Outcomes of Injection Laryngoplasty for Deep Interarytenoid Groove.

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.

Comparison of Caregiver- and Child-Reported Quality of Life in Children With Sleep-Disordered Breathing.

OBJECTIVE: Caregivers frequently report poor quality of life (QOL) in children with sleep-disordered breathing (SDB). Our objective is to assess the correlation between caregiver- and child-reported QOL in children with mild SDB and identify factors associated with differences between caregiver and child report. STUDY DESIGN: Analysis of baseline data from a multi-institutional randomized trial SETTING: Pediatric Adenotonsillectomy Trial for Snoring, where children with mild SDB (obstructive apnea-hypopnea index <3) were randomized to observation or adenotonsillectomy. METHODS: The Pediatric Quality of Life Inventory (PedsQL) assessed baseline global QOL in participating children 5 to 12 years old and their caregivers. Caregiver and child scores were compared. Multivariable regression assessed whether clinical factors were associated with differences between caregiver and child report. RESULTS: PedsQL scores were available for 309 families (mean child age, 7.0 years). The mean caregiver-reported PedsQL score was higher at 75.2 (indicating better QOL) than the mean child-reported score of 67.9 (P < .001). The agreement between caregiver and child total PedsQL scores was poor, with intraclass correlation coefficients of 0.03 (95% CI, -0.09 to 0.15) for children 5 to 7 years old and 0.21 (95% CI, 0.03-0.38) for children 8 to 12 years old. Higher child age and health literacy were associated with closer agreement between caregiver and child report. CONCLUSION: Caregiver- and child-reported global QOL in children with SDB was weakly correlated, more so for young children. In pediatric SDB, child-perceived QOL may be poorer than that reported by caregivers. Further research is needed to assess whether similar trends exist for disease-specific QOL metrics.

Racial Influences on Pediatric Tracheostomy Outcomes.

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.

Nationwide tracheostomy among neonatal admissions - A cross-sectional analysis.

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.

Weight Gain and Severe Obstructive Sleep Apnea in Adolescents with Down Syndrome.

OBJECTIVES/HYPOTHESIS: To determine whether the severity of obstructive sleep apnea (OSA) is affected by weight gain velocity (WGV) in adolescents with Down syndrome. STUDY DESIGN: Retrospective case series. METHODS: We performed a retrospective case series of children with Down syndrome, aged 9-19, referred for polysomnography (PSG) due to suspected OSA at an academic children's hospital. We determined the velocity (slope of change) of yearly weight gain using a mixed effect linear regression model. Subsequently, we determined if velocity of yearly weight gain was greater in adolescents with severe OSA (apnea-hypopnea index > 10). Significance was set at P < .05. RESULTS: A total of 77 adolescents with Down syndrome were identified. The average age was 12.5 years (standard deviation = 3.1); 44 (57%) were male and 46 (60%) were Hispanic. The majority, 51 (66%) had severe OSA. The velocity of yearly weight gain prior to PSG in Down syndrome adolescents was similar regardless of OSA severity (mean diff in weight gain at PSG between severe and nonsevere OSA = -1.42, 95% confidence interval = -5.8 to 2.9, P = .52). Down syndrome adolescents with severe OSA weighed more at PSG (58.4 kg vs. 40.9 kg, P < .001) and all years prior to PSG. These findings remained even when controlling for age at PSG. CONCLUSIONS: Severe OSA in adolescents with Down syndrome is associated with weight. There was no significant difference in WGV in children with Down syndrome with or without severe OSA. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2598-2602, 2021.

Comparing Long-Term Outcomes in Tracheostomy Placed in the First Year of Life.

