS aspiration resolution after cardiac surgery occurred by 9.6 months (SD: 10.0) in the observation group and 47.4 months (SD: 24.1) in the IL group ( P  < .001)., Conclusion: IL can help treat aspiration in children with UVCP after cardiac surgery but the benefit beyond observation remains unclear. Future studies should continue to explore the utility for IL in managing dysphagia in this pediatric population., Competing Interests: None., (© 2024 The Authors. OTO Open published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objectives: To characterize the cause of death among children with a tracheostomy., Study Design: Prospective cohort., Methods: All pediatric patients (<18 years) who had a tracheostomy placed at a tertiary care institution between 2015 and 2020 were included. The location and cause of death were recorded along with patient demographics and age., Results: A total of 271 tracheostomies were placed with 46 mortalities reviewed for a mortality rate of 16.8%. Mean age at placement was 1.7 years (SD: 3.4) and mean age at death was 2.9 years (SD: 3.5). Most tracheostomies were placed for respiratory failure (N = 33, 72%). The mean time to death after tracheostomy was 1.2 years (SD: 1.2) and 28% (N = 13) occurred during the same admission as placement. Mean time to death after hospital discharge was 1.3 years (SD: 1.3). Etiology of death was respiratory failure (33%, N = 15), cardiopulmonary arrest (15%, N = 7), unknown (43%, N = 20), or secondary to a tracheostomy-related complication for 9% (N = 4). Location of death was in intensive care units for 41% (N = 19) and 30% died at home (N = 14). Comfort care measures were taken for 37% (N = 17). Severe neurological disability (HR: 4.06, p = 0.003, 95% CI: 1.59-10.34) and congenital heart disease (HR: 2.36, p = 0.009, 95% CI: 1.24-4.48) correlated with time to death on Cox proportional hazard modeling., Conclusions: Nearly one-third of children with a tracheostomy who expire will do so during the same admission as tracheostomy placement. Although progression of underlying disease will lead to most deaths, 9% will be a result of a tracheostomy-related complication, which represents a meaningful target for quality improvement initiatives., Level of Evidence: 3 Laryngoscope, 133:403-409, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence., Study Design: Prospective cohort., Methods: All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation., Results: A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p = 0.049) with failure to spontaneously close., Conclusions: Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients., Level of Evidence: 3 Laryngoscope, 133:417-422, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP., Methods: A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal., Results: Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63)., Conclusions: Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success., Level of Evidence: 4 Laryngoscope, 134:963-967, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: This study aimed to determine the direct costs of pediatric tracheostomy care within a health care system., Study Design: Prospective analysis., Setting: Academic children's hospital., Methods: Costs associated with caring for pediatric tracheostomy patients under 18 years were analyzed between 2015 and 2021. Direct costs were calculated using the Medicare/Medicaid charges-to-costs ratio for various visit types. Costs were estimated using generalized linear equations, accounting for confounders., Results: A total of 297 children underwent tracheostomy at a median age of 0.94 years. The median follow-up was 2.5 years, resulting in 13,966 visits (mean = 41). The total cost was $321 million. The initial admission accounted for 72% ($231 million) of costs while other inpatient admissions added 24% ($78 million). Emergency department, observation, and outpatient visits comprised 4% of costs. The length of stay (LOS) was the primary cost driver for inpatient visits. Each additional hospital day increased costs by roughly $1195, and each extra admission added about $130,223 after adjusting for confounders. Respiratory failure and infections were the primary reasons for 67% of subsequent admissions., Conclusion: Pediatric tracheostomy care generated over $300 million in direct costs over 5 years. Inpatient stays constituted 96% of these costs, with the LOS being a major factor. To reduce direct health expenditures for these patients, the focus should be on minimizing admissions., Competing Interests: None., (© 2024 The Authors. OTO Open published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Pediatric tracheostomy for COVID-19 infections is uncommon and requires age-appropriate adaptations. This case adds to a limited body of literature related to tracheostomy placement and management in an adolescent. Thoughtful planning and communication by a dedicated tracheostomy team was crucial in obtaining a successful outcome., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To determine the incidence of A-frame deformity and suprastomal collapse after pediatric tracheostomy., Study Design: Retrospective cohort., Methods: All patients (<18 years) that had a tracheostomy placed at a tertiary institution between 2015 and 2020 were included. Children without a surveillance bronchoscopy at least 6 months after tracheostomy were excluded. Operative reports identified tracheal A-frame deformity or suprastomal collapse., Results: A total of 175 children met inclusion with 18% ( N  = 32) developing A-frame deformity within a mean of 35.8 months (SD: 19.4) after tracheostomy. For 18 children (18/32, 56%), A-frame developed within a mean of 11.3 months (SD: 15.7) after decannulation. There were 96 children developing suprastomal collapse (55%) by a mean of 17.7 months (SD: 14.2) after tracheostomy. All suprastomal collapse was identified prior to decannulation. Older age at tracheostomy was associated with a lower likelihood of collapse (OR: 0.92, 95% CI: 0.86-0.99, p  = .03). The estimated 5-year incidence of A-frame deformity after tracheostomy was 32.8% (95% CI: 23.0-45.3) and the 3-year incidence after decannulation was 36.1% (95% CI: 24.0-51.8). Highly complex children had an earlier time to A-frame development ( p  = .04). At 5 years after tracheostomy, the estimated rate of suprastomal collapse was 73.7% (95% CI: 63.8-82.8)., Conclusions: Tracheal A-frame deformity is estimated to occur in 36% of children within 3 years after tracheostomy decannulation. Suprastomal collapse, which approaches 74% at 5 years after tracheostomy, is more common when tracheostomy is placed at a younger age. Surgeons caring for tracheostomy-dependent children should recognize acquired airway obstruction and appropriately monitor these outcomes., Level of Evidence: 3., Competing Interests: Romaine F. Johnson is editor‐in‐chief of Laryngoscope Investigative Otolaryngology. He was not involved in the editorial evaluation of or decision to accept this article for publication. All other authors have no disclosures., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Introduction  Deep interarytenoid groove (DIG) may cause swallowing dysfunction in children; however, the management of DIG has not been established. Objective  We evaluated the subjective and objective outcomes of interarytenoid augmentation with injection in children with DIG. Methods  Consecutive children under 18 years of age who underwent injection laryngoplasty for DIG were reviewed. Data pertaining to demographics, past medical history, past surgical history, and results of pre and postoperative video fluoroscopic swallow study (VFSS) were obtained. The primary outcome measure was the presence of thin liquid aspiration or penetration on postoperative VFSS. The secondary outcome measure was caregiver-reported improvement of symptoms. Results  Twenty-seven patients had VFSS before and after interarytenoid augmentation with injection (IA). Twenty (70%) had thin liquid penetration and 12 (44%) had thin liquid aspiration before the IA. Thin liquid aspiration resolved in 9 children (45%) and persisted in 11 (55%). Of the 12 children who had thin liquid aspiration prior to IA, 6 (50%) had resolution of thin liquid aspiration after IA. Conclusions  Injection laryngoplasty is a safe tool to improve swallowing function in children with DIG. Further studies are needed to assess the long-term outcomes of IA and identify predictors of successful IA in children with DIG., Competing Interests: Conflict of Interests The authors have no conflict of interests to disclose., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ( https://creativecommons.org/licenses/by/4.0/ ).)

