Predictive Value of Laryngeal Penetration to Aspiration in a Cohort of Pediatric Patients.

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6 month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions.

Evaluating the biomechanical characteristics of cuffed-tracheostomy tubes using finite element analysis.

The objective of this study was to perform finite element analysis (FEA) of cuff inflation within an anatomically accurate model of an adult trachea in four different cuffed-tracheostomy tube designs. The leakage quantified by the distance between the cuff and trachea was largest for the Tracoe cuff and smallest for the Portex cuff. The smooth muscle stresses were greatest for the Portex and least for the Distal cuff, respectively. The proposed FEA model offers a promising approach to virtually evaluate the sealing efficacy of cuffed-tracheostomy tubes and the tracheal wall stresses induced by cuff inflation, prior to application.

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

The use of videos in preparation for pediatric otolaryngology cases-a national survey.

OBJECTIVE: 1) Review surgical preparation methods for pediatric otolaryngology fellows and fellowship directors, focusing on surgical video usage. STUDY DESIGN: Cross sectional survey. METHODS: Structured survey querying preparation methods for surgical cases was distributed to current pediatric otolaryngology fellows and fellowship program directors (FD's). RESULTS: 84 surveys were distributed (47 fellows, 37 FD). Overall response rate was 44% (37/84); fellow response rate was 55% (26/47) and FD response rate was 30% (11/37). Most respondents used videos (84%) and textbooks (95%) to prepare for surgery; fellows were more likely than FD's to use videos (96% vs. 55%, p < 0.01). 89% of respondents used YouTube to prepare; C-videos was the next most common platform used (27%). Fellows were more likely to have used YouTube than FD's (100% vs 63%, p < 0.01). 45% of FD's did not know or did not think their fellows use videos to prepare for cases. Mean helpfulness of surgical videos on a 5 point scale was 3.41 (95% CI 3.0-3.8). Videos were considered most helpful for illustrating technical portions of cases (51%), visualizing the case (27%) and reviewing anatomy (24%). Survey respondents mentioned poor quality (59%) and irrelevance to a particular institutions approach (19%) as weaknesses of available surgical videos. CONCLUSIONS: Surgical videos are commonly used by pediatric otolaryngology fellows to prepare for cases, and can assist in building anatomic knowledge and illustrating technical details of complex cases. YouTube is the most commonly utilized platform accessed by fellows, but poor quality and limited generalizability may restrict the usefulness of current video resources. LEVEL OF EVIDENCE: 4.

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric tracheotomy. STUDY DESIGN: Blinded, modified, Delphi consensus process. METHODS: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items. RESULTS: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus. CONCLUSIONS: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:2700-2707, 2020.

How design characteristics of tracheostomy tubes affect the cannula and tracheal flows.

OBJECTIVES: The aim of this study was to perform computational simulations of airflow within an anatomically accurate model of an adult trachea in different tracheostomy tube designs. We hypothesized that tracheal airflow in patients is significantly influenced by the geometry and size of these devices. METHODS: The three-dimensional (3D) geometry of the trachea was reconstructed using computed tomography scans for an adult with no history of lung disease. 3D models of four cuffed tube designs, namely Tracoe, Portex, and Shiley Proximal and Distal tracheostomy tubes were generated using geometric modeling software. Transient simulations of airflow in the tube-airway assembly were performed for each tube using computational fluid dynamics (CFD). RESULTS: Airflow velocity was higher for the Shiley tubes compared with Portex and Tracoe tubes. For all designs, the largest magnitude of inspiratory airflow turbulence was obtained midway in the trachea. The work of breathing, quantified by the resistance of the tracheostomy tube, was lowest for Tracoe. Maximum airway wall shear stress (WSS), defined as flow-induced frictional forces, occurred at the same spatial location in all cases. Low inspiratory WSS at the carina and high expiratory airway WSS at the cuff-airway interface were observed for the Tracoe and Portex tubes. CONCLUSION: Our CFD model offers a promising approach not only for choosing a tracheostomy tube for a patient but for improving existing tracheostomy tube designs. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1791-1799, 2019.