OBJECTIVES//HYPOTHESIS: To characterize long-term outcomes in pediatric patients requiring tracheotomy in the first year of life. STUDY DESIGN: Retrospective case series. METHODS: A retrospective longitudinal registry of tracheostomy patients was queried for patients who underwent tracheotomy from birth to 11 months. Primary outcomes were decannulation and survival. Secondary outcomes included neurocognitive quality of life assessed with the PedsQL Family Impact Module (scored from worst to best, 0 to 100 points). RESULTS: The study included 337 children. Thirty (8.90%) were neonates and 307 (91.10%) were infants. The population was 56.08% male (n = 189), and the racial and ethnicity composition were equally distributed (29.97% White, 31.45% Black, and 31.16% Hispanic). Significant differences between neonates and postneonates included birth weight in grams (2,731.40 vs. 1,950.44, P < .05), extreme prematurity (13.33% vs. 38.88%, P = .01), upper airway obstruction (80.00% vs. 42.67%, P < .05), and the need for mechanical ventilation (40.00% vs. 83.71%, P < .05). Despite these differences, long-term outcomes were similar: decannulation (X2  = 2.19, P = .14), death (X2  = 2.63, P = .11), and neurocognitive quality of life (X2  = 2.63, P = .27). Having a child with a tracheostomy caused the most problems with being physically tired (mean = 75.32 ± 3.90), emotional frustration (mean = 77.31 ± 5.05), and worry (mean standard deviation = 74.23 ± 6.48). CONCLUSION: There were demographic differences between neonatal and infantile tracheostomy patients, but they did not affect long-term outcomes. The presence of a tracheostomy caused a significant impact on a family's quality of life. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2115-2120, 2021.

Treatment of large infectious extracranial carotid artery pseudoaneurysms in children: a systematic review of the literature.

INTRODUCTION: Extracranial carotid artery pseudoaneurysm is a rare complication of deep neck space infection, and no evidence-based treatment guidelines are available in the literature. METHOD: To clarify the existing experience of the different treatment strategies, the authors performed a systematic literature search using the PubMed, Ovid EMBASE, and Scopus databases in accordance with PRISMA guidelines to review all reported cases of pediatric patients with infectious carotid pseudoaneurysms larger than 1 cm. RESULTS: Twenty-six patients with a median age of 4 years (range 6 months-15 years) were identified. Eighteen patients (69.2%) were treated with endovascular methods, 6 patients (23.1%) with surgical methods, 1 patient (3.8%) with a hybrid endovascular/surgical approach, and 1 patient (3.8%) with conservative management. Recurrence of the pseudoaneurysm occurred in 2 cases (7.7%), both of which were successfully retreated. Of the 6 patients (23.1%) who presented with pre-procedure neurologic deficits, 3 patients had complete or near complete resolution of symptoms after intervention and 3 patients had persistent deficits at last follow-up. Four patients (15.4%) experienced new neurologic deficits post-procedure that resolved at last follow-up. CONCLUSION: The endovascular treatment tends to be the preferred option to treat a large or giant infectious pseudoaneurysm of the carotid artery in the pediatric patient. However, more evidence is necessary to elucidate comparative safety and efficacy profiles of endovascular and surgical management strategies.

The Incidence of Pediatric Tracheostomy and Its Association Among Black Children.

OBJECTIVE: In 2012, Black or African American children constituted 21% of pediatric tracheostomies while representing approximately 15% of the US population. It is unclear if this discrepancy is due to differences in associated diagnoses. This study aimed to analyze the incidence of pediatric tracheostomy in the United States from 2003 to 2016 and to determine the odds of placement among Black children when compared with other children. STUDY DESIGN: Retrospective. SETTING: Academic hospital. SUBJECTS AND METHODS: We used the 2003 to 2016 Kid Inpatient Database to determine the incidence of pediatric tracheostomy in the United States and determine the odds of tracheostomy placement in Black children when compared with other children. RESULTS: A total of 26,034 pediatric tracheostomies were performed between 2003 and 2016, among which, 21% were Black children. The median age was 7 years (interquartile range [IQR] = 0 to 17); 43% were ≤2 years old, and 62% were male. The most common principal diagnosis was respiratory failure (72%). When compared with other children, Black children were more likely to undergo tracheostomy (odds ratio [OR] = 1.2; 95% CI, 1.1-1.3), which increased among children younger than 2 years old (OR = 1.5; 95% CI, 1.4-1.5). Black children with tracheostomies were also more likely to be diagnosed with laryngeal stenosis and bronchopulmonary dysplasia and to have an extended length of stay (P < .001). CONCLUSION: Black children are 1.2 times more likely to undergo tracheostomy in the United States compared with other children. Further investigation is warranted to evaluate if there are underlying anatomical, environmental, or psychosocial factors that contribute to this discrepancy.