Objective: Pediatric tracheostomy patients disproportionately experience hearing loss and are at risk for delayed identification due to their medical complexity. Nonetheless, protocols to monitor hearing in these children are lacking. This quality improvement (QI) initiative aimed to increase the rates of audiometric testing within 12 months of pediatric tracheostomy placement., Methods: A retrospective cohort study included children who underwent tracheostomy under 18 months of age between 2012 and 2020. Rates of audiometric assessments before and after QI project implementation (2015) were reported along with hearing loss characteristics., Results: A total of 253 children met inclusion. Before project initiation (2012-2014), 32% of children (28/87) obtained audiometric testing within 12 months after tracheostomy. During the first three years of implementation (2015-2017), 39% (38/97) were tested, while 55% (38/69) were tested during the subsequent three years (2018-2020) (P = .01). A passing newborn hearing screen was obtained for 70% of the 210 children with a recorded result, and 198 survived at least 12 months to receive audiometric testing at a median of 11.3 months (IQR: 6.2-22.8) after tracheostomy. Hearing loss was identified for 44% of children (N = 88), of which 42 children initially passed newborn hearing screen. A second assessment was obtained for 62% of children (123/198) at a median of 11.3 months (IQR: 4.5-17.5) after the initial test. In this group, 23% with a previously normal audiometric exam were found to have hearing loss (15/66)., Conclusions: QI initiatives designed to monitor hearing loss in children with a tracheostomy can result in improved rates of audiometric assessments. This population has disproportionately high rates of hearing loss, including delayed onset hearing loss making audiometric protocols valuable to address speech and language development delays., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: To estimate the incidence of inpatient and ambulatory pediatric tonsillectomies in the United States in 2019., Study Design: Cross-sectional analysis., Setting: Healthcare Cost and Utilization Project databases., Methods: We determined national incidences of hospital-based ambulatory procedures, inpatient admissions, and readmissions among pediatric tonsillectomy patients, ages 0 to 20 years, using the Kids Inpatient Database, Nationwide Ambulatory Surgery Sample, and Nationwide Readmission Database. We described the demographics, commonly associated conditions, complications, and predictors of readmission., Results: An estimated 559,900 ambulatory and 7100 inpatient tonsillectomies were performed in 2019. Among inpatients, the majority were male (59%) and the largest ethnic group was white (37%). Adenotonsillar hypertrophy (ATH), 79%, and obstructive sleep apnea (OSA), 74%, were the most frequent diagnosis and Medicaid (61%) was the most frequent primary payer. The majority of ambulatory tonsillectomy patients were female (52%) and white (65%); ATH, OSA, and Medicaid accounted for 62%, 29%, and 45% of cases, respectively, (all p < .001 when compared to inpatient cases). Common inpatient complications were bleeding (2%), pain/nausea/vomiting (5.6%), and postprocedural respiratory failure (1.7%). On the other hand, ambulatory complications occurred in less than 1% of patients. The readmission rate was 5.2%, with pain/nausea/vomiting and bleeding accounting for 35% and 23% of overall readmissions. All Patient Refined Diagnosis Related Groups severity of illness subclass predicted readmission (odds ratio = 2.18, 95% confidence interval = 1.73-2.73, p < .001)., Conclusion: A total of 567,000 pediatric ambulatory and inpatient tonsillectomies were performed in 2019; the majority were performed in ambulatory settings. The index admission severity of illness was associated with readmission risk., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objectives: To examine the relationship between neighborhood-level advantage and severe obstructive sleep apnea (OSA) in children., Methods: A retrospective case-control study was conducted on 249 children who underwent adenotonsillectomy and had full-night polysomnography conducted within 6 months prior. Patients were divided into more or less socioeconomically disadvantaged groups using a validated measure, the area deprivation index (ADI). The primary outcomes were the relationship between the apnea-hypopnea index (AHI) and the presence of severe OSA, and the secondary outcome was residual moderate or greater OSA after tonsillectomy., Results: Of the 249 children included in the study, 175 (70.3%) were socially disadvantaged (ADI > 50). The median (interquartile range [IQR]) age was 9.4 (7.3-12.3) years, 129 (51.8%) were male, and the majority were White (151, 60.9%), Black (51, 20.6%), and/or of Hispanic (155, 62.5%) ethnicity. A total of 140 (56.2%) children were obese. The median (IQR) AHI was 8.9 (3.9-20.2). There was no significant difference in the median AHI or the presence of severe OSA between the more and less disadvantaged groups. Severe OSA was found to be associated with obesity (odds ratio [OR] = 3.13, 95% confidence interval [CI] = 1.83-5.34), and residual moderate or greater OSA was associated with older age (OR = 1.20, 95% CI = 1.05-1.38)., Conclusions: The ADI was not significantly associated with severe OSA or residual OSA in this cohort of children. Although more neighborhood-level disadvantage may increase the risk of comorbidities associated with OSA, it was not an independent risk factor in this study., Level of Evidence: Level 4., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: The primary objective was to determine if treating pathogenic bacteria in bronchoalveolar lavage (BAL) cultures improves outcomes after pediatric double stage laryngotracheal reconstruction (dsLTR)., Study Design: Case series with chart review., Setting: Tertiary children's hospital., Methods: All children (<18 years) obtaining flexible bronchoscopy with BAL cultures before dsLTR between 2016 and 2022 were included. Cultures identified abnormal bacterial growth or normal respiratory flora. Thirty-day postoperative surgical site or lung infections were captured and tracheostomy decannulation rates were obtained for children with at least 12 months of follow-up., Results: Twenty-seven children obtained presurgical BAL cultures before dsLTR. Median age at reconstruction was 2.9 years (interquartile range: 2.3-3.5) and 89% (24/27) had high grade subglottic stenosis. Positive cultures were obtained in 56% of children (N = 15) with Pseudomonas aeruginosa (40%, 6/15) and methicillin-resistant Staphylococcus aureus (33%, 5/15) the most frequent organisms. All children with positive cultures were treated based on culture and sensitivity data. Postoperative infections developed in 22% (6/27) of children with equal distribution of surgical site and respiratory infections among children with pathogenic bacteria and normal respiratory flora. At 12 months after surgery, the decannulation rate was no different between those treated and not treated for a presurgical positive BAL culture (47% vs. 58%, p = 0.70)., Conclusion: Pathogenic bacteria are common in BAL cultures from tracheostomy-dependent children before dsLTR. Treatment keeps respiratory infections and decannulation rates similar to children with negative cultures, suggesting continued benefit of flexible bronchoscopy and BAL in preparation for these surgeries., (© 2023 Wiley Periodicals LLC.)

