Utility of chest x-ray for tracheostomy tube placement in pediatric patients.

Objective: To evaluate the utility of ordering chest x-rays after pediatric tracheostomy tube placement in identifying acute, post-operative complications and how it impacts clinical decision-making. Methods: In this retrospective cohort study, we identified tracheostomies performed in 139 pediatric patients through CPT codes over a 5-year period from 2013 to 2018. Manual chart review was performed for demographic and clinical characteristics, pre-procedure and post-procedure chest x-ray interpretations, and the presence of complications. Each complication was reviewed to see if action was taken due to post-procedure chest x-ray findings. Multivariable logistic regression was performed to determine associations with changes in pre-procedure versus post-procedure chest x-rays. Results: In a cohort of 139 pediatric patients with pre-procedure and post-procedure chest x-rays, 40 (28.8%) of patients had new significant post-procedure chest x-ray findings compared to pre-procedure chest x-ray findings. Of these 40 instances of changes in pre-procedure versus post-procedure chest x-ray findings, only eight resulted in action being taken due to the observed findings. Among these eight instances of action being taken, only one instance involved in invasive action being taken with a bronchoscopy. With multivariable regression analysis, patient age, race, gender, and the presences of genetic syndromes, were not found to be significant risk factors in predicting changes in pre-procedure versus post-procedure chest x-ray. Conclusion: In our study, post-procedure chest x-ray after tracheostomy tube placement did not significantly impact clinical decision making. It may be worth reconsidering the value in routine chest x-rays after tracheostomy tube placement in pediatric patients.

Revision Endoscopic Posterior Costal Cartilage Grafting: Is It Feasible?

The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty-one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p > .05). There was no difference between groups with respect to decannulation rate (85% primary vs 100% revision, p = .32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients.

Neonatal Laryngotracheal Anomalies.

Respiratory distress in the neonate is one of the most common reasons for referral to a tertiary NICU, accounting for more than 20% of admissions. (1) The cause of respiratory distress can range from parenchymal lung disease to anomalies of any portion of the neonatal airway including the nose, pharynx, larynx, trachea, or bronchi. This review will focus on airway anomalies at or immediately below the level of the larynx. Although rare, those with such congenital or acquired laryngotracheal anomalies often require urgent evaluation and surgical intervention. This review describes 1) the pathophysiology associated with congenital and acquired laryngotracheal deformities in the neonate, 2) the clinical presentation and diagnostic evaluation of these anomalies, and 3) the current medical and surgical strategies available in the NICU and after discharge.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

OBJECTIVE: We describe the Clickbusters initiative implemented at Vanderbilt University Medical Center (VUMC), which was designed to improve safety and quality and reduce burnout through the optimization of clinical decision support (CDS) alerts. MATERIALS AND METHODS: We developed a 10-step Clickbusting process and implemented a program that included a curriculum, CDS alert inventory, oversight process, and gamification. We carried out two 3-month rounds of the Clickbusters program at VUMC. We completed descriptive analyses of the changes made to alerts during the process, and of alert firing rates before and after the program. RESULTS: Prior to Clickbusters, VUMC had 419 CDS alerts in production, with 488 425 firings (42 982 interruptive) each week. After 2 rounds, the Clickbusters program resulted in detailed, comprehensive reviews of 84 CDS alerts and reduced the number of weekly alert firings by more than 70 000 (15.43%). In addition to the direct improvements in CDS, the initiative also increased user engagement and involvement in CDS. CONCLUSIONS: At VUMC, the Clickbusters program was successful in optimizing CDS alerts by reducing alert firings and resulting clicks. The program also involved more users in the process of evaluating and improving CDS and helped build a culture of continuous evaluation and improvement of clinical content in the electronic health record.

Pediatric Otolaryngology Telehealth in Response to COVID-19 Pandemic: Lessons Learned and Impact on the Future Management of Pediatric Patients.