A Longitudinal Analysis of Outcomes in Tracheostomy Placement Among Preterm Infants.

OBJECTIVES: To study a case series of preterm and extremely preterm infants, comparing their decannulation and survival rates after tracheostomy. METHODS: We performed a single-institution longitudinal study of preterm infants with a tracheostomy. Infants were categorized as premature (born > 28 weeks and < 37 weeks) and extremely premature (born ≤ 28 weeks). Decannulation and survival rates were determined using the Kaplan-Meier method. Neurocognitive quality of life (QOL) was reported as normal, mild/moderately, and severely impaired. Statistical significance was set at P < .05. RESULTS: This study included 240 patients. Of those, 111 were premature and 129 were extremely preterm. The median age (interquartile range) at tracheostomy was 4.8 months (0.4). Premature infants were more likely than extremely preterm to have airway obstruction (54% vs. 32%, P < .001); whereas extremely preterm infants were more likely to have bronchopulmonary dysplasia (68% vs. 15%, P < .001) and to be ventilation-dependent (68% vs. 54%, P < .001). The 5-year decannulation rate for premature infants was 46% and for extremely preterm was 64%. The 5-year survival rate post-tracheostomy for preterm was 79% and for extremely preterm was 73%. The log-rank test of equality showed that decannulation and survival were similar (P > .05) for both groups, even after controlling for potentially confounding factors like race, age, gender, birth weight, and age at tracheostomy. For neurocognitive QOL, 47% of patients survived with severely impaired QOL after tracheostomy. Preterm had 56% with severely impaired QOL and extremely preterm had 40% with severely impaired QOL (P = .03). CONCLUSION: This study demonstrated that the time to decannulation and the likelihood of survival did not vary among premature and extremely premature infants even when controlling for other confounding variables. LEVEL OF EVIDENCE: 3b Laryngoscope, 131:417-422, 2021.

Tonsillectomy Outcomes among Children with Mental Health Disorders in the United States.

OBJECTIVES: Recent evidence suggests that children with mental health disorders are more likely to have postoperative complications. Our aim was to determine if mental health disorders affect postoperative complications after tonsillectomy with or without adenoidectomy (T&A). SETTING: Cross-sectional analysis of national databases. SUBJECTS AND METHODS: The 2006 to 2016 Kids Inpatient Database and the 2014 Nationwide Readmission Database were used to identify children (age <21 years) who underwent T&A. We compared children with mental health disorders (eg, autism, developmental delays, or mood disorders) to those without a mental health disorder. We contrasted gender, race, length of stay, complications, and 30-day readmissions. RESULTS: We estimated that 37,386 children underwent T&A, and there were 2138 (5.7%) diagnosed with a mental health disorder. Children with mental health disorders were older (6.0 vs 5.3 years, P < .001), more commonly males (64% vs 58%, P < .001), had a longer length of stay (3.4 days vs 2.3 days, P < .001), and had higher total charges even after controlling for length of stay ($19,000 vs $14,000, P < .001). Children with a mental health disorder were more likely to have a complication (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.7 to 3.4; P < .001) including intubation, mechanical ventilation, or both (OR = 3.3; 95% CI, 2.6 to 3.8; P < .001). The 30-day all-cause readmission rate was higher (12% vs 4.0%, P < .001). CONCLUSION: Children with mental health disorders, especially development delays, have more frequent complications, longer lengths of stay, and readmissions than children without mental health disorders. This information should be included in preoperative counseling.