Importance: The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored., Objective: To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event., Design, Settings, and Participants: This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023., Main Outcomes and Measures: Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy., Results: Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%., Conclusions and Relevance: This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

Objectives/hypothesis: To determine the impact of race on outcomes after pediatric tracheostomy., Study Design: Retrospective case series., Methods: A case series of tracheostomies at an urban, tertiary care children's hospital between 2014 and 2019 was conducted. Children were grouped by race to compare neurocognition, mortality, and decannulation rate., Results: A total of 445 children with a median age at tracheostomy of 0.46 (interquartile range [IQR]: 0.97) years were studied. The cohort was 32% Hispanic, 31% White, 30% Black, 2.9% Asian, and 4.3% other race. Black compared to White children had a lower median birth weight (2,022 vs. 2,449 g, P = .005), were more often extremely premature (≤28 weeks gestation: 62% vs. 57%, P = .007), and more frequently had bronchopulmonary dysplasia (BPD) (35% vs. 17%, P = .002). Hispanic compared to Black children had higher median birth weight (2,529 g, P < .001), less extreme prematurity (44%, P < .001), and less BPD (21%, P = .04). The proportion of Black children was higher (30% vs. 19%, P < .001), while the proportion of Hispanic children with a tracheostomy was lower (32% vs. 42%, P = .003) compared to the racial distribution of all pediatric admissions. Racial differences were not seen for rates of severe neurocognitive disability (P = .51), decannulation (P = .17), or death (P = .92) after controlling for age, sex, prematurity, and ventilator dependence., Conclusion: Black children disproportionately underwent tracheostomy and had a higher comorbidity burden than White or Hispanic children. Hispanic children had proportionally fewer tracheostomies. Neurocognitive ability, decannulation, and mortality were similar for all races implying that health disparities by race may not change long-term outcomes after pediatric tracheostomy. Laryngoscope, 132:1118-1124, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine the impact of a child with a tracheostomy on caregiver quality of life., Methods: A repeated cross-sectional analysis included families with tracheostomy-dependent children between 2019 and 2021. Caregivers were surveyed using the PedsQL™ Family Impact Module with assessments at tracheostomy placement and during ambulatory office visits., Results: Two-hundred and fifty-five surveys were performed with 66 at tracheostomy placement (26%) and 189 at follow-up visits (74%). Compared to families with healthy children, total scores at placement (77.2 vs. 87.6, P < .001) and follow-up visits (78.9 vs. 87.6, P < .001) were significantly lower among pediatric tracheostomy families. Caregivers were likely to report significant improvement in emotional functioning (6.2 points; 95% CI: 0.5-12, P = .03) and worry (9 points, 95% CI: 2.1-15.9, P = .01) over time. Demographic variables demonstrated no confounding or interactive effects., Conclusions: The presence of a tracheostomy is associated with lower caregiver quality of life scores in the short- and long-term compared to caregivers of healthy children. Providers should be sensitive to these challenges and provide appropriate support for families of tracheostomy-dependent children., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Advances in neonatal and pediatric critical care have resulted in a growing population of medically complex children with a tracheostomy. These children are vulnerable to adverse events from underlying comorbidities, risks of tracheostomy, equipment malfunction, and caregiver inexperience. Multidisciplinary tracheostomy teams have emerged as effective initiatives to address these patient safety concerns. Improvements in quality metrics and clinical outcomes can occur after implementation of a multidisciplinary tracheostomy team. This review provides updates on the evidence for multidisciplinary pediatric tracheostomy teams and offers perspectives on the future direction of these programs., Competing Interests: Disclosure The authors have no financial disclosures or conflicts of interest. No additional sources of funding., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To determine whether socioeconomic disadvantage impacts outcomes after pediatric laryngotracheoplasty., Study Design: Case series with chart review., Methods: All laryngotracheoplasty procedures at a tertiary children's hospital between 2010 and 2019 were included. Primary zip code determined Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure, and children were grouped based on less or more community disadvantage. Primary outcomes included complication and decannulation rates., Results: Eighty-four procedures were included with 69% (58/84) double-stage and 31% (26/84) single-stage reconstructions. Median age at surgery was 3.2 (IQR 2.2-4.9) years, 56% (47/84) were male, and median gestational age was 25 (IQR 24-28) weeks. Children from more disadvantaged communities represented 67% (56/84) of surgeries and were more likely to have higher grade stenosis (89% vs. 64%, P = .02). Postoperative airway complications (20% vs. 18%, P = .99), non-airway complications (14% vs. 18%, P = .75), and total length of stay (7 vs. 6 days, P = .26) were not impacted by ADI grouping. While children from higher community disadvantage were just as likely to be decannulated after double stage surgeries (76% vs. 76%, P = .99), it more often took longer than six months to achieve (90% vs. 61%, P = .04)., Conclusions: Community disadvantage is associated with higher grade airway stenosis and longer times to successful decannulation in children requiring expansion airway surgery. Encouragingly, ADI grouping did not impact complication and decannulation rates. Continued work is needed to understand how socioeconomic metrics influence pediatric open airway surgery., 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 © 2022 Elsevier B.V. All rights reserved.)