BACKGROUND: Since the start of the COVID-19 pandemic outpatient medicine has drastically been altered how it is delivered. This time period likely represents the largest volume of telehealth visits in the United States health care history. Telehealth presents unique challenges within each subspecialty, and pediatric otolaryngology is no different. This retrospective review was designed to evaluate our division of pediatric otolaryngology's experience with telehealth during the COVID19 pandemic. METHODS: This study was approved by the Institutional Review Board at Vanderbilt University Medical Center. All telehealth and face-to-face visits for the month of April 2020 completed by the Pediatric Otolaryngology Division were reviewed. A survey, utilizing both open-ended questions and Likert scaled questions was distributed to the 16 pediatric otolaryngology providers in our group to reflect their experience with telehealth during the 1-month study period. RESULTS: In April, 2020 our outpatient clinic performed a total of 877 clinic visits compared to 2260 clinic visits in April 2019. A total of 769 (88%) were telehealth visits. Telemedicine with video comprised 523 (68%) and telephone only comprised 246 (32%). There were 0 telehealth visits in April 2019. Interpretive services were required in 9.3% (N = 211) clinic visits in April 2019 and 7.5% (N = 66) of clinic visits in April 2020. The survey demonstrated a significant difference (P < .00002) in provider's anticipated telehealth experience (mean 3.94, 95% CI [3.0632, 4.8118] compared to their actual experience after the study period (mean 7.5, 95% CI [7.113, 7.887]. CONCLUSIONS: Despite low initial expectations for telehealth, the majority of our providers felt after 1 month of use that telehealth would continue to be a valuable platform post-pandemic clinical practice. Limited physical exam, particularly otoscopy, nasal endoscopy, and nasolaryngoscopy present challenges. However, with adequate information and preparation for the parents and for the physician some of the obstacles can be overcome.

Airway and Swallowing Outcomes Following Laryngotracheoplasty With Posterior Grafting in Children.

OBJECTIVES/HYPOTHESIS: Evaluate swallowing and airway outcomes following laryngotracheoplasty with posterior grafting (LTP PCCG). METHODS: Retrospective review of pediatric patients undergoing LTP PCCG from 2016 to 2019 at a tertiary care pediatric hospital. We included demographics, indications, approach, and revision status. We evaluated preoperative and postoperative instrumental and functional swallow evaluations, and we also gathered information on airway outcomes. RESULTS: Thirty-one patients were included in the study. Median (interquartile range [IQR]) age was 4.0 (2.0, 7.0) years old. Primary indication for surgery was bilateral vocal cord immobility (BVCI) in 11 (35.5%) and posterior glottic stenosis (PGS) in 20 (64.5%). Mean (standard deviation) length of follow-up was 11.0 (8.3) months. Twelve patients had gastrostomy tubes (GT) before surgery, and no patients required placement of GT after surgery. Of the remaining 19 patients, 6 required nasogastric feeding for >4 weeks (average length 1.8 months, longest 3.5 months). At last follow-up, 25 (80.6%) patients were primarily orally fed. Eighteen patients had tracheotomies prior to surgery. No patients without a tracheostomy required placement of tracheostomy before or after surgery and only 1 patient had a tracheostomy at last follow-up. Average time to decannulation was 3.7 months, with surgery-specific success of 87.1% and overall success of 96.8%. Four (12.9%) patients required a major intervention to achieve decannulation. CONCLUSION: LTP PCCG is an effective surgical technique to address PGS and BVCI with high decannulation rates. It may cause temporary swallowing dysfunction, but in this series a majority of children were orally fed at last follow-up. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2798-2804, 2021.

Use of Steroid-Eluting Stents after Endoscopic Repair of Choanal Atresia: A Case Series with Review.

OBJECTIVE(S): To describe a single institution's experience with the use of steroid-eluting stents after endoscopic transnasal repair of choanal atresia. METHODS: A case series with review of children who underwent choanal atresia repair at a tertiary children's hospital from June 2017 to January 2018 was performed. Those who had a mometasone drug-eluting stent (Propel® Mini, Intersect ENT Inc., Palo Alto, CA) placed after primary or secondary choanal atresia repair at our institution were included. The primary outcome measure was need for revision surgery due to stenosis. Postoperative regimens, duration of stenting, and need for return to the operating room (OR) were also assessed. RESULTS: Five patients with a median age of 22 months at the time of repair met inclusion criteria. Two (40%) had bilateral atresia and 3 (60%) had confirmed CHARGE syndrome. A total of 6 mometasone drug-eluting stents were used in the 5 cases. Three patients were reassessed at least once in the OR; however, the majority (57.1%) of postoperative evaluations were able to be performed in the office or bedside setting. The first and last evaluations occurred a mean of 14 and 124 days after surgery, respectively. There were no instances of restenosis, repeat surgical interventions, or stent-related complications noted. CONCLUSION: Placement of a mometasone drug-eluting stent is a promising method to improve postoperative results and management of choanal atresia repair by limiting the need for repeat anesthetics and OR procedures, as well as the complications of traditional stents.