Swallowing dynamics status post caustic ingestion in a pediatric patient: A multidisciplinary case report.

A case report of a 10 year old male illustrates the effect of damage to the tongue base, hypopharynx, cricopharyngeus, and esophagus on the sensory and motor components of the swallowing mechanism. The characteristics of the dysphagia were manifested clinically, radiographically, and endoscopically. A myectomy was required to restore functional swallowing as scar tissue formation in the cricopharyngeus severely interfered with the dynamic components of swallowing. A collaborative approach facilitated communication and effective treatment planning; the multidisciplinary components in the management of this case are discussed.

A Systematic Review of Patient- or Proxy-Reported Validated Instruments Assessing Pediatric Dysphagia.

OBJECTIVE: Pediatric dysphagia occurs in 500,000 children each year; however, there is not a common tool to assess these children. Our aim was to identify validated patient- or parent-reported outcome assessment tools evaluating pediatric dysphagia. DATA SOURCES: Scopus, EMBASE, PubMed, Cochrane Library, and CINAHL electronic databases (all indexed years through August 2014). REVIEW METHODS: Inclusion criteria included English-language articles containing instruments evaluated in children. Two investigators independently reviewed all articles, and the review was performed according to PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). RESULTS: The initial search yielded 1697 abstracts; 158 studies were assessed further. Four symptom questionnaires, validated in adults, were used to report pediatric dysphagia outcomes. Four outcomes tools assessing dysphagia were validated in pediatrics in selected populations. The Dysphagia in Multiple Sclerosis questionnaire and the Dysphagia Symptom Questionnaire for eosinophilic esophagitis were validated in adolescents and adults. The Symptom Questionnaire for Eosinophilic Esophagitis was validated in children with eosinophilic esophagitis. The Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module, validated in children with gastrointestinal disorders, includes 2 domains that assess swallowing function. CONCLUSION: We did not identify any validated patient- or parent-reported outcome assessment tools examining dysphagia symptoms in a general pediatric population. However, we identified 4 questionnaires that have been validated in specific pediatric disease cohorts. Having a standardized assessment instrument validated in all children would allow clinicians to systematically report symptoms and compare results of pediatric clinical trials. With this in mind, we recommend establishing a standard questionnaire for the broader pediatric population.

Persistent velopharyngeal insufficiency.

This chapter outlines the management of patients who have failed initial surgical correction of velopharyngeal insufficiency. Clinical judgment is required to determine the most appropriate revision option for each patient.

Obstructive sleep apnea.

This chapter outlines the surgical management of children who experience symptoms of airway obstruction after undergoing pharyngeal flap surgery or sphincter pharyngoplasty for the correction of velopharyngeal insufficiency. It also describes the management of children with hyponasality following these corrective surgical interventions.

Compensatory laryngeal function and airway protection in children following airway reconstruction.

OBJECTIVES: Laryngotracheal reconstruction (LTR) procedures for repair of complex congenital or acquired airway stenosis of the larynx and/or trachea in pediatric patients have advanced over recent decades. The aim of the present project was to investigate the relationships among diagnoses, type of surgical intervention, and laryngeal findings in a post-LTR patient cohort to identify factors associated with adequate airway protection and swallowing outcomes. METHODS: A retrospective review of 30 airway patients undergoing simultaneous or close interval functional laryngeal and swallowing examinations was completed. Analyses of the data were performed to examine factors associated with postoperative airway protection and swallowing function. The patient cohort was separated into 2 groups according to the adequacy of their airway protection (aspiration and no aspiration) as judged by clinicians via instrumental examination. RESULTS: Data analyses revealed statistically significant differences between the 2 groups for 3 key parameters: laryngeal closure, laryngeal closure timeliness (relative to bolus flow), and overall swallowing coordination. CONCLUSIONS: These findings contribute to the knowledge of laryngeal closure patterns present in patients undergoing airway reconstruction and the effect on the essential laryngeal function of airway protection during swallowing. Implications of the data for swallowing function in this population are discussed.

