Neighborhood Socioeconomic Disadvantage and Long-Term Outcomes After Pediatric Tracheostomy.

OBJECTIVES: To determine whether long-term outcomes after pediatric tracheostomy are impacted by neighborhood socioeconomic disadvantage. METHODS: A prospective cohort of children with tracheostomies was followed at an academic pediatric hospital between 2015 and 2020. Patients were grouped into low or high socioeconomic disadvantage using their neighborhood area deprivation index (ADI). Survival and logistic regression analyses determined the relationship between ADI group, decannulation, and mortality. RESULTS: A total of 260 children were included with a median age at tracheostomy of 6.6 months (interquartile range [IQR], 3.9-42.3). The cohort was 53% male (N = 138), 55% White race (N = 143), and 35% Black or African American (N = 90). Tracheostomy was most frequently indicated for respiratory failure (N = 189, 73%). High neighborhood socioeconomic disadvantage was noted for 66% of children (N = 172) and 61% (N = 158) had severe neurocognitive disability. ADI was not associated with time to decannulation (HR = 0.90, 95% confidence interval [95% CI]: 0.53-1.53) or time to death (HR = 0.92, 95% CI: 0.49-1.72). CONCLUSIONS: Neighborhood socioeconomic disadvantage was not associated with decannulation or mortality among children with a tracheostomy. These findings suggest that long-term outcomes after pediatric tracheostomy are less dependent on socioeconomic factors in an individual community. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2415-2421, 2024.

Bronchopulmonary dysplasia and ventilation-associated outcomes after pediatric tracheostomy.

OBJECTIVES: The objective of this study is to determine the time to ventilator liberation and decannulation after tracheostomy placement in children with bronchopulmonary dysplasia (BPD) and pulmonary hypertension. METHODS: A prospective cohort study included all children (<18 years old) who underwent tracheostomy between 2015 and 2021 with or without a diagnosis of BPD. The primary outcomes were time to ventilator liberation, tracheostomy decannulation, or death with tracheostomy in place. RESULTS: A total of 303 children met inclusion with a median (interquartile range [IQR]) age at tracheostomy of 6.9 (IQR: 4.0-49.5) months. A diagnosis of BPD was made for 42% (N = 127) and this group was younger (5.1 vs. 24.5 months, p < .001) and more often had pulmonary hypertension (68% vs. 24%, p < .001). Children with BPD spent a median of 2.9 years (IQR: 1.6-4.0) on ventilation compared to 1.9 years (IQR: 0.9-3.7) for children without BPD (p = .009). The time to decannulation was greater among children with BPD (3.4 vs. 1.8 years, p < .001). However, unadjusted estimates of ventilator liberation (hazard ratio [HR]: 1.05, 95% confidence interval [95% CI]: 0.77-1.44) and decannulation (HR: 1.11, 95% CI: 0.74-1.66) over time were not prolonged by BPD. Pulmonary hypertension was associated with shorter time to death (adjusted HR [aHR] = 1.99, 95% CI: 1.17-3.38, p = .01), while BPD was associated with longer time to death (aHR: 0.38, 95% CI: 0.22-0.67, p = .001). CONCLUSION: BPD is associated with increased ventilation and duration of tracheostomy but over time many children with BPD will wean off the ventilator and be decannulated. Pulmonary hypertension and not BPD is associated with increased time to death after tracheostomy.

Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation.

OBJECTIVES: To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence. STUDY DESIGN: Prospective cohort. METHODS: All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation. RESULTS: A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p = 0.049) with failure to spontaneously close. CONCLUSIONS: Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:417-422, 2023.

Association of Genre of Singing and Phonotraumatic Vocal Fold Lesions in Singers.

OBJECTIVES/HYPOTHESIS: To determine if (1) the likelihood of presenting with phonotraumatic lesions differs by singing genre in treatment-seeking singers and (2) if the distribution of phonotraumatic lesion types differs by singing genre. STUDY TYPE: Retrospective. METHODS: Records of singers who presented with a voice complaint over the course of 2.5 years (June 2017-December 2019) were reviewed to determine the proportion of those with phonotraumatic lesions as a function of genre (Study 1). Separately, the lesion types and genres of singers diagnosed with phonotraumatic lesions over a 9-year period (July 2011-March 2020) were determined (Study 2). RESULTS: In Study 1, 191 of 712 (26.8%) dysphonic singers were diagnosed with phonotraumatic lesions. Country/folk, gospel/jazz, and musical theater singers were more likely to present with phonotraumatic lesions. In Study 2, in 443 singers with phonotraumatic lesions, polyps and pseudocysts, but not nodules, were found to be distributed unequally across genres (χ2 p = 0.006, p < 0.0001, p = 0.064, respectively). Praise/worship singers had significantly higher proportions of polyps compared to choral singers (OR 4.8 [95% CI 1.9-12.5]) or compared to musical theater singers (OR 7.2 [95% CI 2.5-20.8]). Opera singers had significantly higher proportions of pseudocysts than choral singers (OR 3.1 [95% CI 1.5-6.1]) or musical theater singers (OR 3.7 [95% CI 1.8-7.6]). CONCLUSIONS: The higher incidence of polyps in praise/worship singers likely reflects the more emphatic nature of singing and the tendency for acute injury. The higher incidence of pseudocysts in opera singers may reflect a more chronic nature of injury. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1683-1689, 2023.

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children.

Importance: The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored. Objective: To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event. Design, Settings, and Participants: This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023. Main Outcomes and Measures: Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy. Results: Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%. Conclusions and Relevance: This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

Emergency Department Visits and Hospitalizations After Pediatric Tracheostomy.

OBJECTIVE: To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy. METHODS: A prospective cohort of children (<18 years) with a tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits). RESULTS: A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory-related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18-3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35-5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47-10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy-related complications, which accounted for 4.8% of all encounters. A sub-analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure. CONCLUSION: Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy-related visits are uncommon, strategies to anticipate and decrease respiratory-related admissions may have the most impact. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2018-2024, 2023.

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.