International pediatric otolaryngology group (IPOG) consensus on approach to aspiration.

OBJECTIVE: To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration. METHODS: Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step. RESULTS: Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children. CONCLUSION: Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.

Pediatric Voice.

Pediatric voice disorders are increasing being noted as a barrier to success in school and socialization. Significant advances over the past decade in evaluation, diagnosis, and management of pediatric voice disorders have improved both short-term and long-term outcomes. Practitioners should have a thorough understanding of anatomy and physiology, accurately work up a pediatric voice disorder, and efficiently treat voice disorders. Comprehensive voice evaluation in children is essential to properly assessing pediatric dysphonia. Diagnosis and treatment are best managed by a multidisciplinary team. Accurate diagnosis allows for effective treatment, which includes voice therapy, medical therapy, and surgical intervention as needed.

The Surgical Treatment of Robin Sequence: Neonatal Mandibular Distraction Osteogenesis in the Unfavorable Patient.

INTRODUCTION: Neonates with severe Pierre Robin sequence (PRS) can be treated by mandibular distraction osteogenesis (MDO), tongue-lip adhesion, or tracheostomy; however, there is an active debate regarding the indications of MDO in this patient population. Published algorithms identify tracheomalacia, bronchomalacia, laryngomalacia, hypotonic syndromes, and central sleep apnea as contraindications for MDO and indications for tracheostomy, but these comorbidities may exist along a spectrum of severity. The authors propose that appropriately selected neonates with PRS who concurrently express 1 or more of these traditional contraindications may be successfully treated with MDO. METHODS: The authors performed a 5-year retrospective chart review of all neonates who underwent MDO for treatment of severe PRS. All patients expressed a comorbidity previously identified as an indication for tracheostomy. Pre- and postoperative characteristics were recorded. Apnea/hypopnea index (AHI) before and after MDO were compared using 2-tailed repeated measures t-test. RESULTS: The authors identified 12 patients with severe PRS and conditions associated with contraindications to MDO: 9 (75.0%) patients had laryngomalacia, 6 (50.0%) patients had tracheomalacia, 2 (16.6%) patients had bronchomalacia, 1 (8.3%) patient had central sleep apnea, and 3 (25.0%) patients had hypotonia. Five (41.7%) patients underwent concurrent gastrostomy tube placement due to feeding insufficiency. Average birthweight was 3.0 kg. Average pre-op AHI was 34.8. Average post-op AHI was 7.3. All patients successfully underwent MDO with avoidance of tracheostomy. CONCLUSIONS: By employing an interdisciplinary evaluation of patient candidacy, MDO can safely and effectively treat upper airway obstruction and avoid tracheostomy in higher-risk neonatal patients with traditional indications for tracheostomy.

Pediatric Otolaryngology in the COVID-19 Era.

Although the majority of attention to the health care impact of COVID-19 has focused on adult first responders and critical care providers, the pandemic has had a profound effect on the entire health care industry, including the pediatric otolaryngology community. This article highlights the unique ramifications of COVID-19 on pediatric otolaryngology, with a focus on the immediate and potential long-term shifts in practice. Specifically, the article is divided into 3 sections (care for the patient, care for the practitioner, and care for the practice) and details the unique effects of the pandemic on the pediatric otolaryngology specialty.

International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction.

OBJECTIVE: To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery. METHODS: Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses. RESULTS: Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure. CONCLUSIONS: Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.

Sleep-Disordered Breathing and Airway Assessment Using Polysomnography in Pediatric Patients With Craniofacial Disorders.

Children with cleft and craniofacial conditions commonly present with concurrent airway anomalies, which often manifest as sleep disordered breathing. Craniofacial surgeons and members of the multidisciplinary team involved in the care of these patients should appreciate and understand the scope of airway pathology as well as the proper means of airway assessment. This review article details the prevalence and assessment of sleep disordered breathing in patients with craniofacial anomalies, with emphasis on indications, limitations, and interpretation of polysomnography.

Granulomas of the membranous vocal fold after intubation and other airway instrumentation.

OBJECTIVES/HYPOTHESIS: We describe the clinical features of granulomas of the membranous vocal fold secondary to endotracheal intubation, bronchoscopy or esophagogastroduodenoscopy. STUDY DESIGN: Retrospective case series. METHODS: Review of cases at a single tertiary institution with evaluation of patient demographic characteristics, time to presentation, time to treatment, and clinical outcomes. RESULTS: Thirteen adult patients were identified with postintervention granuloma of the membranous vocal fold. All patients were female, with a mean age of 60 years (range, 28-81 years). None noted hoarseness prior to the intervention, and all noted significant hoarseness postoperatively. Conservative treatment with proton pump inhibitors and vocal rest was initially implemented in all patients. Four cases resolved without further intervention. Nine underwent surgical management because of airway symptoms, failure to improve, or patient request. One patient had injury to the contralateral vocal fold upon intubation. None experienced recurrence. Five had complete recovery of voice postoperatively, four did not. CONCLUSION: Iatrogenic granulomas of the membranous vocal fold after intubation or other upper airway instrumentation are rare complications presenting in the early postprocedure period with worsening hoarseness. Initial conservative treatment may be sufficient to yield resolution, and surgical treatment is effective for those failing medical management. Permanent voice damage may result from the original injury. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:441-447, 2019.