Survival analysis and decannulation outcomes of infants with tracheotomies.

OBJECTIVE: To evaluate for differences in time to decannulation and survival rates for pediatric tracheotomy patients based on ventilator status upon discharge. STUDY DESIGN: Retrospective longitudinal cohort study. METHODS: A single-institution longitudinal study of pediatric tracheostomy patients was conducted. Patients were categorized based on mechanical ventilation status on discharge and principal reason for tracheostomy. Survival rates were determined using the Kaplan-Meier method. The Wilcoxon's Rank Sum test and Cox regression analysis evaluated differences in survival times and time to decannulation based on primary indication for tracheotomy and ventilation status. RESULTS: Chart review identified 305 patients who required a tracheostomy under the age of 3. The median age at the time of tracheotomy was 5.2 months. The indications for tracheotomy in these patients were airway obstruction in 145 (48%), respiratory failure in 214 (70%), and pulmonary toilet in 10 (3.3%). Seventy-nine percent of patients were ventilator dependent at discharge. At the conclusion of the study period, 55% of patients were alive with tracheostomy in place, 30% patients were decannulated, and 15% patients were deceased. Patients with ventilator dependence at initial discharge, bronchopulmonary dysplasia, or airway obstruction were more likely to be decannulated. Hispanic patients were less likely to be decannulated. Patients had an equal probability of death regardless of ventilator status at discharge. CONCLUSIONS: This study demonstrated that the time to decannulation and likelihood of decannulation varies based on the indication for the tracheostomy. The majority of patients with a tracheostomy were not decannulated at the conclusion of this study. Median time to decannulation was 2.5 years for patients with a median death time of 6 months. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:2319-2324, 2020.

Tracheostomy in Extremely Preterm Neonates in the United States: A Cross-Sectional Analysis.

OBJECTIVES/HYPOTHESIS: Bronchopulmonary dysplasia (BPD) and invasive respiratory support is increasing among extremely preterm neonates. Yet, it is unclear if there is a corresponding increase in tracheostomies. We hypothesize that in extremely preterm neonates with BPD, the incidence of tracheostomy has increased. STUDY DESIGN: Retrospective cross-sectional analysis. METHODS: We analyzed the 2006 to 2012 Kids' Inpatient Databases (KID) for hospital discharges of nonextremely preterm neonates (gestational age >28 weeks and <37 weeks or birth weight >1,500 g) and extremely preterm neonates (gestational age ≤28 weeks or birth weight ≤1,500 g). We studied tracheostomy placement trends in these two populations to see if they are increasing among extremely preterm neonates, especially those with BPD. RESULTS: The study included 1,418,681 preterm neonates (52% male, 50% white, 19% black, 20% Hispanic, 4.2% Asian), of whom 118,676 (8.4%) were extremely preterm. A total of 2,029 tracheostomies were performed, of which 803 (0.68%) were in extremely preterm neonates. The estimated percent change of occurrence of extremely preterm neonates with BPD increased 17% between 2006 and 2012, and tracheostomy placement increased 31%. Amongst all who received tracheostomies, mortality rate was higher in extremely preterm neonates compared to nonextremely preterm neonates (18% vs. 14%, P = .05). However, in extremely preterm neonates, those with tracheostomies had a lower mortality rate compared to those without (18% vs. 24%, P = .002). CONCLUSIONS: Extremely preterm neonates, compared to nonextremely preterm neonates, experienced a marked increase in tracheostomies placed from 2006 to 2012 as well as an increased incidence of BPD, confirming our primary study hypothesis. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 2056-2062, 2020.

Weight gain velocity as a predictor of severe obstructive sleep apnea among obese adolescents.

