Management of the Disrupted Airway in Children.

OBJECTIVE: Our objective was to gather data that would enable us to suggest more specific guidelines for the management of children with airway disruption. STUDY DESIGN: Retrospective case series with data from five tertiary medical centers. METHODS: Children younger than 18 years of age with a disrupted airway were enrolled in this series. Data pertaining to age, sex, etiology and location of the disruption, type of injury, previous surgery, presence of air extravasation, management, and outcome were obtained and summarized. RESULTS: Twenty children with a mean age of 4.4 years (range 1 day-14.75 years) were included in the study. All were evaluated by flexible endoscopy and/or microlaryngoscopy in the operating room. Twelve (60%) children had tracheal involvement; seven had bronchial involvement; and one had involvement of the cricoid cartilage. Nine children had air extravasation, and all these children required surgical repair. Of the 11 who did not have air extravasation, only one underwent surgical repair. Complete healing of the disrupted airway was seen in all cases. CONCLUSION: This series suggests that if there is no continuous air extravasation demonstrated on imaging studies or clinical examination, nonoperative management may allow for spontaneous healing without sequelae. However, surgical repair may be considered in those patients with continuous air extravasation unless a cuffed tube can be placed distal to the site of injury. For children in whom airway injury occurs in a previously operated area, the risk of extravasation is reduced. This risk is also diminished if positive pressure ventilation can be avoided or minimized. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:921-924, 2021.

Effectiveness of pediatric drug-induced sleep endoscopy for REM-predominant obstructive sleep apnea.

STUDY OBJECTIVES: Because dexmedetomidine (DEX)-induced sedation mimics non-rapid eye movement (NREM) sleep, its utility in sedating children with REM-predominant disease is unclear. We sought to determine the effectiveness of pediatric drug-induced sleep endoscopy (DISE) using DEX and ketamine for children with REM-predominant OSA, specifically whether or not at least one site of obstruction could be identified. METHODS: A retrospective case series of children without tonsillar hypertrophy undergoing DISE at a tertiary pediatric hospital from 10/2013 through 9/2015 who underwent subsequent surgery to address OSA with polysomnography (PSG) before and after. RESULTS: We included 56 children, mean age 5.6±5.4 years, age range 0.1-17.4 years, mean BMI 20.3±7.4 kg/m2 (76±29 percentile). At least one site of obstruction was identified in all patients, regardless of REM- or NREM-predominance. The mean obstructive apnea-hypopnea index (oAHI) improved (12.6 ± 10.7 to 9.0 ± 14.0 events/h) in children with REM-predominant (P = 0.013) and NREM-predominant disease (21.3 ± 18.9 to 10.3 ± 16.2 events/h) (P = 0.008). The proportion of children with a postoperative oAHI < 5 was 53% and 55% for REM- and NREMpredominant OSA, respectively. Unlike children with NREM-predominant disease, children with REM-predominant disease had significant improvement in the mean saturation nadir (P < 0.001), total sleep time (P = 0.006), and sleep efficiency (P = 0.015). CONCLUSIONS: For children with OSA without tonsillar hypertrophy, DISE using DEX/ketamine was useful to predict at least one site of obstruction, even for those with REM-predominant OSA. DISE-directed outcomes resulted in significant improvements in mean oAHI, total sleep time, sleep efficiency, saturation nadir, and the proportion with oAHI < 5, after surgery for some children with REM-predominant disease.

Pilot Study to Assess the Use of Ultrasound in Evaluating the Abnormal Pediatric Airway.

In this study, we sought to explore the feasibility of using ultrasonography to evaluate airway anomalies in awake children with previous airway reconstruction. For the month of December 2018, we reviewed the medical records of patients aged <18 years old with prior airway reconstruction who had an outpatient appointment and a microlaryngoscopy and bronchoscopy within 24 hours of each other. Four patients met inclusion criteria and were enrolled. Sonographic airway images and measurements were obtained during the outpatient appointment and compared with those obtained during endoscopy. Ultrasound identified extraluminal stents and glottic, subglottic, and tracheal pathology. Subglottic measurements obtained sonographically were within 0.1 to 0.5 mm of the outer diameter of the appropriate endotracheal tubes. Ultrasound did not visualize tracheotomy tubes or posterolateral pathology. Our findings lay the foundation for expanding the role of ultrasound in pediatric airway assessment, keeping in mind its apparent inability to visualize posterolateral airway pathology.

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.

The Effect of Cleft Palate Repair on Polysomnography Results.