Objectives/hypothesis: To estimate the incidence of laryngotracheal stenosis among adults after intubation., Study Design: Cross-sectional analysis., Methods: We used the Nationwide Readmission Database to examine adult patients readmitted within 45 days after admission for mechanical ventilation. Those with a diagnosis of laryngotracheal stenosis or tracheostomy dependence on their index admission were excluded. Patient demographics, associated comorbidities, and intubation lengths were compared among those with and without a diagnosis of airway stenosis at readmission., Results: An estimated 624,918 patients met inclusion with a mean age of 59 years (standard error = 0.2). There were 1,230 patients readmitted within 45 days and diagnosed with laryngeal (N = 362) or tracheal stenosis (N = 920) estimating an incidence of 1.98 per 1,000 discharges. Compared with those without a diagnosis of airway stenosis, those with stenosis were younger (57 vs. 59 years, P < .001), more often female (62% vs. 45%, P < .001) and frequently intubated for >96 hours (47% vs. 32%, P < .001). Additionally, a history of respiratory failure, pneumonia, obesity, gastroesophageal reflux disease, and chronic steroid use were also more common among patients with stenosis. Multiple logistic regression analysis identified a decreased risk of stenosis with advancing age while an increased risk was associated strongest for females (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.58-2.44, P < .001) and those with chronic steroid use (OR: 2.69, 95% CI: 1.80-4.02, P < .001)., Conclusion: The incidence of laryngotracheal stenosis after intubation in adults is rare but is associated with female gender and younger age., Level of Evidence: NA Laryngoscope, 132:1723-1728, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine the rate of surgical site infections (SSI) after pediatric open airway reconstruction using a nationwide database., Study Design: Cross-sectional study of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) Database., Methods: The ACS NSQIP-P was queried for open airway surgeries between 2013 and 2019 determining postoperative SSI and wound dehiscence with a random sample of non-airway cases serving as a control group., Results: A total of 637 laryngotracheoplasties (LTP), 411 tracheal resections (TR) and 2100 control procedures were included. LTP and TR were both performed on younger children with more comorbidities than control surgeries ( p  < .05). Postoperative wound complications occurred more often after airway reconstructions than non-airway cases (6.4% vs. 2.9%, p  < .001). Compared to non-airway procedures, LTP (OR: 2.42, 95% CI: 1.62-3.61) and TR (OR: 2.07, 95% CI: 1.28-3.66) developed increased SSI. Multiple logistic regression identified dirty or infected wounds (OR: 4.61, p  < .001, 95% CI: 2.35-9.03) and American Society of Anesthesiologists (ASA) Class IV (OR: 3.19, p  = .02, 95% CI: 1.12-8.39) as the strongest predictors of SSI after airway reconstruction., Conclusions: SSI after pediatric airway reconstruction occur in 6% of cases and are increased in infected wounds and ASA Class IV surgeries. Recognizing common factors for these complications provide reliable benchmarking to design surgical quality improvement initiatives., Level of Evidence: 4., Competing Interests: Dr. Johnson is the editor of Laryngoscope Investigative Otolaryngology. He was not involved in the editorial evaluation of or decision to accept this article for publication., (© 2022 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: To determine the rate of tracheostomy-related complications in pediatric patients from nationally representative databases., Study Design: Cross-sectional analysis., Setting: 2016 Kids' Inpatient Database and 2016 Nationwide Readmission Database., Methods: All pediatric tracheostomy procedures were included. Complication type, admission outcomes, and readmission rates were recorded with a logistic regression analysis to determine patient characteristics associated with complications., Results: An estimated 5309 tracheostomies were performed among pediatric patients in 2016, 8% (n = 432) of whom developed tracheostomy-related complications. This group was younger (4.7 vs 8.7 years, P < .001) and required longer hospital admissions (68.7 vs 33.2 days, P < .001) than children without tracheostomy-related complications. Mean costs ($459,324 vs $397,937, P < .001) and mean total charges ($1,573,964 vs $1,099,347, P < .001) were increased if a tracheostomy-related complication occurred. These events occurred more often in those with bronchopulmonary dysplasia (24% vs 12%, P < .001), heart disease (24% vs 12%, P = .001), gastroesophageal reflux disease (31% vs 19%, P < .001), short gestational age (24% vs 14%, P < .001), and subglottic stenosis (9.9% vs 5.4%, P = .001). The estimated 30-day readmission rate was 24% (SE, 1.7%) but did not increase after tracheostomy complications (27% vs 15%, P = .04). Tracheostomy-related complications were predicted by gastroesophageal reflux disease (odds ratio [OR], 1.50; 95% CI, 1.14-1.97; P = .004), younger age (OR, 1.12; 95% CI, 1.04-1.22; P = .002), and lengthier hospitalization (OR, 1.00; 95% CI, 1.00-1.01; P < .001) on multiple logistic regression analysis., Conclusion: Tracheostomy-related complications occur in approximately 8% of pediatric patients and are higher in younger children or those with longer admission lengths. These data have implications for benchmarking standards of posttracheostomy complications across institutions.