Timing of Initial Posttracheostomy Surveillance Endoscopy in Pediatric Patients.

OBJECTIVE: To determine the optimal timing of the first posttracheostomy microlaryngoscopy and bronchoscopy (MLB). STUDY DESIGN: Case series with chart review. SETTING: Tertiary pediatric medical center. SUBJECTS AND METHODS: Patients (<21 years of age) who underwent tracheostomy placement from January 1, 2011, to December 31, 2016. Patients were divided into early and late posttracheostomy surveillance groups (<6 weeks vs 6 to 14 weeks, respectively) based on the timing of their first posttracheostomy MLB. The primary outcome was to ascertain the clinical yield of the initial posttracheostomy MLB by documenting whether a medical or surgical treatment decision was made based on MLB findings. RESULTS: In total, 202 patients were included; of these patients, 162 met criteria for placement in the early group and 40 met criteria for the late group. There was no significant difference between the early and late groups regarding whether a medical or surgical decision was made at the time of the first MLB (21.5% vs 19%, respectively; P = .49). Multiple logistic regression identified that the presence of tracheostomy-related symptoms prior to MLB (odds ratio, 6.75; 95% confidence interval, 2.78-16.39) was the sole predictor of a medical or surgical decision being made at the first posttracheostomy MLB. CONCLUSION: The presence of tracheostomy-related symptoms was predictive of a medical or surgical decision being made using information obtained at the time of the first posttracheostomy MLB. We thus recommend that surveillance endoscopy be initiated when tracheotomized children start to develop tracheostomy-related symptoms.

CO2 laser supraglottic resurfacing for non-granulomatous chronic supraglottitis in two children.

Chronic epiglottitis and supraglottitis are clinical entities that present with respiratory distress and are primarily associated with autoimmune disorders, gastroesophageal reflux disease, or angioedema. First described in adults with sarcoidosis in 2010, CO2 laser epiglottis resurfacing has been effective in reducing epiglottic edema. We present two cases of adolescent males with non-granulomatous chronic supraglottitis who were successfully treated with CO2 laser supraglottic resurfacing.

Growth and Management of Repaired Complete Tracheal Rings after Slide Tracheoplasty.

OBJECTIVE: This study documents the growth and course of repaired complete tracheal rings over time after slide tracheoplasty. STUDY DESIGN: Case series with review. SETTING: Tertiary pediatric academic medical center. SUBJECTS/METHODS: Medical records of pediatric patients with confirmed tracheal rings on bronchoscopy who underwent slide tracheoplasty between January 2001 and December 2015 were reviewed. Patients who had operative notes documenting tracheal sizing over time were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings, surgical repair prior to presentation at our institution, or lack of adequate sizing information. The postoperative follow-up was examined and airway growth over time documented. RESULTS: Of 197 slide tracheoplasties performed during the study time period, 139 were for complete tracheal rings, and 40 of those children met inclusion criteria. The median age at time of surgery was 7 months, and the median initial airway size was 3.9 mm (n = 34). The median growth postoperatively was 1.9 mm over a median follow-up period of 57 months (0.42 mm/year), which is similar to growth rates of unrepaired complete tracheal rings (P = .53). Children underwent a median of 10 postoperative endoscopies, with time between endoscopies increasing further out from surgery. The most commonly performed adjunctive procedure was balloon dilation. CONCLUSIONS: This is the first study documenting continued growth of repaired complete tracheal rings after slide tracheoplasty. Postoperative endoscopic surveillance ensures adequate growth. Intervals between airway endoscopies can be increased as the child gets older, as the airway increases in size, and as long as symptoms are minimal.

Thoracoscopic posterior tracheopexy for tracheomalacia: A minimally invasive technique.

BACKGROUND: Tracheomalacia is the most common congenital abnormality of the trachea. Posterior tracheopexy to alleviate posterior intrusion contributing to dynamic tracheal collapse has been reported using thoracotomy or median sternotomy. Here we describe the minimally invasive operative technique of thoracoscopic posterior tracheopexy with bronchoscopic guidance. OPERATIVE TECHNIQUE: After preoperative computed tomography and bronchoscopy, a right thoracoscopic approach is utilized. The esophagus is mobilized and the membranous trachea is sutured to the prevertebral fascia under direct bronchoscopic visualization. Immediate improvement in tracheal collapse is noted. No major complications are reported and length of stay is short. Aortopexy may also be required to address anterior vascular compression. CONCLUSION: Thoracoscopic posterior tracheopexy is safe and feasible. Further studies with more patients and longer follow-up are needed to assess durability.