Pediatric Exercise Stress Laryngoscopy following Laryngotracheoplasty: A Comparative Review.

OBJECTIVE: Exercise-induced airway obstruction in pediatric patients is a unique phenomenon with multiple potential etiologies. An accurate diagnosis can be challenging to establish in pediatric patients because they are frequently asymptomatic at rest. Exercise stress laryngoscopy (ESL) is a modality by which pediatric patients can be evaluated under physiologic conditions that produce their symptoms. The purpose of this study was to demonstrate (1) the diagnostic effectiveness of pediatric ESL and (2) the ability of ESL to guide treatment for "normal" and post-airway reconstruction patients with exercise intolerance. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Patients undergoing ESL for exercise intolerance were reviewed. Demographics, surgical history, examination findings, and management recommendations were extracted. RESULTS: Thirty-seven patients (average age, 13.5 years; range, 5-21 years) were included. There were 14 male and 23 female patients. Airway abnormalities became evident in 56% of patients. Of these, 24% had focal supraglottic collapse, 43% had evidence of paradoxical vocal fold motion, 24% had combined supraglottic and glottic dysfunction, and 9% had distal airway abnormalities. Overall, 18 patients had changes in management after ESL. Twelve patients in this review had histories of laryngotracheoplasty with equivocal findings on operative bronchoscopy. Of these patients, 10 (83%) received focal diagnoses after ESL. CONCLUSION: ESL is a contemporary modality by which complex patients with undiagnosed exercise intolerance can be effectively evaluated. ESL can be an important tool used to guide treatment in pediatric patients with exercise-induced dyspnea after airway reconstruction.

Future of pediatric tonsillectomy and perioperative outcomes.

OBJECTIVE: Although commonly performed, pediatric tonsillectomy is not necessarily a low risk procedure due to potentially life threatening perioperative complications. There is paucity of literature on lethal anesthesia and surgical complications of tonsillectomy. In this article, we have reviewed both minor and serious complications following tonsillectomy. Hemorrhage, burn injuries, respiratory complications, postoperative nausea and vomiting, and pain management are discussed. We have highlighted our practice of pain management at Cincinnati Children's Hospital after tonsillectomy recent warning about codeine by the FDA on children undergoing tonsillectomy. We describe post-tonsillectomy outcomes including postanesthesia care unit stay, post discharge maladaptive behavioral outcomes and finally effective ways to identify children at risk for anesthesia and a few preventive strategies. METHODS: In addition to literature review, the LexisNexis "MEGA™ Jury Verdicts and Settlements" database was reviewed from 1984 through 2010 for deaths and complications during and following tonsillectomy. Data including year of case, cause of death, surgical, anesthetic and postoperative opioid related complications, injury, case result, and judgment awarded were collected and analyzed. RESULTS: The results of this analysis are presented with an emphasis on hemorrhage and on anesthesia and opioid related claims and their characteristics. Two hundred and thirty-three claim reports were reviewed. There were 96 deaths (41%) and 137 perioperative injuries (59%). Deaths were primarily related to surgery (n=46, 48%) with post-tonsillectomy bleed the most frequent cause (n=38, 40%) followed by opioid toxicity (n=17, 18%) and anesthesia complications (n=9, 9%). Non-fatal injuries included, postoperative bleeding (n=59, 25%), impaired function (n=29, 12%), anoxic events (n=20, 9%) and postoperative opioid toxicity (n=20, 8.6%). Anoxic event was noted to have the highest monetary award with a mean award at $9,017,379. Injuries (including anoxia) had higher mean monetary awards than deaths. CONCLUSION: Tonsillectomy in children carries a high risk of perioperative complications and malpractice claims. Though postoperative bleeding is the most common complication associated with malpractice claims, anoxia related to anesthesia and opioids had the greatest overall risk from a monetary standpoint.

Postoperative assessment of laryngopharyngeal dysfunction in neonates after Norwood operation.