OBJECTIVES/HYPOTHESIS: To evaluate a cohort of obese adolescents with obstructive sleep apnea (OSA) to determine if increased yearly weight gain was a predictor of severe OSA. STUDY DESIGN: Retrospective cohort study. METHODS: Obese adolescents (body mass index percentile >95% for that age and sex based upon the Centers for Disease Control and Prevention weight classifications), ages 12 to 17 years, referred for full night polysomnography (PSG) were analyzed. We examined demographics, weight classifications, yearly weight gain from age 9 years onward, PSG data (apnea-hypopnea index), and tonsil size. We performed a mixed-effect linear regression model to test whether the velocity of weight gain was increased in obese patients with severe OSA when compared to those without severe OSA. RESULTS: This study included 166 obese adolescents, 105 with and 61 without severe OSA. The average age was 14 years and was predominately male (57%) and Hispanic (44%). The regression analysis found that the yearly change in weight among obese adolescents with severe OSA was significantly higher than those without (B = 1.4, standard error = 0.50, P = .005, 95% confidence interval: 0.42-2.4). For the group with severe OSA, weight increased 6.5 kg every year before their PSG, whereas for those without, weight increased 5.1 kg per year. CONCLUSIONS: The rate of weight gain over time is an important predictor of severe OSA in obese adolescents. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:1339-1342, 2020.

Congenital nasal pyriform aperture stenosis: Analysis of twenty cases at a single institution.

OBJECTIVES: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of neonatal respiratory distress that is difficult to treat. The primary objective of this study was to identify factors that predict the need for initial and revision surgery for CNAPS. The secondary objective is to identify risk factors in maternal history associated with the development of CNPAS. METHODS: Infants with CNPAS between 2010 and 2017 were identified by ICD- 9 and 10 codes. Demographics, maternal history, anatomic features on imaging and medical and/or surgical management were reviewed. Frequencies, means and standard deviations were calculated. A p-value <.05 was considered significant. RESULTS: Twenty infants were included. All underwent flexible nasal endoscopy with inability to pass the scope in either nostril in 65% of infants. Nineteen had a CT scan and 13 had a MRI with midline defects in 76.3% and 53.8%, respectively. Solitary central mega-incisor was present in 65%. Half underwent surgical intervention at a mean age of 74.8 days, with 90% requiring revision surgery. There was no difference in pyriform aperture distance in the surgical and non-surgical patient subgroups (5.4 mm and 5.2 mm, p = .6 respectively). No specific variables were predictive of need for initial or revision surgery. Maternal diabetes mellitus (MDM) was found in 55% of mothers of infants with CNPAS. CONCLUSION: Pyriform aperture distance was not a predictor of surgical intervention. MRI should be considered in all infants with CNPAS as the rate of intracranial complications is high. MDM may be a risk factor for CNPAS.

Postoperative respiratory complications and racial disparities following inpatient pediatric tonsillectomy: A cross-sectional study.

OBJECTIVES/HYPOTHESIS: To study rates of respiratory complications/interventions among inpatient tonsillectomy patients in the United States and identify risk factors for these events. STUDY DESIGN: Retrospective database review. METHODS: Children (age < 18 years) undergoing tonsillectomy with or without adenoidectomy in 2006, 2009, and 2012 were studied using the Kids Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Outcomes were analyzed for respiratory events (complications/interventions) and racial disparities. Pearson χ test was used to analyze categorical data and regression analysis was used for continuous variables. Respiratory events were analyzed by racial identity using logistic regression analysis. A P < .05 was considered significant. RESULTS: The study included 30,617 patients (41% female, 51% white, 24% African American, 23% Hispanic, 3.0% Asian). The mean age was 5.2 years, and mean length of stay 2.3 days. The overall complication rate was 6.0%, and overall intervention rate was 3.6%. Respiratory events were more common among African American children (odds ratio [OR]: 1.5, 95% confidence interval [CI]: 1.3-1.6) and less common among white children (OR: 0.8, 95% CI: 0.8-0.9). These differences were significant after controlling for age, gender, obesity, obstructive sleep apnea, and asthma. The mortality rate was 0.05% with no ethnic predilection. CONCLUSIONS: Respiratory events after inpatient tonsillectomy included laryngo/bronchospasm, pneumonia, pulmonary edema, intubation, prolonged intubation, and ventilation. Although uncommon, these were more common among African American children. Further research is needed to understand the etiology of this disparity. LEVEL OF EVIDENCE: NA Laryngoscope, 129:995-1000, 2019.

