Neuropathological features of pediatric laryngomalacia.

OBJECTIVE: Laryngomalacia is the most common pediatric laryngeal anomaly. The pathophysiology of laryngomalacia is not well defined; the leading hypothesis suggests weak laryngeal tone and neuromuscular discoordination. Only a few studies explored the histopathology of the laryngeal submucosal nerves, with reported nerve hypertrophy. Our study aims to describe the histopathology of submucosal nerves in specimens obtained from children with severe laryngomalacia compared to pediatric cadaveric controls. STUDY DESIGN: Prospective study. SETTINGS: Tertiary care children's hospital. METHODS: Histologic and immunohistochemical sections of supraglottic tissue from 26 children with severe laryngomalacia and six pediatric autopsies were digitally scanned and assessed with image analysis software (QuPath), resulting in the identification and measurement of 4561 peripheral nerves and over 100,000 foci of neurofilaments. RESULTS: Chronic inflammation was noted in all patients. Eosinophils were rare. The mean nerve area and perimeter were significantly smaller for patients with laryngomalacia compared to the control group (1594.0 ± 593.2 µm^2 vs. 2612.1 ± 2824.0 µm^2, p < 0.0001, and 158.8 ± 30.3 µm vs. 217.6 ± 165.0 µm, p < 0.0001). Nerve-per-area unit was significantly greater for patients with laryngomalacia compared to controls (1.39E-05 vs. 6.19 E-06, p = 0.009). The mean area and the number of neurofilaments per total nerve area were similar. Immunohistochemistry for calretinin, a marker for intestinal ganglion cells in Hirschsprung disease, was absent from all specimens. CONCLUSIONS: This series includes a comparison of all identifiable nerve fibers obtained from children with severe laryngomalacia and shows that the mucosal nerves are smaller on average than controls. These findings fail to provide support for significant morphologic peripheral nerve pathology in laryngomalacia.

Flexible and Rigid Bronchoscopy for Critically Ill Children on Extracorporeal Membrane Oxygenation.

BACKGROUND: We aim to describe our experience with bronchoscopy to diagnose and relieve tracheobronchial obstruction in anticipation of decannulation in children on extracorporeal membrane oxygenation (ECMO) support. METHODS: A retrospective cohort study of children on ECMO between 1/2018 and 12/2022. RESULTS: A total of 107 children required ECMO support during the study period for cardiac (n = 48, 45%), pulmonary (n = 38, 36%), or cardiopulmonary dysfunction (n = 21, 20%). Thirty-seven (35%) patients underwent 99 bronchoscopies while on ECMO. Most (76%, n = 75) experienced no improvement or worsening of chest radiography 24 hours following bronchoscopy. Clinical improvement in tidal volumes 48 hours after the first bronchoscopy was noted in 13/25 patients with available data (p = 0.05). Adverse events were seen in 18 (49%) patients who underwent bronchoscopy, including pneumothorax (n = 8, 22%), pneumonia (n = 7, 19%), pulmonary hemorrhage (n = 6, 16%), and sepsis (n = 5, 14%). ECMO courses were longer (25.4 ± 37.2 vs 6.1 ± 8.8 days, p < 0.0001) and more likely to be complicated by pneumonia (p = 0.0004) and sepsis (p = 0.047) in patients who underwent bronchoscopy compared with those who did not. Adverse events following bronchoscopy were associated with the number of bronchoscopies (p = 0.0003) and the presence of obstructive materials but not with the type of bronchoscopy or indication for ECMO. Mortality rates were similar between patients who underwent bronchoscopy and those who did not. CONCLUSION: Children requiring bronchoscopy represent a subset of the sickest children on ECMO. Bronchoscopy may provide benefit in children with persistent cardiopulmonary failure who could not otherwise be decannulated. Adverse events are associated with the number of bronchoscopies and the presence of obstructive material. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Transtracheal Pressure for Evaluation of Decannulation Readiness.