Background: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P) database monitors quality outcomes in pediatric surgery. However, the registry might underreport low-volume procedures. This review describes complications after laryngotracheal reconstruction (LTR) based on ACS-NSQIP-P reporting standards., Methods: A case series with chart review at a tertiary children's hospital included consecutive LTR procedures between 2010 and 2018. Surgical procedures were grouped into single- or double-stage for comparison of thirty-day complication rates., Results: Eighty-four procedures were reviewed with 70% (59/84) double-stage and 30% (25/84) single-stage. Children requiring double-stage procedures were younger (3.3 vs. 6.0 years, P = .002) and more often Black or African American (51% vs. 24%, P = .03). Double-stage LTR was frequently performed on children with grade 3 or 4 subglottic stenosis (90% vs. 52%, P < 001), with a tracheostomy (97% vs. 68%, P = .001) and with gastroesophageal reflux disease (93% vs. 67%, P = .004). Airway-related complications occurred in 19% (16/84) of children and non-airway complications occurred in 16% (13/84) with similar rates between groups. Unplanned reintubation (20% vs. 0%, P = .002), ventilator support longer than 48 hours (12% vs. 0%, P = .02), and total hospitalization lengths (15.6 vs. 6.5 days, P < .001) were increased after single-stage LTR. Children with non-airway complications had more central nervous system disorders (46% vs. 10%, P = .004)., Conclusion: Postoperative complications after pediatric LTR occur in nearly 20% of children and single-stage procedures have higher unplanned reintubations, prolonged ventilator support and hospitalization lengths. Surgeons should recognize that these typically minor events should be consistently monitored and reported after surgical expansion of the pediatric airway., Level of Evidence: IV., Competing Interests: Declaration of Competing Interest The authors have no funding, financial relationships, or conflicts of interest to disclose., (Copyright © 2021. Published by Elsevier Inc.)

Objective: To compare outcomes after tracheostomy between children from Spanish- and English-speaking families., Study Design: Prospective cohort study., Setting: Tertiary care children's hospital., Methods: All children <18 years of age who had a tracheostomy placed between 2014 and 2020 were included. Comorbidities and postsurgical outcomes were compared between (1) children whose families preferred speaking Spanish or identified as Hispanic/Latino and (2) children from English-language or non-Hispanic families., Results: A total of 339 children met inclusion, with 11% (37/339) from families identifying Spanish as their primary language and 33% (112/339) identifying as Hispanic. Spanish-speaking families were more likely to have tracheostomy-dependent children with cardiac conditions (65% vs 42%, P = .008) and high complexity (72% vs 49%, P = .007). Outcomes were similar regardless of language preference, with 45% (153/339) still tracheostomy dependent, 28% (94/339) decannulated, and 6.8% (23/339) deceased at a median follow-up of 1.77 years (interquartile range, 0.65-3.43). Severe neurocognitive disabilities were similar between Spanish- and English-language families ( P > .05). Spanish language was not associated with times to decannulation or death in univariate or multiple regression models. A sensitivity analysis of self-identified Hispanic or Latino patients did not show significant differences for time to decannulation, death, or neurocognitive disability rates ( P > .05)., Conclusion: Spanish language and Hispanic ethnicity appear to have minimal impact on pediatric tracheostomy outcomes.

Objective: To determine the cumulative 24-month incidence of middle ear effusion (MEE) among tracheostomy-dependent children requiring ventilatory support., Methods: A prospective longitudinal cohort study included all children under 2 years of age with a tracheostomy placed at a tertiary care children's hospital between 2015 and 2020 that obtained at least one tympanometry exam. The development of MEE, defined as a flat tympanogram with normal external canal volume, and mechanical ventilation requirement at examination were recorded., Results: Ninety-four children with a mean age at tracheostomy of 5.4 months (SD: 3.7) were included. During a mean follow-up of 18.3 months (SD: 14.6) (median: 14.1 months, interquartile range: 6.6-27.8), 192 tympanometry examinations were obtained with 59% (114/192) while requiring mechanical ventilation. Within 24 months after tracheostomy, 56.5% (95% CI: 48.9-64.4%) of children developed at least one MEE. Among those on mechanical ventilation, 74.0% (95% CI: 65.6-82.5%) developed MEE compared to 31.2% (95% CI: 21.4-44.0%) not on mechanical ventilation (HR: 2.97, 95% CI: 1.46-6.05, P = .003). A persistent MEE on two consecutive exams was not statistically more common for children on a ventilator (OR: 0.64, 95% CI: 0.01-6.95, P = .70). When controlling for age at exam, craniofacial syndrome, and newborn hearing test results on logistic regression, ventilator-dependence significantly predicted the presence of MEE (OR: 2.34, 95% CI: 1.18-4.68, P = .02)., Conclusion: Children with a tracheostomy were more likely to develop MEE when requiring mechanical ventilation. Clinicians should recognize this risk factor and appropriately assess for development of MEE to mitigate adverse speech and language development outcomes in this vulnerable population., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: To describe characteristics and outcomes of infants admitted as neonates requiring tracheostomy placement., Methods: A cross-sectional analysis of the Kids' Inpatient Database (KID) between 2003 and 2016 included all children admitted within the first 28 days of life that had a tracheostomy placed prior to discharge. Patient characteristics and surgical outcomes were compared between term (≥37 weeks gestation) and preterm (<37 weeks gestation) infants. A subset analysis for Black or African American neonates was performed given disproportional preterm births., Results: An estimated 4268 (95% CI: 4123-4414) tracheostomies were performed in infants admitted as a neonate with preterm infants accounting for 47% (1998/4268). Among preterm children, 20% were Black or African American compared to 12% in the term group (P < .001). More preterm infants had bronchopulmonary dysplasia (46% vs. 14%, P < .001), cardiac defects (66% vs. 58%, P < .001) and developed pneumonia, newborn sepsis, or sepsis during admissions (P < .001). Laryngotracheal anomalies (25% vs. 