Gonorrhea-positive sinus cultures in a 15-year-old with allergic fungal sinusitis.

This article describes a patient with gonorrhea in sinus cultures and allergic fungal sinusitis. A multidisciplinary team was assembled to deliver the results to the minor patient and her family and provide support and resources for long-term care.

Endoscopic culture-directed antibiotic therapy: Impact on patient symptoms in chronic rhinosinusitis.

BACKGROUND: Endoscopically guided cultures are frequently employed to guide antimicrobial therapy in refractory chronic rhinosinusitis (CRS) patients. The objective of this study was to determine the impact of culture-directed antibiotics on patient symptoms. METHODS: Retrospective review was conducted of 105 adult CRS patients undergoing evaluation in the ambulatory clinic of tertiary care academic medical center. RESULTS: The most common microbes were Staphylococcus aureus (29.5%), Pseudomonas aeruginosa (23.8%) and methicillin-resistant S. aureus (11.4%). Normal respiratory flora or no growth was found in 19% of patients. Culture results changed antibiotic choices in 77% of patients. Statistically significant change in total SNOT-20 scores and all 4 subdomains was noted, with improvement being clinically meaningful in the rhinologic subdomain (-1.10, p<0.0001). Repeat purulence was only noted in 5 cases (4.8%). Multivariate regression analysis demonstrated that concurrent use of oral steroids was independently associated with improvement in the rhinologic subdomain (p=0.0041). The mean length of follow-up was 37 days. Length of follow-up (14-30, 31-60, 61-90 days) did not statistically impact SNOT-20 scores. CONCLUSION: Endoscopic-derived sinus cultures are associated with clinically meaningful change in the rhinologic subdomain of SNOT-20 scores, and repeat purulence was infrequently noted at follow-up. Further prospective studies are needed to better delineate the role of cultures in CRS management. LEVEL OF EVIDENCE: 4.

Recurrent meningitis secondary to a petrous apex meningocele.

This case report describes a patient who was found to have a cerebrospinal fluid (CSF) leak originating from the petrous apex. The patient initially presented with multiple bouts of meningitis. The patient was treated surgically via a middle cranial fossa approach but presented five years later with recurrent meningitis and was found to have an osseous defect of the petrous apex which was not recognized prior to the initial surgery.

Surgical Outcomes by Early Airway Endoscopy Findings after Pediatric Staged Laryngotracheoplasty.

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.

Tracheal A-frame deformity and suprastomal collapse after pediatric tracheostomy.

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.

Subglottic Stenosis After Pediatric Tracheostomy.

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.

Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis.

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.

Neighborhood Socioeconomic Disadvantage and Long-Term Outcomes After Pediatric Tracheostomy.

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.

Injection Laryngoplasty for Children with Dysphagia after Cardiac Surgery.

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.

Evaluation of Pediatric Posterior Glottic Diastasis Using Dynamic Voice Computed Tomography.

OBJECTIVES: Posterior glottic diastasis (PGD) is an underappreciated etiology of dysphonia in patients with prior airway reconstruction or prolonged intubation. In endoscopic posterior cricoid reduction (ePCR), cricoid is removed to minimize the posterior glottic gap. Dynamic voice computed tomography (DVCT) permits visualization of the posterior glottis, estimating the amount of cricoid to be removed. Posterior glottic gaps in patients undergoing ePCR were compared to non-dysphonic patients to describe pediatric PGD and establish surgical parameters for ePCR. METHODS: DVCTs performed in non-dysphonic patients and dysphonic patients undergoing ePCR from 2014 to 2023 were reviewed. EPCR operative reports were queried. Pre- and postoperative Pediatric Voice Handicap Index (pVHI) and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores and aerodynamic measures were reviewed. RESULTS: Seventeen pediatric patients who underwent ePCR and 19 non-dysphonic patients were included. Posterior glottic gaps were significantly larger in the dysphonic group (median 2.4 mm [IQR: 2.0, 2.8] vs. 1.3 mm [IQR: 1.1, 1.7], p < 0.001). Mean width of the cricoid removed was 1.6 mm (SD 0.4 mm). Mean (SD) pre- and postoperative pVHI scores were 55.5 (19.9) and 34.6 (16.0; p < 0.001). Mean (SD) pre- and postoperative CAPE-V scores were 52.7 (15.4) and 36.5 (20.4; p < 0.001), respectively. CONCLUSIONS: Children in this cohort tolerated an average 1.3 mm posterior glottic gap without dysphonia. Dysphonic patients with PGD had a median 2.4 mm gap and underwent cricoid reduction by 1.6 mm. All ePCR patients demonstrated improvement in dysphonia. Results seek to optimize the management of pediatric PGD and present a safe and effective amount of cricoid to remove during ePCR. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.