BACKGROUND: Pediatric tracheostomy decannulation protocols vary among institutions and may include toleration of Passy Muir Valve (PMV), microlaryngoscopy and bronchoscopy (MLB) findings, and polysomnography evaluation. Transtracheal pressure (TTP) is an objective measurement utilized to evaluate PMV toleration. We aimed to investigate the role of TTP in decannulation candidates and compare TTP measurements with polysomnography and MLB findings. METHODS: A retrospective cohort study of children who underwent TTP measurement during PMV trial between December 2012 and November 2022. RESULTS: A total of 79 patients underwent TTP measurement and MLB evaluation; of these, 16 (20.3%) patients had a capped polysomnography. Twenty-eight (35.4%) patients had TTPs ≤10 cm H2O, and 51 (64.6%) patients had TTPs >10 cm H2O. The most common indication for tracheostomy was upper airway obstruction (n = 41, 51.9%), followed by a need for mechanical ventilation (n = 24, 30.4%). Twenty-five (31.6%) patients were decannulated. Patients with TTPs ≤10 cm H2O had a mean Apnea-Hypopnea Index of 0.17 ± 0.26/h compared with 6.93 ± 7.67/h in those with TTPs >10 cm H2O, p = 0.0365. Patients with TTPs >10 cm H2O were found to have a significantly higher occurrence of airway obstruction (96.1% vs. 46.4%, p < 0.0001) and multilevel airway obstruction (70.6% vs. 21.4%, p < 0.0001) on MLB. Neither TTP measured at time of PMV assessment nor capped polysomnography was associated with successful decannulation. CONCLUSIONS: TTP measurements at time of PMV evaluation are associated with polysomnography and MLB findings. One-time PMV measurements were not indicative of decannulation success. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3377-3383, 2024.

Reworking Classification of First Branchial Cleft Anomalies.

OBJECTIVES: To evaluate the clinical features of first branchial cleft anomalies (BCAs) and their relationship to pre-operative imaging, pathologic data, and post-operative surveillance outcomes. Additional aims were to assess the validity of the Work classification and describe features of recurrent cysts. METHODS: Records for 56 children (34 females, 22 males; age at surgery of 5.6 ± 4.4 years) collected over a 12-year period (2009-2021) were reviewed. Imaging and pathologic slides were re-reviewed in a blinded fashion by experts in those respective areas. Parents were contacted via telephone to obtain extended follow-up. An alternate classification method based on the presence (type II) or absence (type I) of parotid involvement is provided. RESULTS: Only 55% of first BCAs could be successfully classified using Work's method. First BCAs within the parotid were more likely to present with recurrent infections, involve scarred tissue planes and lymphadenopathy, and demonstrate enlarged lymphoid follicles on pathology. The overall recurrence rate was 16%, and recurrence was 5.3 times more likely when external auditory canal cartilage was not resected. Preoperative imaging was useful for predicting the extent of surgery required and the presence of scarred tissue planes. CONCLUSION: First BCAs within the parotid gland involve more difficult and extensive surgical resection and the potential for morbidity related to facial nerve dissection. Appropriately aggressive surgical resection, which may include the resection of involved ear cartilage, is necessary to prevent morbidity related to recurrence. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:459-465, 2024.

Swallowing Function After Epiglottopexy in Children.

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

Persistence of aerodigestive symptoms after vascular ring repair.

OBJECTIVE: Vascular rings are often associated with respiratory and swallowing difficulties due to tracheal or esophageal compression. While the results of a vascular ring repair are considered excellent, the long-term effect of tracheal and esophageal remodeling and the persistence of symptoms have scarcely been reported. Our study aims to evaluate the respiratory and swallowing outcomes of vascular ring repair. STUDY DESIGN AND METHODS: A retrospective cohort study of children who underwent vascular ring repair between 2010 and 2022 in a tertiary-care children's hospital. RESULTS: There were 108 patients enrolled: sixty-three patients (57.41 %) with a right aortic arch, 42 patients (38.89 %) with a double aortic arch, and 3 patients (2.78 %) with other vascular rings. Forty-three (39.81 %) patients were diagnosed prenatally. Of the 65 patients (60.19 %) diagnosed postnatally, 35/65 (53.85 %) had either respiratory or swallowing symptoms as the indication for diagnostic workup. Persistent respiratory and swallowing symptoms were noted in 34/108 (31.48 %) and 30/108 (27.78 %) patients, respectively, within a year of surgical repair. Fourteen patients underwent repeated laryngoscopy and bronchoscopy that demonstrated residual tracheomalacia; however, only 2/14 (1.9 %) patients required tracheostomy tube placement, and 6-out-of-7 patients were weaned off positive pressure airway support. Persistent respiratory symptoms were significantly more common in patients with a double aortic arch compared to a right aortic arch. No differences were noted in demographics, comorbidities, and preoperative aerodigestive symptoms between patients with residual symptoms and patients with no residual symptoms. CONCLUSIONS: Persistent respiratory and swallowing symptoms after vascular ring repair are not uncommon. Postoperative evaluation should be pursued by a dedicated team, and treatment considered as appropriate.