BACKGROUND: The purpose of this study was to evaluate the incidence of vocal cord (VC) and swallowing dysfunction in infants after the Norwood operation and to examine the relationship between laryngopharyngeal dysfunction and postoperative outcomes. METHODS: We conducted a retrospective review of 63 infants who underwent routine postoperative fiberoptic endoscopic evaluation of swallowing function and vocal cords after a Norwood operation at our institution during a recent 6-year period (2003-2009). RESULTS: The overall incidence of VC dysfunction after the Norwood operation was 58.7%. After a modification of the aortic arch dissection technique in 2007, the incidence of VC dysfunction decreased significantly from 79.5% in 2003 through 2006 to 25% in 2007 through 2009 (p<0.001). The incidence of swallowing dysfunction also decreased from 23.1% in 2003 through 2006 to 4.2% in 2007 through 2009 (p=0.07). Swallowing dysfunction was more common in patients with VC dysfunction (21.6%) as compared with patients without VC dysfunction (7.7%; p=0.18). Patients with VC dysfunction were more often discharged home on tube-only feeding regimens compared with infants without VC dysfunction (46% versus 26.9%). In infants with both VC and swallowing dysfunction, 75% were discharged exclusively to have tube feeding. Median hospital length of stay tended to be longer in infants with swallowing dysfunction (31 days) than in infants without swallowing dysfunction (23 days; p=0.16). CONCLUSIONS: Vocal cord and swallowing dysfunction are common in infants after the Norwood operation and may increase the need for tube feeding regimens. Modification of surgical techniques for dissection and mobilization of the aorta can significantly reduce the incidence of these adverse outcomes.

Automated high-level disinfection of nonchanneled flexible endoscopes: duty cycles and endoscope repair.

PURPOSE: Guidelines issued by the Association of Operating Room Nurses and the Association of Professionals in Infection Control and Epidemiology recommend high-level disinfection (HLD) for semicritical instruments, such as flexible endoscopes. We aim to examine the durability of endoscopes to continued use and automated HLD. We report the number of duty cycles a flexible endoscope can withstand before repairs should be anticipated. METHODS: Retrospective review. RESULTS: A total of 4,336 endoscopic exams and subsequent disinfection cycles were performed with 60 flexible endoscopes in an outpatient tertiary pediatric otolaryngology practice from 2005 to 2009. All endoscopes were systemically cleaned with mechanical cleansing followed by leak testing, enzymatic cleaning, and exposure to Orthophthaldehyde (0.55%) for 5 minutes at a temperature of at least 25°C, followed by rinsing for 3 minutes. A total of 77 repairs were performed, 48 major (average cost $3,815.97), and 29 minor (average cost $326.85). On average, the 2.2-mm flexible endoscopes were utilized for 61.9 examinations before major repair was needed, whereas the 3.6 mm endoscopes were utilized for 154.5 exams before needing minor repairs. No major repairs have been needed to date on the 3.6-mm endoscopes. CONCLUSIONS: Automated endoscope reprocessor use for HLD is an effective means to disinfect and process flexible endoscopes. This minimizes variability in the processing of the endoscopes and maximizes the rate of successful HLD. Even when utilizing standardized, automated HLD and limiting the number of personnel processing the endoscopes, smaller fiberoptic endoscopes demonstrate a shortened time interval between repairs than that seen with the larger endoscopes. Laryngoscope, 2010.

A preliminary investigation of four-dimensional ultrasound for evaluation of middle ear ossicles: an in vitro study.