18%, P < .001) and vocal cord paralysis (11% vs. 4.9%, P < .001) were more common in term infants. Median length of stay (LOS) (154 vs. 100 days, P < .001) and total charges ($1,395,106 vs. $917,478, P < .001) were greater among preterm infants. Mortality was no different between groups (13% vs. 15%, P = .07). Characteristics strongly associated with preterm status were newborn sepsis (OR: 2.31, 95% CI: 1.97-2.72, P < .001), bronchopulmonary dysplasia (OR: 2.17, 95% CI: 1.77-2.65, P < .001) and Black or African American race (OR: 1.78, 95% CI: 1.46-2.17, P < .001). The following factors increased among all neonates between the baseline year 2003 to the final study year 2016: complications of care (OR: 1.9, 95% CI: 1.5-2.5, P < .001); sepsis (OR: 4.1, 95% CI: 3.0-5.5, P < .001); congenital cardiac anomalies (OR: 5.8, 95% CI: 4.5-7.4, P < .001); and respiratory failure (OR: 1.9, 95% CI: 1.5-2.4, P < .001). Compared to other races, median LOS and total charges were greater among Black or African American infants., Conclusion: Tracheostomies among preterm infants admitted as neonates reflect a growing and complex group with increased costs and hospitalization lengths. Black or African American children are disproportionately born preterm with higher costs and LOS compared to other racial cohorts. Future work will be necessary to design quality-improvement initiatives to improve outcomes for this vulnerable population., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The indication for frontal sinus drainage is uncertain when managing pediatric acute sinusitis with intracranial complications., Objective: The primary objective was to determine if addressing the frontal sinus reduced need for subsequent surgical procedures in children presenting with acute sinusitis complicated by intracranial abscess., Methods: A case series with chart review was performed at a tertiary children's hospital between 2007 and 2019. Children under 18 years of age requiring surgery for complicated acute sinusitis that included the frontal sinus with noncontiguous intracranial abscess were included. Outcomes were compared among children for whom the frontal sinus was drained endoscopically, opened intracranially, or left undrained., Results: Thirty-five children with a mean age of 11.1 years (95% CI: 9.9-12.3) met inclusion. Most presented with epidural abscess (37%). Hospitalizations lasted 12.9 days (95% CI: 10.2-15.5), 46% required a second surgery, 11% required three or more surgeries, and 31% were readmitted within 60 days. Initial surgery for 29% included endoscopic frontal sinusotomy, 34% had a frontal sinus cranialization and 37% did not have any initial drainage of the frontal sinus. Groups were similar with respect to demographics, severity of infection, need for repeat surgery, length of stay, and readmissions (p > .05). Further, persistence of cranial neuropathies, seizures, or major neurological sequelae after discharge were no different among groups (p > .05)., Conclusion: Drainage of the frontal sinus, when technically feasible, was not associated with reduced surgical procedures or increased complications and there is unclear benefit on measured clinical outcomes.

Objectives: To determine if socioeconomic disadvantage impacts perioperative outcomes after tracheostomy., Methods: We performed a retrospective case series of children who underwent tracheostomy. Children were divided into less and more disadvantaged groups based on their community's Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure. Primary outcomes were the length of stay, total cost, in-hospital mortality, and 30-day all-cause readmission after tracheostomy placement. Length of stay was further analyzed using parametric survival analysis., Results: A total of 239 patients met inclusion criteria, with 153 (64%) residing in more disadvantaged communities. Children from more disadvantaged communities were less likely to be White (42% vs. 26%, P = .009) and more likely to have Medicaid coverage (90% vs. 62%, P < .001). The two groups had similar medical complexity and comorbidities. The main outcome measures showed differences in median total length of stay (113 vs. 79 days, P = .04) and median total cost ($461 000 vs. $279 000, P = .01). Children with tracheostomies who were from more disadvantaged communities also had increased risk of prolonged hospitalizations (HR = 0.63, 95% CI = 0.48-0.83, P = .001). Readmissions, mortality rates, and quality of life scores were similar between groups., Conclusions: Community disadvantage was associated with differences in hospitalization length and costs after pediatric tracheostomy placement. Further research should continue to describe how health disparities impact children's safe and efficient care with tracheostomies., Level of Evidence: 4 Laryngoscope, 131:2603-2609, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To analyze a multidisciplinary tracheostomy team's effect on length of stay and cost., Methods: An airway management program using a balanced scorecard was created to track key performance measures. Interventions included weekly rounding, standardized placement, postoperative care, and caregiver education. Process measures included time to first education, speech-language pathology consultation rates, and pretracheostomy consultations. Outcome measures focused on the total length of stay, 30-day revisit rates after discharge, accidental decannulation rate, and standardized cost. Regression analysis was used to predict the program's effect on length of stay and total cost., Results: In total, 239 children met inclusion. The mean time to first education class was reduced from 13.7 to 1.9 days ( P < .001). The speech-language pathology consultation rate increased from 68% to 95% ( P < .001), and the presurgical consultation rate with the tracheostomy team increased from 14% to 93% ( P < .001). The length of stay decreased from 133 to 96 days ( P = .006). Total costs were lower for short admissions but higher for prolonged admissions. Revisits within 30 days remained stable over time (18%)., Discussion: Establishing a multidisciplinary tracheostomy team results in improvements in quality metrics when caring for children with tracheostomies. Controlling for associated factors showed the mean length of stay decreased significantly in the first full year of program implementation. Cost analysis estimated significant reductions for tracheostomy patients spending less time in the hospital., Implications for Practice: A airway management program can positively affect tracheostomy processes and outcomes., (© The Authors 2021.)