An analysis of a new rapid difficult airway response team in a vertically built children's hospital.

BACKGROUND: Intrahospital transport is associated with adverse events. This challenge is amplified during airway management. Although difficult airway response teams have been described, little attention has been paid to patient transport during difficult airway management versus the alternative of managing patient airways without moving the patient. This is especially needed in a 22-floor vertical hospital. HYPOTHESIS: Development of a rapid difficult airway response team and an associated difficult airway cart will allow for the ability to manage difficult airways in the patient's primary location. METHODS: A retrospective chart review of all rapid difficult airway response activations from December 18, 2019 to December 31, 2021 was performed to determine the number of airways secured in the patient's primary location (primary outcome). Secondary outcomes included length of time until airway securement, airway device used, number of attempts, complications, use of front of neck access, and mortality. RESULTS: There were 96 rapid difficult airway response activations in a 2-year period, with 18 activations deemed inappropriate. Of the 78 indicated rapid difficult airway response deployments, all activations resulted in a secure airway, and 76 (97.4%) of cases had an airway secured in the patient's primary location. The mean time to airway securement was 17.1 min (standard deviation 18.8 min). The most common methods of airway securement were direct laryngoscopy (42.3%, 33/78) and video laryngoscopy (29.5%, 23/78). The mean number of attempts by the rapid difficult airway response team was 1.4. There were no documented cases requiring front of neck access. The Cormack-Lehane airway grade at time of intubation was I-II in 83.3% (65/78) of activations. Rapid difficult airway response activation resulted in 16 cases of cardiac arrest and 4 patient deaths within 48 h. CONCLUSIONS: A rapid difficult airway response team allows a large majority of patients' airways to be managed and secured in the patient's primary hospital location. Future directions include reducing time to airway securement and identifying factors associated with cardiac arrest.

Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) and poor quality of sleep negatively impacts health-related quality of life in adults, but few studies have evaluated the association between sleep disturbance (eg, OSA, inadequate sleep) and health-related quality of life domains (eg, family relations, life satisfaction) in children. METHODS: Children ages 8-17 years referred to a sleep center for routine polysomnography from April 2022 to August 2022 were approached to participate in the study, and children visiting the department of pediatrics for their wellness visit were recruited for comparisons. Statistical analysis was conducted using R 3.6.0. RESULTS: Ninety-nine children were recruited from the sleep clinic, and 23 children were recruited from the primary care clinic. Of these children, 62 were diagnosed with obstructive sleep apnea (31 mild, 12 moderate, 19 severe), and 37 did not meet criteria for a diagnosis. Health-related quality of life domains did not differ across OSA severity levels. Children in general had lower life satisfaction and higher physical stress experience compared to children visiting for their wellness examination (well-child visitors, P = .05 and P = .005, respectively). Children with severe OSA had significantly lower life satisfaction and significantly higher physical stress experience when compared with well-child visitors (P = .008 and P = .009, respectively). Correlation analysis showed that N3 (deep) sleep was positively associated with family relations and life satisfaction, while it was negatively associated with anger. CONCLUSIONS: Based on caregiver response, N3 sleep is positively associated with family relations and life satisfaction and negatively associated with anger. Severe OSA is associated with lower life satisfaction and higher physical stress experience. CITATION: Bhushan B, Zee PC, Grandner MA, et al. Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective. J Clin Sleep Med. 2023;19(12):2087-2095.

The prevalence of Chiari malformation among children with persistent dysphagia.