Nasal Septal Anatomy in Skeletally Mature Patients With Cleft Lip and Palate.

IMPORTANCE: Septal deviation commonly occurs in patients with cleft lip and palate (CLP); however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood. OBJECTIVES: To describe the internal nasal airway anatomy of skeletally mature patients with CLP and to determine the contributors to airway obstruction. DESIGN, SETTING, AND PARTICIPANTS: This single-center retrospective review included patients undergoing cone-beam computed tomography (CBCT) from November 1, 2011, to July 6, 2015, at the cleft lip and palate division of a major academic tertiary referral center. Patients met inclusion criteria for the study if they were at least 15 years old at the time of CBCT, and images were used only if they were obtained before Le Fort I osteotomy and/or formal septorhinoplasty. Twenty-four skeletally mature patients with CLP and 16 age-matched control individuals were identified for the study. MAIN OUTCOMES AND MEASURES: Septal deviation and airway stenosis were measured in the following 3 coronal sections: at the cartilaginous septum (anterior nasal spine), bony septum (posterior nasal spine), and midpoint between the anterior and posterior nasal spine. The perpendicular plate of the ethmoid bone and vomer displacement were measured as angles from the vertical plane at the coronal section of maximal septal deviation. The site of maximal septal deviation was identified. RESULTS: Among the 40 study participants, 26 were male. The mean (SD) age was 21 (5) and 23 (6) years for patients with CLP and controls, respectively. Septal deviation in patients with CLP was significantly worse than that of controls at the anterior nasal spine (2.1 [0.5] vs 0.8 [0.2] mm; P < .05) and posterior nasal spine (2.9 [0.5] vs 1.0 [0.3] mm; P < .01) and most severe at the midpoint (mean [SD], 4.4 [0.6] vs 2.1 [0.3] mm; P < .01). The point of maximal septal deviation occurred in the bony posterior half of the nasal airway in 27 of 40 patients (68%). The CLP bony angular deviation from the vertical plane was significant in the CLP group compared with the control group (perpendicular plate of the ethmoid bone, 14° [2°] vs 8° [1°]; vomer, 34° [5°] vs 13° [2°]; P < .05 for both), and vomer deviation was significantly associated with anterior nasal airway stenosis (r = -0.61; P < .01). CONCLUSIONS AND RELEVANCE: Skeletally mature patients with CLP have significant septal deviation involving bone and cartilage. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty. LEVEL OF EVIDENCE: NA.

Prevalence of Voice Disturbances in the Pediatric Craniofacial Patient Population.

OBJECTIVE: To report on the prevalence of voice disturbances in the pediatric craniofacial population and to prove that the pediatric Voice Handicap Index (pVHI) is a useful questionnaire for this unique population. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center. SUBJECTS: Pediatric patients seen by a pediatric otolaryngologist in a craniofacial clinic. METHODS: Consecutive patients (N = 366) seen by a single pediatric otolaryngologist in a craniofacial clinic from July 2011 to September 2012 were included. Any patient specifically referred for airway problems or voice difficulties completed a pVHI questionnaire. Patients each underwent an evaluation including flexible fiberoptic laryngoscopy and videostroboscopy. Voice disturbance was further characterized into dysphonia, hypernasality, or hyponasality. RESULTS: Of all the patients evaluated, 280 (77%) were specifically referred for airway problems or voice disturbance. Of those referred, 39 (10.7%) were found to have an organic vocal fold pathology causing dysphonia, as seen on the videostroboscopic examination; 53.7% of these lesions were attributable to potential iatrogenic causes. Hypernasality and hyponasality were seen in 116 (31.7%) and 78 (21.3%) patients, respectively. The pVHI was 3.95, 26.3, 11.34, and 10.53 for those with no voice disturbance, dysphonia, hypernasality, and hyponasality, respectively. CONCLUSION: Pediatric patients with craniofacial disorders have a higher prevalence of dysphonia than the general pediatric population. The majority of causes of dysphonia in these patients are possibly iatrogenic in origin. The pVHI serves as a useful questionnaire in this unique patient cohort to quantify the disability from not only dysphonia but also hypernasality and hyponasality.

Isolated congenital maxillomandibular synechiae.