Unrepaired Complete Tracheal Rings: Natural History and Management Considerations.

Objectives To document the natural growth pattern of unrepaired complete tracheal rings (UCTRs) and describe the patient population managed conservatively. Study Design Case series with chart review. Setting Tertiary pediatric academic center. Subjects/Methods Medical records of patients with confirmed complete tracheal rings on bronchoscopy from 1993 to 2017 were reviewed. Patients aged 0 to 18 who had documented tracheal sizing over time and did not require surgical intervention were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings. Comorbidities and airway characteristics were documented in addition to endoscopic findings. These were compared with children requiring surgical repair. Results In total, 149 patients with complete tracheal rings were identified. Twenty-five had UCTRs for an overall 16.8% rate of conservative management. Nineteen patients met inclusion criteria and underwent a total of 90 microlaryngoscopy and bronchoscopies (MLBs) with sizing. The growth of the UCTRs over time, based on MLB sizing, was chronicled. The median airway growth noted was 0.38 mm/y. A moderately strong positive correlation was seen between age and airway size ( rs = 0.72, P < .0001). Children with UCTRs were less likely to have long-segment involvement than those who required repair (92%, P = .024). Conclusions A select group of children with complete tracheal rings can be managed expectantly without surgical intervention. Conservative management may be less successful in children with long-segment complete tracheal rings. Airway growth does occur in this population and can be monitored over time. Having a standardized method for sizing UCTRs allows for more effective communication between providers and assurance of continued growth of the airway while following these patients.

An updated review of pediatric drug-induced sleep endoscopy.

Objectives: Drug-induced sleep endoscopy (DISE) involves assessment of the upper airway using a flexible endoscope while patients are in a pharmacologically-induced sleep-like state. The aim of this article is to review the current literature regarding the role of DISE in children with obstructive sleep apnea (OSA). The indications, typical anesthetic protocol, comparison to other diagnostic modalities, scoring systems, and outcomes are discussed. Methods: A comprehensive review of literature regarding pediatric DISE up through May 2017 was performed. Results: DISE provides a thorough evaluation of sites of obstruction during sedation. It is typically indicated for children with persistent OSA after tonsillectomy, those with OSA without tonsillar hypertrophy, children with risk factors predisposing then to multiple sites of obstruction, or when sleep-state dependent laryngomalacia is suspected. The dexmedotomidine and ketamine protocol, which replicates non-REM sleep, appears to be safe and is often used for pediatric DISE, although propofol is the most commonly employed agent for DISE in adults. Six different scoring systems (VOTE, SERS, Chan, Bachar, Fishman, Boudewyns) have been used to report pediatric DISE findings, but none is universally accepted. Conclusions: DISE is a safe and useful technique to assess levels of obstruction in children. There is currently no universally-accepted anesthetic protocol or scoring system for pediatric DISE, but both will be necessary in order to provide a consistent method to report findings, enhance communication among providers and optimize surgical outcomes. Level of Evidence: N/A.

Tracheostomy Complications in Institutionalized Children with Long-term Tracheostomy and Ventilator Dependence.

OBJECTIVES: (1) To identify tracheostomy complications in institutionalized children with chronic tracheostomy. (2) To determine factors that predispose to development of tracheostomy complications in institutionalized children with chronic tracheostomy. STUDY DESIGN: Case series with chart review over 10 years. SETTING: Tertiary children's hospital. SUBJECTS AND METHODS: Children were included if they underwent tracheostomy before 21 years of age and resided at a pediatric nursing facility. Most children were ventilator dependent and had severe comorbid medical conditions, including developmental delay and cerebral palsy. The number of tracheostomy complications and unplanned hospital admissions were recorded. Interventions for tracheostomy complications were also reviewed. RESULTS: Thirty-two institutionalized children with chronic tracheostomy were included. The mean age at time of tracheostomy was 5.4 years, with a mean duration of institutionalization of 9.1 years. Twenty-seven children (84%) experienced tracheostomy complications. The total number of complications was 79. The most common tracheostomy complications identified were peristomal granulation (n = 13) and suprastomal granulation (n = 12). Age at time of tracheostomy, duration of institutionalization, and ventilator dependence did not predict the likelihood of developing a complication. Of 32 patients, 20 were evaluated in the emergency room during the study, and there were 48 unplanned admissions for tracheostomy-related complications during the study. Forty-five urgent direct laryngoscopy and bronchoscopy procedures were performed in a total of 20 children with tracheostomy complications. CONCLUSIONS: Tracheostomy complications are common in institutionalized children with chronic tracheostomy and are challenging to manage. Further research is necessary to determine novel ways to reduce tracheostomy complications in this population.