BACKGROUND: Brain imaging has been utilized as a diagnostic tool in the workup of persistent pediatric dysphagia, yet the indications for imaging and the prevalence of Chiari malformation (CM) have not been established. OBJECTIVE: to evaluate the prevalence of CM anomalies in children who underwent brain magnetic resonance imaging (MRI) for pharyngeal dysphagia and to review the clinical findings in the CM group compared to the non-CM group. METHODS: A retrospective cohort study of children who underwent MRI as part of the workup for the diagnosis of dysphagia in a tertiary care children's hospital between 2010 and 2021. RESULTS: 150 patients were included. The mean age at diagnosis of dysphagia was 1 ± 3.4 years, and the mean age at MRI was 3.5 ± 4.2 years. Common comorbidities in our cohort included prematurity (n = 70, 46.7 %), gastroesophageal reflux (n = 65, 43.3 %), neuromuscular/seizure disorder (n = 53,35.3 %), and underlying syndrome (n = 16, 10.7 %). Abnormal brain findings were seen in 32 (21.3 %) patients, of whom 5 (3.3 %) were diagnosed with CM-I and 4 (2.7 %) patients with tonsillar ectopia. Clinical characteristics and dysphagia severity were similar between patients with CM-I/tonsillar ectopia and patients without tonsillar herniation. CONCLUSIONS: Brain MRI should be pursued as part of the work-up for persistent dysphagia in pediatric patients given the relatively higher prevalence of CM-I. Multi-institutional studies are required to establish the criteria and timing of brain imaging in patients with dysphagia.

The Clinical Impact of Vagal Nerve Stimulator Implantation on Laryngopharyngeal Function in Children: A Single-Center Experience.

OBJECTIVE: A vagal nerve stimulator (VNS) has been established as the treatment of choice for children with refractory epilepsy. The outcomes of the procedure have been well documented in adults but are less clear in children. The goal of our study was to review laryngopharyngeal (LP) function following VNS implantation in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care children's hospital. METHODS: Voice, swallowing, and sleep apnea symptoms were extracted from the charts of children who underwent VNS implantation between 2013 and 2021. A questionnaire was sent to parents of implanted children to ascertain the degree of the social and functional impact of the implant. RESULTS: There were 69 patients, aged 2.3 to 21.4 years old, who met the inclusion criteria. LP symptoms were most common during the first year following implantation; 26 patients (37.6%) demonstrated at least 1 symptom (voice alteration, chronic cough, sleep-disordered breathing, or dysphagia), and 15 patients required adjustments to their implant settings. The incidence of symptoms and the need to adjust VNS settings significantly dropped during years 2 to 5 and 6 to 8 (22% vs 7% and 5%, respectively, p = .0002). The mean score of the Pediatric Voice Handicap Index differed greatly from a normal control group on each subscale and the total score. CONCLUSION: LP dysfunction in children following VNS implantation is comparable to adults, with the most burden noticed during the first year after implantation. The presence of voice alterations did not correlate with the presence of dysphagia and sleep-disordered breathing. Thorough evaluation, preferably by a multidisciplinary team, is required to assess LP dysfunction postoperatively.

Tonsillectomy Outcomes in Children After Solid-Organ Transplantation: A 15-Year Single-Center Experience.

OBJECTIVE: Solid-organ transplantation (SOT) has become the standard of care for children with terminal organ failure. Long-term immunosuppression has improved survival substantially but is associated with secondary malignancies and impaired wound healing. Our goal was to review the incidence, outcomes, complications, and rate of posttransplant lymphoproliferative disorder on pathologic examination following tonsillectomy/adenotonsillectomy (T/AT) in children after SOT. STUDY DESIGN: A retrospective cohort study. SETTING: Tertiary care children's hospital. METHODS: Data were extracted from charts of children with a history of kidney, heart, or liver transplantation, who underwent T/AT between 2006 and 2021. RESULTS: A total of 110 patients met the inclusion criteria, including 46 hearts, 41 kidneys, 19 livers, and 4 liver-and-kidney transplants. The mean age at transplantation was 4.2 years, and the mean transplantation-to-T/AT time interval was 28.8 months. The posttransplant lymphoproliferative disorder was diagnosed in 52 (47.3%) patients, and 25% of these had no tonsillar hypertrophy. There was no difference in age at transplantation, organ received, transplantation-to-T/AT time interval, immunosuppressive medications, tonsil size, or tonsillar asymmetry between patients diagnosed with the posttransplant lymphoproliferative disorder and patients with benign tonsillar/adenotonsillar hypertrophy. Posttonsillectomy complications were similar between the groups. CONCLUSION: The incidence of posttransplant lymphoproliferative disorder undergoing tonsillectomy for any indication was 47.3%. There was no association between preoperative signs and symptoms and the histopathological diagnosis of posttransplant lymphoproliferative disorder. Stratification by organ received and immunosuppressive medications did not identify differences among the groups relative to the incidence of posttransplant lymphoproliferative disorder and other postoperative complications.