Objectives: Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction., Methods: A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019., Results: A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy ( P  = .86), age at decannulation ( P  = .97), duration of tracheostomy ( P  = .43), or gestational age ( P  = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P  = .03). Tracheostomy tube diameter ( P  = .02) and stent size ( P  < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up., Conclusions: Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

Objectives/hypothesis: The primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post-tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis., Study Design: Case series with chart review., Methods: Patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses., Results: There were 250 children included. Mean age was 8.8 years (95% CI: 8.2-9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4-6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001)., Conclusions: Obtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders., Level of Evidence: 4 Laryngoscope, 131:E2069-E2073, 2021., (© 2021 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Background: The extent of surgery required in the management of pediatric non-medial subperiosteal orbital abscess (SPOA) due to medically refractory complicated acute sinusitis is unknown., Objectives: The primary objective is to compare operative outcomes of children treated with combined endoscopic sinus surgery (ESS) and external orbital drainage (EOD) versus those treated with EOD alone., Methods: Retrospective case series from a tertiary children's hospital analyzing outcomes in children requiring surgical management for acute sinusitis complicated by non-medial SPOA between November 2007 and September 2019., Results: Sixteen children with a mean age of 9.4 years (95% CI: 7.3-11.4) met inclusion. Eleven (68.8%) underwent combined EOD and ESS, while five (31.2%) underwent EOD alone. Groups were similar in age, symptom duration, white blood cell count, C-reactive protein level, intraocular pressure, Lund-Mackay score, and abscess volume. There was no significant difference in median length of stay between patients treated with a combined approach versus those treated by EOD alone. Cultures identified non-beta-hemolytic Streptococcus species in 56.3% of patients, with Streptococcus intermedius representing the most common organism in 37.5%. In one case, ESS identified a pathogen not acquired via concomitant EOD, which did influence management. No child required a subsequent surgical procedure and there were no operative complications., Conclusions: The addition of ESS in the management of pediatric non-medial SPOA was not associated with a statistically different duration of hospitalization. Cultures from concomitant ESS rarely aided in diagnosis or antibiotic therapy. Further study should delineate the indications for ESS in these cases.

Objective: The primary objective was to determine if obstructive sleep apnea (OSA) can improve after adenoidectomy., Study Design: Case series with chart review., Setting: Tertiary children's hospital between 2016 and 2018., Methods: The study included children under 3.5 years with small (1+ or 2+) palatine tonsils, large (3+ or 4+) adenoids, and documented OSA on polysomnogram (PSG)., Results: Seventy-one children were included. Age at adenoidectomy was 2.0 years (95% CI, 1.8-2.2) and 71.8% were male. Mean follow-up was 2.5 years (95% CI, 2.3-2.7). Twenty-six children (36.6%) obtained a repeat PSG at a mean of 9.7 months (95% CI, 6.3-13.2) after adenoidectomy. Among those with a postoperative PSG, apnea-hypopnea index decreased in 77.0% (mean, -3.2 events/h; 95% CI, -14.1 to 7.6), and the proportion with moderate to severe OSA decreased from 65.4% to 30.8% ( P = .03). Six children (23.1%) had a normal PSG after adenoidectomy. Tonsillectomy was performed in 14.1% of children at 12.1 months (95% CI, 7.5-16.7) after adenoidectomy. Despite similar preoperative PSG variables, younger children (1.5 vs 2.1 years, P = .02) were more likely to require tonsillectomy. Substantial adenoid regrowth was identified in 1 child at the time of tonsillectomy., Conclusion: Adenoidectomy may improve OSA in young children with large adenoids and small tonsils. However, younger age predicted the need for subsequent tonsillectomy. Prospective studies with additional PSG data are necessary to corroborate these findings.

Objective: The first pediatric tracheostomy tube change often occurs within 7 days after placement; however, the optimal timing is not known. The primary objective was to determine the rate of adverse events of an early tube change. Secondary objectives compared rates of significant peristomal wounds, sedation requirements, and expedited intensive care discharges., Study Design: Prospective randomized controlled trial., Setting: Tertiary children's hospital between October 2018 and April 2020., Methods: A randomized controlled trial enrolled children under 24 months to early (day 4) or late (day 7) first tracheostomy tube changes., Results: Sixteen children were enrolled with 10 randomized to an early change. Median age was 5.9 months (interquartile range, 5.4-8.3), and 86.7% required tracheostomy for respiratory failure. All tracheostomy tube changes were performed without adverse events. There were no accidental decannulations. Significant wounds developed in 10% of children with early tracheostomy tube changes and 83.3% of children with late tracheostomy tube changes (odds ratio [OR], 45.0; 95% CI, 2.3-885.6; P = .01). This significant reduction in wound complications justified concluding trial enrollment. Hours of dexmedetomidine sedation ( P = .11) and boluses of midazolam during the first 7 days ( P = .08) were no different between groups. After the first change, 90% of the early group were discharged from intensive care within 5 weeks compared to 33.3% of patients in the late group (OR, 18.0; 95% CI, 1.2-260.9; P = .03)., Conclusion: The first tracheostomy tube change in children can occur without adverse events on day 4, resulting in fewer significant peristomal wounds and earlier intensive care discharge.