Tracheostomy demographics and outcomes among pediatric patients ages 18 years or younger-United States 2012.

OBJECTIVES/HYPOTHESIS: To estimate the number, demographics, and outcomes of pediatric patients who underwent tracheostomy in 2012 and to contrast those outcomes by age, race, and gender. STUDY DESIGN: Cross-sectional study. METHODS: The 2012 Kids Inpatient Database was queried to identify tracheostomy patients using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedural codes 311, 3121, and 3129. All patients ≤18 years of age at the time of admission were included and categorized as neonates (≤28 days), infants (>28 days ≤1 year), toddler (1 to 3 years), children (4 to 12 years), adolescents (13 to 17 years), and adults (=18 years). We recorded age, gender, race, insurance status, and zip code of primary residence. We used these variables to contrast the following outcomes: length of stay, total charges, complications of care, and mortality using multiple regression analysis. RESULTS: An estimated 4,424 pediatric tracheostomies occurred during 2012. Fifty-one percent of the patients were ≤3 years old, and 62% were male. Forty-eight percentwere white followed by black (21%), Hispanic (20%), and Asian (3%). The median length of stay was 42 days, and the median total charges were $472,738. The complication rate was 29% and the mortality rate was 8.0%. The length of stay and total charges was predicted by age, with neonates having significantly longer hospitalizations. The complication rate was not associated with age, gender, or ethnicity. However, the mortality rate was associated with younger age. CONCLUSIONS: Pediatric tracheostomies are associated with significant hospital utilizations, complications, and mortality. Increased risk of mortality is observed among neonates and infants. Continued study of tracheostomy outcomes among these subsets of the pediatric population are warranted. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1706-1711, 2019.

Treatment of chronic rhinosinusitis with dornase alfa in patients with cystic fibrosis: a systematic review.

BACKGROUND: A major component of sputum in cystic fibrosis (CF) patients is polymerized DNA, a byproduct of degraded neutrophils. Dornase alfa (dornase) selectively cleaves extracellular DNA and reduces the viscosity of sputum. It improves mucociliary clearance and pulmonary function. The benefit of dornase on CF-associated sinusitis is less clear. Therefore, the objective of this study was to systematically review the use of dornase on chronic rhinosinusitis (CRS) in CF patients. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed for this systematic review. Ovid Medline, EMBASE, PubMed, and the Cochrane Library were searched. The search terms "dornase alfa," "deoxyribonucleases," "rhinosinusitis," and "cystic fibrosis" were used to find articles published between 1990 and 2016. The articles were reviewed for study design, level of evidence, and clinical outcomes. RESULTS: Sixty-two articles were identified; 6 met the inclusion criteria (104 patients). Improvement measured by sinonasal symptoms, endoscopic and radiographic findings, and pulmonary function was variably reported between the studies. Sinonasal symptoms were shown to improve in all studies with use of intranasal topical dornase. Three placebo-controlled studies showed that topical dornase significantly improved sinonasal symptoms more than saline alone. The impact on pulmonary function and radiographic and endoscopy findings was variable. CONCLUSION: Topical intranasal dornase appears to improve sinonasal symptoms in CF patients to a greater degree than saline alone. The impact on other outcomes is less clear. Larger studies are needed to fully elucidate the true efficacy of dornase alfa in the treatment of CRS in CF patients.