Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency.

OBJECTIVE: To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers. DESIGN: Multicenter blinded R (inter) and R (intra) study. SETTING: Eight academic tertiary care centers. PARTICIPANTS: Sixteen otolaryngologists from 8 centers. MAIN OUTCOME MEASURES: Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated. RESULTS: The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size. CONCLUSIONS: In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Major aorto-pulmonary collateral arteries (MAPCAs)--Bronchial fistula presenting as tracheotomy bleed.

Tracheal hemorrhage is a common occurrence in pediatric patients with long-term tracheotomies. The majority of these events are related to self-limited etiologies, such as granulation tissue or suction trauma. Tracheo-arterial fistula, however, represents a frequently fatal form of tracheal hemorrhage that may initially be difficult to distinguish from other causes. Previous reports have described the pathophysiology, presentation and management of tracheo-arterial fistula involving the innominate artery. We describe a case of a 21-month-old male with a history of significant congenital cardiac malformations and chronic tracheotomy tube dependence who presented with intermittent, brisk bleeding from the tracheotomy tube. He was ultimately diagnosed with and treated for an arterio-bronchial fistula from a major aorto-pulmonary collateral artery. We review the etiology and management of this disorder.

Impact of adenotonsillectomy on quality of life in children with obstructive sleep disorders.

OBJECTIVES: To determine the impact of adenotonsillectomy on quality of life (QOL) in children with obstructive sleep disorders (OSDs) before and after surgery. DESIGN: Prospective, observational, before-and-after trial. SETTING: Seven tertiary pediatric otolaryngology practices. PATIENTS: Convenience sample of 101 children (mean age, 6.2 years) with adenotonsillar hypertrophy and OSD scheduled for adenotonsillectomy. INTERVENTION: Adenotonsillectomy was performed in children for OSDs. Quality of life was assessed using the Obstructive Sleep Disorders-6 survey, a validated instrument for detecting QOL change in children with OSDs. Surveys were completed at the initial office visit (visit 1), the day of surgery (visit 2), and at the postoperative office visit (visit 3). Physical characteristics were assessed using tonsillar and orocraniofacial scales (visit 1). Satisfaction with health care decisions was assessed using the Satisfaction With Decision and Satisfaction With Office Visit scales (visit 1). MAIN OUTCOME MEASURES: Short-term changes in QOL before (visits 1 and 2) and after (visits 2 and 3) surgery. RESULTS: Changes in QOL before surgery were trivial or small, and smaller than changes after surgery (mean change score, 0.18 vs 2.3; P<.001). Large, moderate, and small improvements in QOL were seen in 74.5%, 6.1%, and 7.1% of children, respectively. Sleep disturbance, caregiver concern, and physical suffering were the most improved domains, although significant changes also occurred for speech and swallowing problems, emotional disturbance, and activity limitations. Five percent of children had poorer QOL after surgery, but no predictive factors were identified. CONCLUSION: Adenotonsillectomy produces large improvements in at least short-term QOL in most children with OSDs.