Objective: Gastroesophageal reflux (GER) has been identified as a risk factor for complications following pediatric tonsillectomy. The primary objective of this study was to examine outcomes after tonsillectomy among children with GER using a nationwide database. Secondary objectives included analyzing duration of hospitalization and total charges after admission., Methods: A cross-sectional review of the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Databases (KID) from 2012 and 2016., Results: A total of 21,232 children had a tonsillectomy with or without adenoidectomy, with 1683 (7.9%) diagnosed with GER. Average age for patients with reflux was 4.4 years and for those without was 5.6 years (P < .001). The rate of primary hemorrhage was not statistically different between groups (P = .87). Patients with reflux were more likely to have respiratory complications (P = .03), aspiration pneumonitis (P < .001), and hypoxemia (P < .001) during their hospital course. Noninvasive ventilation and reintubation also occurred more frequently in this population (P < .001). Children with reflux had a longer duration of postoperative admission (3.8 vs. 2.3 days, P < .001) and higher total hospital charges ($47,129 vs. $27,584, P < .001). Multivariable regression analysis determined that reflux remained a statistically significant indicator of aspiration pneumonitis, hypoxemia, invasive and non-invasive ventilation, as well as length of admission., Conclusion: Children with GER were significantly more likely to experience inpatient complications following tonsillectomy. Further, length of admission was higher compared to children without reflux. These results suggest that children with GER experience poorer outcomes after tonsillectomy and highlight the role for appropriate preoperative counseling and planning in this patient population. Laryngoscope, 131:907-910, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation., Methods: Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings., Results: Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) ( P  = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement., Conclusion: Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration., Level of Evidence: 2b.

Introduction: An airway assessment often occurs prior to tracheocutaneous fistula (TCF) closure in children. Bronchoscopy (MLB) with or without fistula-occluded polysomnography (PSG) helps determine candidacy and localize potential obstruction. To date, little has been published on MLB or PSG findings in children before surgically closing a TCF., Methods: A case series with chart review of children between 2017 and 2020 who underwent repair of a TCF after tracheostomy decannulation., Results: Thirty-six children were included for review. Mean age was 5.9 years (95% CI: 4.5-7.3), 58.3% were male, and 50% had chronic lung disease. Surgery occurred 13.3 months (95% CI: 11.9-14.8) after decannulation, with 80.6% by primary closure and 19.4% by secondary intention. There was one unsuccessful closure and two patients (5.6%) presented with a postoperative complication. An MLB was performed in 97.2% of children, where 22.9% identified supraglottic pathology, 11.4% had grade 2 subglottic stenosis, and 11.4% had difficult exposure of the larynx. Further, one child had a non-obstructing subglottic cyst, one had a supraglottoplasty for redundant arytenoid mucosa, and two children had suprastomal granulomas requiring removal. A PSG was obtained in 36.1%, with a mean Apnea-Hypopnea Index of 2.4 events/hour (95% CI: 0.9-3.9), nadir Oxygen saturation of 90.5% (95% CI: 87.9-93.0), and peak end-tidal CO 2 of 46.1 mmHg (95% CI: 43.7-48.5)., Conclusion: The selection of candidates for pediatric TCF closure requires careful evaluation of the airway. Surgeons should be familiar with the potential findings on MLB and PSG prior to closure., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Surgeons resuming elective procedures during the COVID-19 pandemic should consider strategies to mitigate risk of exposure. For otolaryngologists performing surgery on children, unique vulnerability to SARS-CoV-2 results from a regular interface with the upper respiratory tract mucosa. A growing interest in perioperative application of povidone‑iodine (PVP-I) to the nasopharynx and oropharynx has emerged. The purpose of this review is to provide an evidence-based assessment of PVP-I in pediatric oral, nasal and pharyngeal surgery., Methods: A contemporary literature review with algorithmic approach to the potential use of PVP-I in pediatric mucosal surgery., Results: Several formulations of PVP-I have shown rapid in vitro virucidal activity against SARS-CoV-2. Antisepsis using 1.0% PVP-I mouthwash and 0.45% PVP-I throat spray can occur after 30 seconds of contact time. To date, in vivo effectiveness of PVP-I against SARS-CoV-2 has yet to be established and possible risks of its direct use on upper aerodigestive mucosa of children must be weighed., Conclusion: Further research is required prior to strongly recommending PVP-I use in preparation for nasal, oral or pharyngeal surgery in children., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The coronavirus disease 2019 (COVID-19) pandemic requires clinicians to explore alternatives to routine patient management. Otolaryngologists caring for children commonly depend on physical examination, laboratory data, and ambulatory surgical procedures. Limiting patient care, mindful allocation of resources, and concern for safety have challenged all aspects of our health care system. This evidence-based clinical consensus is designed to guide practitioners of pediatric otolaryngology for common scenarios during this time., Data Sources: Peer-reviewed literature, published reports, institutional guidelines, and expert consensus., Review Methods: A clinical consensus on 6 common scenarios in pediatric otolaryngology developed with evidence-based strategies., Conclusions: Providers should suspend all in-person nonessential office visits and elective surgical procedures. An emphasis on medical management and caregiver education will provide reasonable approaches to many of the common outpatient concerns. Surgery for chronic otitis media, obstructive sleep apnea, and acute rhinosinusitis should occur only in response to severe complications or failure of medical regimens. The approach to the pediatric neck mass focuses on timely management for oncologic etiologies and cautious surgical intervention for abscess drainage or tissue sampling. Finally, epistaxis and otorrhea must be triaged and addressed without the usual ambulatory procedures., Implications for Practice: Adaptation of practice patterns during this unprecedented moment for our health care system requires thoughtful planning. The strategies described allow for safe handling of common pediatric otolaryngology diagnoses. Ultimately, otolaryngologists must be stewards of our global health community while advocating for the care of individual pediatric patients.