Identifying musical difficulties as they relate to congenital amusia in the pediatric population.

INTRODUCTIONS/OBJECTIVES: Approximately 4% of the population fails to develop basic music skills and can be identified as "amusic". Congenital amusia (CA), or "tone deafness", is thought to be a hereditary disordera predominantly affecting the perception and production of music. The gold standard for diagnosis is the Montreal Battery for Evaluation of Amusia (MBEA). This study aims to pinpoint factors in the history that may help identify amusic children and to determine if amusic pediatric patients can be identified using a widely available, shorter test validated in adults. METHODS: Subjects ages 7-17 years were recruited to take an online test, validated against the MBEA, for CA. The sections tested recognition of "off-beat" (OB), "mistuned" (MT), and "out-of-key" (OOK) conditions. Parents filled out a questionnaire regarding the subject's past medical, educational, musical exposure, and family history. RESULTS: Of 114 subjects recruited, complete data was available on 105 with a mean age of 12.5 years. According to adult criteria, 63/105 (60%) of subjects scored in the "amusic" range. Children >10 years of age scored significantly higher on the off-beat section (p=0.001) and total scores (p=0.025). Subjects who were born prematurely scored significantly lower (p=0.045). Children whose father had difficulties with music scored significantly lower on the off-beat section (p=0.003) and total scores (p=0.008). CONCLUSIONS: CA is a disorder that has implications for quality of life. Earlier identification may help elucidate the pathogenesis of the condition and, in the future, the institution of prompt treatment. Further studies are needed to identify the most appropriate and convenient tests, as well as the optimal timing of testing, for reliably diagnosing CA in children.

A case of mania due to cryptococcal meningitis, successfully treated with adjunctive olanzapine, in a patient with acquired immunodeficiency syndrome.

We report on the case of a patient with acquired immune deficiency syndrome- and Cryptococcus neoformans meningitis-related mania in which olanzapine was successfully used adjunctively and transiently to antifungal therapy.

Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: comparing three tonsillectomy techniques.

OBJECTIVE: To compare the rates of major complications (postoperative hemorrhage requiring return to the operating room or cauterization in the emergency department and dehydration requiring intravenous fluids or readmission) in a large cohort of children undergoing adenotonsillectomy by three different techniques. STUDY DESIGN: Case series with chart review, case-controlled study. SETTING: Regional children's hospital. SUBJECTS AND METHODS: Subjects comprised patients aged 1 to 18 years undergoing adenoidectomy, tonsillectomy, or adenotonsillectomy by microdebrider, coblator, or Bovie over a 36-month period. Major complications identified were compared to two case-matched controls to try to identify patients at risk for major postoperative complications. RESULTS: The overall complication rate was 80 of 4776 (1.7 +/- 0.4% [percent +/- 95% confidence interval]). Of the 3362 patients who received either an adenotonsillectomy or tonsillectomy alone, 80 had a complication (2.3 +/- 0.5%). Major complication rates differed among tonsil removal techniques: 34 of 1235 (2.8 +/- 0.9%) coblation; 40 of 1289 (3.1 +/- 0.9%) electrocautery; six of 824 (0.7 +/- 0.7%) microdebrider (P < 0.001). Postoperative hemorrhage occurred in older children (8.5 vs 5.5 years; P < 0.001), while age did not influence postsurgical dehydration (5.33 vs 5.49 years). The case-control portion of the study did not find any reliable way to identify patients at risk for complications during adenotonsillectomy. Identity of the surgeon was not a confounding independent variable, nor was participation by resident surgeons. CONCLUSION: In this "real life" teaching hospital surgical setting in which three different techniques of tonsillectomy are routinely performed by a variety of resident and attending surgeons, microdebrider intracapsular tonsillectomy is associated with lower rates of post-tonsillectomy hemorrhage and dehydration when compared to coblation and electrocautery complete tonsillectomy technique.