Virtually Assisted Personalized Tracheostomy Tube Design in Pediatric Complex Airway Anomalies.

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

Evaluating obesity as a risk factor for complications after pediatric adenotonsillectomy.

OBJECTIVES: To evaluate associations between childhood obesity and post-adenotonsillectomy complications, informing guidelines for postoperative management. METHODS: The retrospective review assessed outpatient pediatric tonsillectomy/adenoidectomy cases performed at 2 ambulatory surgery centers in 2020. Complications in the recovery unit and within 2 weeks of surgical discharge were reviewed along with clinical and demographic variables. Obesity was defined as sex-specific body mass index-for-age, or weight-for-age if height data were unavailable, at/above the 95th percentile. The 99th percentile served as the threshold for severe obesity. Analyses used Chi-square/Fisher's exact tests and independent-samples t-tests with relative risk or effect sizes. RESULTS: The review included 707 cases (180 patients with obesity). Overall incidence of complications in the recovery unit was 9.1%. Patients with obesity were significantly more likely to require supplemental blow-by oxygen (P = .02); relative risk was 1.65 (95% CI: 1.16-2.35) times greater in the cohort with obesity. Obesity had a small effect on postoperative oxygen saturation nadirs, which were significantly lower among patients with obesity (d = -0.34; P < .001). No differences emerged between cohorts with and without obesity in the incidence of any other complications before or after surgical discharge. Overall incidence of post-discharge returns was 7.9%. Incidence of complications did not vary by obesity severity. CONCLUSION: From this cohort, childhood obesity without other significant comorbidities may not warrant routine inpatient care following adenotonsillectomy. Patients with obesity should receive additional monitoring for oxygen desaturation events during the first hours of recovery. Further prospective studies should continue to address this important topic.

Predictors of Success After Furlow Palatoplasty for Repair of Cleft Palate: Does Syndrome Matter?

OBJECTIVE: To determine predictors of success following Veau 1 and 2 cleft palate repair in patients with and without syndromes. STUDY DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care children's hospital. METHODS: All children <18 months of age undergoing Furlow palatoplasty for Veau 1 and 2 cleft repair between 2000 and 2014 with postoperative perceptual speech assessment (PSA). RESULTS: In total, 368 consecutive patients were identified; 95 were excluded, resulting in 273 patients. Median age at surgery was 13.0 months (interquartile range [IQR], 11-15 months) with postoperative PSA at a median of 32.3 months (IQR, 26.3-44.5 months). Fifty patients (18.3%) had syndrome diagnosis; 59 patients (21.6%) had nonsyndromic Robin sequence. Velopharyngeal insufficiency (VPI) occurred in 27 patients (10.5%); 13 underwent secondary speech surgery. Cleft-related speech errors occurred in 46 patients (17.6%). Non-cleft-related speech errors occurred in 155 patients (59.6%) and reduced intelligibility in 127 patients (47.9%). Oronasal fistula occurred in 23 patients (8.8%) and was exclusive to Veau 2 clefts. In multivariate analysis, age >13 months at palatoplasty demonstrated a 6-fold higher rate of VPI (hazard ratio [HR], 6.64; P < .01), worse speech outcomes (HR, 6.04; P < .01; HR, 1.60; P < .01; HR, 1.57; P = .02), and greater speech therapy utilization (HR, 2.18; P < .01). CONCLUSION: VPI occurred in 10% of patients undergoing Furlow palatoplasty repair of Veau 1 or 2 clefts. Age <13 months at palatoplasty was associated with improved speech outcomes and lower VPI incidence (2.8% vs 16.2%). Syndromic diagnosis was associated with noncleft speech errors and reduced intelligibility on univariate analysis but not velopharyngeal function after palatoplasty.

Defining Essential Services for Deaf and Hard of Hearing Children during the COVID-19 Pandemic.

COVID-19 is a rapidly growing global pandemic caused by a novel coronavirus. With no vaccine or definitive treatment, public health authorities have recommended a strategy of "social distancing," reducing individual interaction, canceling elective procedures, and limiting nonessential services. Health care providers must determine what procedures are considered "elective," balancing risk of treatment delays with that of coronavirus exposure to patient, family, and providers. Given critical periods for language development and the long-term impact of auditory deprivation, some audiologic and otologic services should be considered essential. In this article, we describe the experience of a quaternary referral pediatric hospital in Seattle, the epicenter of COVID-19 in the United States, and share strategies for risk minimization employed by Seattle Children's Hospital. We hope that this work can be a reference for other centers continuing care for children who are deaf and hard of hearing during the COVID-19 and future resource-limiting crises.

Pediatric Otolaryngology Divisional and Institutional Preparatory Response at Seattle Children's Hospital after COVID-19 Regional Exposure.

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

Validation of the Maxillary Sinus Roof as a Landmark for Navigating the Pediatric Skull Base.