OBJECTIVE: Temporal bone imaging in children has several inherent limitations. Computed tomography has the disadvantage of ionizing radiation, possible sedation, cost and accessibility. Magnetic resonance imaging has most of these disadvantages, with the exception of radiation, and provides bone images of limited resolution. Recent advances in ultrasound have led to its increased application in numerous medical fields. The purpose of this study was to investigate the ability of four-dimensional ultrasound (4DUS) to image middle ear ossicles in vitro and determine if this technology should be adapted for future clinical use. METHODS: Thirty cadaveric ossicles (10 malleus, 10 incus, and 10 stapes) were randomized and measured by two evaluators under a microscope. The ossicles were then immersed in a cold water bath and imaged, randomized, and measured using four-dimensional ultrasound by the same two evaluators. A separate cadaveric temporal bone, modified to allow the ultrasound probe to rest on the tympanic membrane, was imaged to visualize the ossicles in situ and evaluate whether or not the tympanic membrane and malleus would impede visualization of more medial structures. RESULTS: Microscopic measurements were: malleus (h=8.0 mm+/-0.32, w=2.7 mm+/-0.20), incus (h=6.8 mm+/-0.41, w=5.3 mm+/-0.46), stapes (h=3.5 mm+/-0.34, w=2.4 mm+/-0.17). Inter-rater reliability was 0.8. Measurements were in agreement with previously published values. Ultrasound measurements were: malleus (h=8.0 mm+/-0.51, w=2.9 mm+/-0.27), incus (h=6.8 mm+/-0.49, w=5.5 mm+/-0.42), stapes (h=3.6 mm+/-0.41, w=2.5 mm+/-0.19). Inter-rater reliability was 0.7. Mean intra-class correlation coefficient for microscopic and ultrasound measurements was 0.7. Images of the ossicular chain in continuity in the temporal bone specimen were not as clear as images of individual ossicles that were disarticulated and imaged under water. CONCLUSIONS: 4DUS provides reasonable images of ossicles disarticulated and mounted in underwater medium. However, images of the intact ossicular chain in a modified cadaveric temporal bone were not as clear, making interpretation difficult. Further investigation into the development of a thinner ultrasound probe that can pass through the external auditory canal and into overcoming limitations of air in the middle ear cleft are warranted. This could allow for a clinically relevant, faster, lower cost and lower risk alternative to current imaging techniques.

Real-time assessment of perioperative behaviors in children and parents: development and validation of the perioperative adult child behavioral interaction scale.

BACKGROUND: Behavior in response to distressful events during outpatient pediatric surgery can contribute to postoperative maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, and attention seeking. Currently available perioperative behavioral assessment tools have limited utility in guiding interventions to ameliorate maladaptive behaviors because they cannot be used in real time, are only intended to be used during 1 phase of the experience (e.g., perioperative), or provide only a static assessment of the child (e.g., level of anxiety). A simple, reliable, real-time tool is needed to appropriately identify children and parents whose behaviors in response to distressful events at any point in the perioperative continuum could benefit from timely behavioral intervention. Our specific aims were to (1) refine the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to improve its reliability in identifying perioperative behaviors and (2) validate the refined PACBIS against several established instruments. METHODS: The PACBIS was used to assess the perioperative behaviors of 89 children aged 3 to 12 years presenting for adenotonsillectomy and their parents. Assessments using the PACBIS were made during perioperative events likely to prove distressing to children and/or parents (perioperative measurement of blood pressure, induction of anesthesia, and removal of the IV catheter before discharge). Static measurements of perioperative anxiety and behavioral compliance during anesthetic induction were made using the modified Yale Preoperative Anxiety Scale and the Induction Compliance Checklist (ICC). Each event was videotaped for later scoring using the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) and Observational Scale of Behavioral Distress (OSBD). Interrater reliability using linear weighted kappa (kappa(w)) and multiple validations using Spearman correlation coefficients were analyzed. RESULTS: The PACBIS demonstrated good to excellent interrater reliability, with kappa(w) ranging from 0.62 to 0.94. The Child Coping and Child Distress subscores of the PACBIS demonstrated strong concurrent correlations with the modified Yale Preoperative Anxiety Scale, ICC, CAMPIS-SF, and OSBD. The Parent Positive subscore of the PACBIS correlated strongly with the CAMPIS-SF and OSBD, whereas the Parent Negative subscore showed significant correlation with the ICC. The PACBIS has strong construct and predictive validities. CONCLUSIONS: The PACBIS is a simple, easy to use, real-time instrument to evaluate perioperative behaviors of both children and parents. It has good to excellent interrater reliability and strong concurrent validity against currently accepted scales. The PACBIS offers a means to identify maladaptive child or parental behaviors in real time, making it possible to intervene to modify such behaviors in a timely fashion.