Epiglottopexy in Infants Younger Than 6 Months Old: A Case Series.

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

Review of the Utility of Extended Recovery Room Observation after Adenotonsillectomy.

BACKGROUND: Our institution implemented a post-anesthesia care unit (PACU) extended-stay model (Grey Zone model), where the post-operative level of care for high-risk adenotonsillectomy patients (general care vs. intensive care unit) was decided based on the clinical course of 2-4 h of PACU admission. OBJECTIVE: To assess the correlation between post-tonsillectomy respiratory compromise and the need for respiratory support during an extended stay at PACU. To identify comorbidities associated with a need for intensive care after extended observation. METHODS: A retrospective cohort study of high-risk children who underwent adenotonsillectomy and were admitted to the Grey Zone following surgery. RESULTS: 274 patients met inclusion criteria. 262 (95.6%) met criteria for general care unit transfer (mean oxygen saturation 94.4 ± 5.1%). Twelve (4.4%) patients were transferred from the PACU to the ICU due to respiratory distress (mean oxygen saturation 86.8 ± 11%). Of the patients admitted to general care, 4 (1.5%) secondarily developed respiratory compromise, requiring escalation of care. Three of these maintained oxygen saturation ≥95% throughout the PACU period. There was no difference between the groups with respect to demographic data, rates of morbid obesity, and severity of obstructive sleep apnea. Neuromuscular disease, chronic lung disease, seizure disorder, and gastrostomy-tube status were more prevalent in those requiring ICU level of care compared to the general care unit. CONCLUSIONS: The Grey Zone model accurately identifies patients requiring ICU-level care following adenotonsillectomy, allowing for a safe reduction in the utilization of ICU resources. Due to rare delayed respiratory events, overnight observation in this cohort is recommended. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3582-3587, 2023.

The safety of respiratory positive pressure support immediately following pediatric tonsillectomy.

INTRODUCTION: Adenotonsillectomy is the first-line treatment for pediatric obstructive sleep apnea (OSA). The postoperative course may be complicated by hypoxia, requiring intervention. Positive pressure respiratory support (PPS) could be used to bridge the postoperative period and avoid invasive mechanical ventilation; however, the safety of PPS following tonsillectomy has not been established. Objective To review the incidence of complications and risk factors associated with PPS use immediately after tonsillectomy. METHODS: A retrospective cohort study between 2015 and 2020 of patients who underwent tonsillectomy and were admitted to the pediatric intensive care unit at a single healthcare system. RESULTS: Seven hundred eighty patients met inclusion criteria, including 101 patients treated with PPS immediately following surgery. A similar number of patients were diagnosed with severe OSA in each group prior to surgery. One patient in the PPS cohort developed pneumomediastinum and pneumothorax. Eleven patients (12%) in the PPS group and 18 patients (2%) in the non-PPS group developed life-threatening complications, defined as pneumothorax/pneumomediastinum, re-intubation, post-tonsillectomy bleeding that required surgical intervention, pulmonary edema and death, and all occurred in patients who had not used PPS at baseline. Regression analysis identified body mass index, surgical technique, and PPS use to be associated with increased odds of life-threatening complications. CONCLUSION: Our study suggests that PPS is generally safe to use. New-onset PPS is associated with increased odds of life-threatening complications, likely reflecting a severe post-surgical clinical course.

Epiglottopexy for refractory obstructive sleep apnea in children - A single-institution experience.