OBJECTIVE: To define a new anatomic relationship in pediatric sinus surgery, assessing the maxillary roof as a constant safe landmark to avoid skull base injury in the pediatric population. STUDY DESIGN: Retrospective analysis. SETTING: Tertiary care children hospital. SUBJECTS AND METHODS: A retrospective analysis was performed of all computed tomography scans of the sinuses and facial bones at the emergency department of a tertiary children's hospital over the course of a year. Radiographic measurements included the lowest cribriform plate and planum sphenoidale (PS) heights, or posterior skull base when not yet pneumatized, as well as the highest maxillary roof height. The nasal floor was used for reference. Statistics were performed via Shapiro-Wilks test with a P-value of .05 indicating statistical significance. RESULTS: Three hundred and seven unique scans were reviewed (38.9% female; n = 122; P = .58). Age stratification was based on previously described sinus growth patterns. In all patients, the maximum maxillary height was inferior to the lowest measured cribriform lamella and PS (P < .001; CI, 98.5%-99%). Inter- and intrarater reliability and accuracy were verified through blinded review and re-review (ρ = .99 and .98 respectively, P ≤ .001). The validity of sole coronal measurements due to incomplete sagittal reformatting was also confirmed (ρ = 1.00, P ≤ .001). CONCLUSION: Despite variation in sinus growth and development in children, the current study demonstrated the validity of the maxillary sinus roof as a constant safe landmark in the pediatric population, offering a novel anatomic relationship for teaching safety in performing pediatric sinus surgery. LEVEL OF EVIDENCE: 4.

Increasing preoperative apnea severity improves upper airway stimulation response in OSA treatment.

OBJECTIVE: Examine the patient characteristics of those undergoing upper airway stimulation (UAS) for the treatment of continuous positive airway pressure (CPAP)-refractive obstructive sleep apnea (OSA) at a tertiary care medical center to determine objective clinical predictors of success. METHODS: Retrospective chart review of the first 25 consecutive patients between August 2015 and December 2016 treated with UAS at a tertiary care academic center. Demographic data, medical and sleep history, pre- and postoperative polysomnography data, and sleep endoscopy findings were collected. Statistical analysis was performed using two-sided t test with bivariate and linear regression analysis. RESULTS: In our cohort of 25 patients, mean age was 67.5 ± 7.6 years, and mean body mass index (BMI) was 28.2 ± 3.8 kg/m2 with 42% female. One patient was excluded from analysis for unmasking of complete central apnea with therapy. AHI decreased by a mean of 33.8 events/hour following treatment (95% confidence interval: 25.8 to 41.7, P < 0.001). Preintervention AHI was associated with therapy response, with each point of preintervention AHI leading to an average decrease of 1.03 points (P < 0.001). Eighty-three percent of patients achieved a treatment AHI < 5, whereas 92% achieved an AHI < 10. Mean device use was 49.5 ± 10.4 hours per week. Ninety-two percent of patients were discharged the day of surgery. No major adverse events occurred. CONCLUSION: UAS continues to gain popularity for the treatment of CPAP-refractive OSA; therefore, identification of predictors of success is crucial. Our study, although small, suggests that more severe preintervention AHI does not preclude significant therapy response and may expand the inclusion criteria for UAS, meriting further investigation. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:556-560, 2020.

Revisiting age-related admission following tonsillectomy in the pediatric population.

OBJECTIVES/HYPOTHESIS: The objectives of this study were to examine patient outcomes using a 36-month age cutoff as a strict admission criterion following tonsillectomy, and review the safety and determine the plausibility of same-day discharge of children under 3 years old following tonsillectomy. STUDY DESIGN: Retrospective chart review. METHODS: A chart review of patients aged 24 to 42 months undergoing tonsillectomy over a 3-year period was conducted. Patients were stratified into <36 months and ≥ 36 months cohorts. Data collected included demographics, medical/sleep history, inpatient records, 30-day emergency department visits, and readmission data. Bivariate comparisons were made using χ2 and Wilcoxon tests for categorical and continuous variables. RESULTS: Between July 2014 and July 2017, 427 patients aged 24 to 42 months underwent tonsillectomy at our institution. Thirty-day emergency department visit, readmission, and greater-than-expected length of stay rates were 3.0% versus 3.7% (P = .75), 1.0 versus 1.8% (P = .61), and 4.7% versus 4.5% (P = 1.00) between the younger and older cohorts, respectively, with no difference in complication rates identified based on age. CONCLUSIONS: No significant difference in adverse outcomes was appreciated based on a cutoff of 36 months of age at a tertiary center over 3 years. There should continue to be ongoing studies addressing strict age-related admission criteria. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:E389-E394, 2019.

Retropharyngeal phlegmon in Rosai Dorfman disease.

Rosai Dorfman disease (RD), also known as sinus histiocytosis with massive lymphadenopathy (SHML), is a benign histiocytic proliferative condition of unsubstantiated etiology that most often presents as bilateral painless cervical lymphadenopathy. Head and neck manifestations of RD are diverse but most commonly present as massive cervical lymphadenopathy. Interestingly, a retropharyngeal fluid collection has never been described as a sequelae of RD. Our objective is to present a novel case of a 9-year old female with RD that suffered from recurrent retropharyngeal phlegmon and to discuss diagnostic and treatment recommendations for this disease process.