The significance of post-operative fever following airway reconstruction.

OBJECTIVE: Post-operative management of children undergoing airway reconstruction has been well-described. However, many of these patients develop post-operative fevers. We conducted a retrospective review in an attempt to define the significance of post-operative fever following pediatric airway reconstruction. METHOD: Retrospective analysis of 78 pediatric laryngotracheoplasties (LTPs) from May 1, 2006 - April 30, 2007 at a tertiary care pediatric hospital. Fever was defined as temperature >or=38.5. A fever was "significant" if accompanied by a positive sputum, blood or urine culture, or an elevated WBC. Chest radiograph (CXR) results and co-morbidities were examined. RESULTS: Forty-five percent of cases (35/78) had fever. Of those febrile, 46% (n=16) had significant fever. Overall, 20.5% had significant fevers. Fifty-two cases were single-stage LTP (SSLTP) with 31 febrile and 26 cases were double-stage LTP (DSLTP) with 4 febrile. SSLTP cases were at a significantly greater risk for post-operative fever compared with DSLTP, 59% vs 15% respectively (p=0.0002). 42% of febrile SSLTPs (n=13) had significant fevers compared to 50% (n=2) of febrile DSLTPs (Fisher's Exact p=1.0). 81.5% of cases with CXR findings had fevers, but only 50% of these fevers were significant. Subjects with post-operative atelectasis were more likely to have a fever compared to subjects with no post-operative atelactasis (93% vs. 33% respectively, p<0001). 30.8% of those with atelectasis had significant fever, compared to 52% of those without atelectasis (p=0.2) and 25 of SSLTPs vs. 3.9% of DSLTPs had atelactasis (p=0.027). No comorbidities were shown to be significant risk factors for post-operative fever. CONCLUSION: Based on our review, most children undergoing LTPs will have insignificant fevers. Those children undergoing SSTLP and/or having post-operative atelectasis are at higher risk for post-operative fever. Fevers in children with double-stage procedures or all reconstruction cases with CXR findings other than atelectasis should have a thorough fever work-up.

Clinical practice guideline: hoarseness (dysphonia).

OBJECTIVE: This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness. PURPOSE: The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology-head and neck surgery, pediatrics, and consumers. RESULTS: The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patient's larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures. DISCLAIMER: This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Adding the third dimension--a new tool for constructing 3D models of the airway from 2D bronchoscopic video.

OBJECTIVE: To develop a new method of using existing bronchoscopic video technology to generate a 3D model of the airway for clinical purposes. DESIGN: Prospective pilot study with clinical correlation. METHODS: A Storz 7200 bronchoscope was used to obtain video of a standardized tube. The images were then processed using "open source" tools which detected feature points. A three dimensional model was then constructed using these feature points. An in-house 3D image program was then used to compare the 3D model with the standardized tube. Video from a representative airway patient who had previously had a CT of the chest and a bronchoscopic examination was also analyzed using this technique. The 3D model was correlated with CT images to clinically validate this technique. SETTING: Tertiary care hospital. PATIENTS: One airway patient video was used for clinical validation. OUTCOME MEASURES: (1) Average diameters of the 3D video derived tube model were compared to the actual tube and (2) a cross section of the 3D video derived patient model was compared to the patient CT derived model. RESULTS: Repeated measures on standardized tubes demonstrated that is it possible to construct an airway model using this novel technique with a less than 5% error. Further, it is possible to construct a 3D model from patient video using existing bronchoscopic technology. CONCLUSIONS: It is possible to extract 3D data from a sequence of 2D images. Further, this 3D model can be used for the purposes of management and planning and is quantitatively accurate and reliable. Initial data suggests that these measurements correlate with actual airway size and may provide a better instrument with which to make surgical decisions.