BACKGROUND: Refractory obstructive sleep apnea (OSA) is a common condition in children with medical comorbidities, leading to a significant impact on quality of life. Drug-induced sleep endoscopy (DISE) has become the standard of care in identifying the levels of obstruction in children with refractory OSA. Epiglottopexy has been shown to improve OSA symptoms in adults and healthy children with epiglottic prolapse in a few studies, with minimal long-term complications. The objective of our study was to evaluate the role of epiglottopexy in children with refractory OSA. METHODS: A retrospective chart review of children with refractory OSA who were found to have epiglottic prolapse on DISE, and underwent epiglottopexy between January 2018 and November 2021 at a pediatric tertiary care hospital. RESULTS: 42 patients (age 8.1 ± 5.1 years) met inclusion criteria. Thirty patients (71.4 %) suffered from neurodevelopmental disease or congenital syndrome, and 14 patients (33.3 %) were gastrostomy-tube dependent. All patients had at least one prior surgical procedure to address their OSA. Thirty-six patients (85.7 %) were diagnosed with refractory OSA by polysomnography prior to surgery, with an average apnea-hypopnea index (AHI) of 12.4 ± 9.7/h. Forty patients (95.2 %) required an additional procedure in conjunction with epiglottopexy including lingual tonsillectomy (n = 27, 64.3 %), supraglottoplasty (n = 14, 33.3 %), tonsillectomy with or without revision adenoidectomy (n = 9, 21.4 %) and tongue base suspension (n = 1, 2.4 %). Twenty-one patients had repeated polysomnography; 4 patients were found to have residual severe OSA post-operatively (average AHI 17.4 ± 11.4/h), while the remaining patients demonstrated clinical improvement and a significant reduction in OSA severity, with an average AHI of 1.5 ± 2.2/h. Regression analysis identified pre-operative oxygen nadir <75 % to be associated with residual OSA postoperatively. Following surgery, 7 patients were found to have new-onset or worsening dysphagia, 6 of whom were diagnosed with complex medical comorbidities. CONCLUSIONS: Epiglottopexy, as part of multi-level airway surgery, is associated with a significant improvement in the severity of refractory OSA. Dysphagia may complicate the post-operative course, particularly in children with medical comorbidities.

Perioperative outcomes in children with Hashimoto's thyroiditis undergoing total thyroidectomy.

BACKGROUND: Hashimoto's thyroiditis (HT) affects 1-2 % of the pediatric population. In adults with HT, thyroidectomy is considered challenging and prone to postoperative complications due to the chronic inflammatory process. However, the complications of thyroidectomy among children with HT have not been established. The objective of our study was to evaluate whether children with HT undergoing total thyroidectomy for presumed thyroid cancer have higher complication rates than children without HT. METHODS: A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 2014 and 2021. RESULTS: 111 patients met inclusion criteria, 15 of these were diagnosed with HT preoperatively. Operative time and length of admission were similar among the groups. Postoperatively, patients with HT were more likely to have low levels of parathyroid hormone (60 % vs 26 %, p = 0.014) and transient hypocalcemia compared to non-HT patients, present with symptomatic hypocalcemia (67 % vs 27 %, p = 0.006), demonstrate EKG changes (20 % vs 6.3 %, p = 0.035) within 24 h of surgery, and to require both oral and intravenous calcium supplements (80 % vs 35 %, p = 0.001 and 60 % vs 22 % p = 0.004 respectively). Persistent hypocalcemia at 6 months follow-up, and recurrent laryngeal nerve paralysis rates were similar between groups. Parathyroid tissue was found in the thyroid specimen of 9 (60 %) HT patients vs 34 (35 %) non-HT patients (p = 0.069). CONCLUSIONS: The risk of permanent complications among children with HT following thyroidectomy is low. However, patients with HT are more likely to develop symptomatic transient hypocalcemia and to require oral and intravenous calcium supplements in the immediate post-operative period compared to non-HT patients. Tailoring a perioperative treatment protocol to optimize calcium levels may be considered for children with HT.

Total Thyroidectomy and Subsequent Weight Gain in Pediatric Populations.