INTRODUCTION: Congenital maxillomandibular syngnathia, or fusion of the jaws, is a rare condition that has a broad spectrum of presentations. The restricted mouth opening can lead to issues with feeding, swallowing, and respiration resulting in failure to thrive and temporomandibular joint ankylosis. Early recognition and treatment is necessary for proper growth and development. CASE REPORT: We report a 1-day-old male with isolated bilateral soft tissue alveolar fibrous bands. He presented with difficulty feeding secondary to trismus. No bony or muscular involvement in the synechiae was noted and the remainder of the physical exam was unremarkable. The bilateral alveolar synechiae were divided under local anesthesia using surgical scissors. The patient immediately showed improvement in mouth opening and had resolution of his feeding problems. He is now gaining weight and developing appropriately. DISCUSSION: The accompanying review of the literature demonstrates only 11 cases worldwide of isolated maxillomandibular fusion. Depending upon the composition of the synechiae, simple surgical division under local anesthesia can be curative.

Lymphatic malformations of the airway.

OBJECTIVES/HYPOTHESIS: To characterize the anatomic distribution of lymphatic malformations of the upper airway. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care referral center specializing in the diagnosis and treatment of vascular anomalies. METHODS: A 7-year (2004-2011) retrospective chart review of patients with lymphatic malformations was performed at a tertiary care referral center. Patients with airway lymphatic malformations were identified. The anatomic distribution of lymphatic malformations within the airway was reviewed. RESULTS: A total of 141 patients with lymphatic malformations of the upper aerodigestive tract (UADT) were studied. Of these, 15 (11%) had laryngeal (supraglottic) involvement. In all of these patients, the disease was above the true vocal folds. Seventy-four (52%) patients had involvement of 1 anatomic zone (most common was the oral cavity), and 67 (48%) had involvement of multiple zones. With regard to each zone, 105 (75%) patients had involvement of the oral cavity, 50 (36%) the oropharynx, 8 (6%) the hypopharynx, 42 (30%) the parapharynx, and 12 (9%) had retropharygeal disease (some patients had multiple zones involved). No patients were identified with glottic, subglottic, or tracheal involvement. CONCLUSIONS: Based on our large series, airway involvement in head and neck lymphatic malformations may occur at multiple sites above the glottis. A high percentage of these patients have involvement of the oral cavity (75%) and oropharynx (35%). None involve the glottis, subglottis, or trachea.

Laryngeal electromyography for prognosis of vocal fold palsy: a meta-analysis.

OBJECTIVES/HYPOTHESIS: To analyze existing evidence regarding utility of laryngeal electromyography (LEMG) for prognosis in cases of vocal fold palsy (VFP). STUDY DESIGN: Meta-analysis of studies reporting LEMG results and clinical outcomes in 503 patients with of VFP identified by literature search. METHODS: Studies were identified by literature search. Method of diagnosis, interval to LEMG, criteria for prognostication, and outcome were assessed. Criteria for prognosis were standardized to the extent possible across all studies, and studies were checked for consistency in outcome measures and assessments. Pooled data were subjected to statistical analysis. RESULTS: A total of 296/503 patients (58.8%) had findings predictive with poor prognosis, whereas 207/503 (41.2%) had findings of recovery. According to laryngoscopic examination, 269/296 patients with predicted poor recovery had poor recovery (positive predictive value=90.9%), whereas 27/296 (9.1%) had good recovery. In patients with findings consistent with recovery, 115/207 (negative predictive value=55.6%) noted return of motion, whereas 88/207 (44.4%) did not. The odds ratio was 11.56 with 95% confidence interval of 7.10-18.81. CONCLUSIONS: LEMG is a good predictor of poor recovery in patients with VFP and is clinically useful in identifying candidates for early definitive intervention.

Duration-related efficacy of postoperative antibiotics following pediatric tonsillectomy: a prospective, randomized, placebo-controlled trial.

OBJECTIVE: To determine whether a 3-day course of postoperative antibiotics is as effective as a 7-day course in reducing pain and reducing time to resumption of a normal diet and level of activity following pediatric tonsillectomy. DESIGN: A prospective, randomized, placebo-controlled trial. SETTING: Academic medical center. PATIENTS: Forty-nine patients were enrolled in the study. Preoperative demographic information was obtained. INTERVENTIONS: Tonsillectomy with or without adenoidectomy was performed by the senior author (J.J.) using electrocautery. Patients were randomized to receive either a 3- or 7-day course of amoxicillin. MAIN OUTCOME MEASURES: Parents were asked to record the following information: analgesic use for the first 7 postoperative days, postoperative days the child initiated his or her usual diet and level of activity, and medical treatment for oral hemorrhage or dehydration. RESULTS: Of the 49 patients, 26 were randomized to receive 7 days of postoperative antibiotics (group A) and 23 to receive 3 days of antibiotics, followed by 4 days of placebo (group B). Results were obtained for 47 of the enrolled patients (96%). No statistically significant difference was noted between the 2 groups with regard to postoperative pain or time to resumption of a normal diet and level of activity. CONCLUSION: A 3-day course of antibiotics following pediatric tonsillectomy is as effective as a 7-day course with regard to postoperative analgesic use and resumption of normal diet and level of activity. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00662987.