OBJECTIVE: To evaluate weight gain in children post-thyroidectomy and identify predictors. METHODS: Charts from patients at a tertiary health care facility who underwent total thyroidectomy from 2014 to 2020 were reviewed for Body Mass Index z-scores (BMIz) at the time of thyroidectomy and at 1 and 2-year post-operation intervals. Patient demographic information, comorbidities, pre- and postoperative thyroid stimulating hormone, and postoperative free T4 levels were also extracted. Patients with other known endocrine abnormalities, chronic kidney disease, or without sufficient follow-up were excluded. RESULTS: A total of 56 patients (ages 3-17 years old) met the inclusion criteria (n = 17 Graves' disease; n = 39 presumed cancer). Over the first year, average BMIz significantly increased in patients with Graves' disease (∆BMIz = 0.45 ± 0.77, p = 0.03), Hispanic ethnicity (∆BMIz = 0.43 ± 0.68, p = 0.004), Medicaid/no insurance coverage (∆BMIz = 0.33 ± 0.74, p = 0.038), age <13 years at thyroidectomy (∆BMIz = 0.35 ± 0.68, p = 0.016), and persistent postoperative hypothyroidism (∆BMIz = 0.41 ± 0.41, p = 0.012). These changes remained significant after the second year. Age at thyroidectomy correlated negatively with ∆BMIz only after the first year (r = -0.40, p = 0.002). Regression analysis, controlling for Graves' status, persistent postoperative hypothyroidism, and insurance coverage, identified age at thyroidectomy as a significant predictor of ∆BMIz after the first year (b = -0.06, p = 0.004) and Hispanic ethnicity as a significant predictor after the second year (b = 0.60, p = 0.003). CONCLUSION: A small increase in BMIz post-thyroidectomy was observed across several patient subgroups. Younger age at thyroidectomy and Hispanic ethnicity were associated with increased BMIz in the first 2 years post-thyroidectomy. LEVEL OF EVIDENCE: Level 4 - Historically controlled cohort Laryngoscope, 133:1518-1523, 2023.

Perioperative management in chronically anticoagulated children undergoing tonsillectomy.

BACKGROUND: When undergoing tonsillectomy, patients at high risk of thrombosis who require chronic anticoagulation therapy pose a special challenge as bleeding may occur up to 2 weeks after surgery. Because of a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our study was to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy. METHODS: The study group were a retrospective series of patients on chronic anticoagulation therapy at high risk of a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued because of a low risk of thromboembolic events were excluded. RESULTS: Four patients met the inclusion criteria (age range, 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH), drip-titrated to a therapeutic dose until 4-6 h prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. Unfractionated heparin was readministered according to the hospital protocol on the night of surgery and titrated to a therapeutic dose. Warfarin was restarted within 2 days postsurgery for all patients. High-risk patients were kept in hospital until postoperative day 6-8 because of concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention; none of the patients developed early or delayed hematemesis. CONCLUSIONS: Our data show that bridging therapy with UFH has been successful in chronically anticoagulated patients undergoing tonsillectomy. These patients require multidisciplinary care for the management of their pre- and postoperative course.

Abnormal TSH Prior to Surgery in Children with Graves' Disease Predicts Abnormal TSH Following Thyroidectomy.

OBJECTIVE: To identify variables that are associated with poor compliance to thyroid hormone replacement therapy in children after total thyroidectomy. METHOD: A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 1/2014 and 9/2021. Postoperative poor compliance was characterized by at least three separate measurements of high TSH levels not associated with radioactive iodine treatment. RESULTS: There were 100 patients, ages 3-20 years old who met inclusion criteria; 44 patients underwent thyroidectomy for cancer diagnosis, and 56 for Graves' disease. The mean follow-up time was 36.5 months (range 3.0-95.6 months). Overall, 42 patients (42%) were found to have at least three measurements of high TSH during follow-up, and 29 patients (29%) were diagnosed with clinical hypothyroidism. Sex, race, income, insurance type, and benign versus malignant etiology for thyroidectomy were not associated with adherence to therapy. Multivariate regression analysis identified patients with Graves' disease and hyperthyroidism at the time of surgery and Hispanic ethnicity to be associated with postoperative clinical hypothyroidism (OR 9.38, 95% CI 2.16-49.2, p = 0.004 and OR 6.15, 95% CI 1.21-36.0, p = 0.033, respectively). CONCLUSIONS: Preoperative hyperthyroidism in patients with Graves' disease and Hispanic ethnicity were predictors of postoperative TSH abnormalities. Preoperative counseling for patients and their families on the implications of total thyroidectomy and the need for life-long medications postoperatively is necessary. Efforts should be made to evaluate and improve adherence to therapy pre-and postoperatively in patients with Graves' disease. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2402-2406, 2023.