STUDY OBJECTIVES: In view of the risk that surgical repair of cleft palate may induce or worsen obstructive sleep apnea (OSA), the goal of this study was to assess presurgical and postsurgical polysomnography (PSG) results for children who underwent primary palatoplasty. METHODS: Retrospective case-control series for children with cleft palate repair performed between January 2008 and December 2016 at a tertiary pediatric center. Children underwent PSG before and after surgery. RESULTS: Sixty-four children (53.1% female) with a mean age of 2.0 ± 2.8 years (range 0.6-16.4) were included in the study. Pierre-Robin sequence was the most common comorbidity (67%). Before palatal repair, the mean obstructive apnea-hypopnea index (oAHI) was 3.4 ± 3.9 (range 0-17.9) events/h; this did not significantly change, with 5.9 ± 14.5 (range 0-105.7) events/h after surgery (P = 0.30). However, 34.4% of patients had a worsening of more than 1 obstructive event/h and 18.9% had a worsening of 5 or more obstructive events/h. The presence of a concomitant syndrome (eg, Treacher Collins) was a risk factor for postoperative OSA (odds ratio 4.2, 95% confidence interval 1.1-15.8, P = .03). CONCLUSIONS: OSA did not develop or worsen following primary palatoplasty. However, the oAHI increased by 5 or more events/h in approximately 20% of study participants. The presence of a syndrome was the only factor predictive of worsening OSA after palatoplasty. These findings suggest that palatoplasty does not worsen or cause OSA in most patients, and that nonsyndromic children are at low risk for the development or worsening of OSA.

Endoscopic posterior cricoid reduction: A surgical method to improve posterior glottic diastasis.

OBJECTIVES/HYPOTHESIS: Describe the preoperative evaluation of patients with glottic diastasis who are candidates for endoscopic posterior cricoid reduction (EPCR) and their perioperative and postoperative surgical and voice outcomes, and validate the aerodynamic benefit of EPCR using computation fluid dynamics (CFD)-based modeling from computed tomography (CT) scans. STUDY DESIGN: Retrospective case series. METHODS: Thirteen patients who underwent EPCR were followed from 2013 to 2017. They received a preoperative voice evaluation, microlaryngoscopy and bronchoscopy, dynamic voice CT (performed on patients seen from 2014 to study completion), and postoperative voice evaluation (n = 12). Postoperative inpatient days, complications, and postoperative endoscopic intervention were collected. To validate the aerodynamic benefit of EPCR, CFD modeling was carried out on one patient. RESULTS: Thirteen patients (nine females, nine with intubation injury, and four with post-airway reconstruction dysphonia) underwent EPCR at a mean age of 11.0 years. The mean preoperative and postoperative Pediatric Voice handicap Index scores were 53.8 and 33.8, respectively (P = .006). Mean maximum phonation time preoperatively and postoperatively was 5.3 and 6.7, respectively (P = .04). Of eight patients who underwent preoperative CT imaging, all demonstrated a posterior gap. Modeling demonstrated a change in flow and pressure. The mean hospital stay was 2.4 days. Nine patients underwent postoperative endoscopic intervention, and one experienced a complication that resolved with intervention. CONCLUSIONS: Patients who underwent EPCR for dysphonia following intubation or airway reconstruction showed improvements in vocal efficiency, loudness, and perceived voice handicapping. Their hospital stay was brief, with few complications. CFD modeling corroborated these clinical findings. EPCR thus warrants consideration in the management of patients with posterior glottic diastasis. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:S1-S9, 2019.

Development of a survival animal model for subglottic stenosis.

OBJECTIVE: To develop a reproducible survival animal model for subglottic stenosis. STUDY DESIGN: Prospective study. METHODS: We evaluated five methods of inducing airway injury in 30 New Zealand white rabbits to produce a subglottic stenosis model. Experimental groups comprised: group 1 (n = 5), which underwent 4-hour intubation; group 2 (n = 5), which underwent induced subglottic injury with a nylon brush; group 3 (n = 10), which underwent subglottic injury with a nylon brush, followed by 4-hour intubation; group 4 (n = 5), which underwent subglottic injury with Bugbee cautery in 50% of the subglottic circumference, followed by 4-hour intubation; and group 5 (n = 5), which underwent subglottic injury with Bugbee cautery in 75% of the subglottic circumference, followed by 4-hour intubation. Five animals were used as controls. Endoscopy of the airway and sacrifice of animals were planned at an interval of 14 days postinjury. Histologic measurements were analyzed. RESULTS: No animals in groups 1 or 2 developed stenosis. In group 3, 50% of animals developed symptomatic grade 3 subglottic and tracheal stenosis, necessitating early endoscopy and sacrifice in three animals. Four animals in group 4 developed grade 1 subglottic stenosis, and four in group 5 developed grade 2 subglottic stenosis. Histologic measurements of lumen areas within each of these two groups were similar; all animals survived the follow-up period. CONCLUSION: We successfully developed a reproducible survival model for induced subglottic stenosis using a combination of cautery-induced subglottic injury followed by 4-hour intubation. This model lays the foundation for future studies that evaluate endoscopic interventions for the management of subglottic stenosis. LEVEL OF EVIDENCE: NA Laryngoscope, 129:989-994, 2019.

Circadian Dysregulation: The Next Frontier in Obstructive Sleep Apnea Research.

OBJECTIVE: To review the effects of the circadian clock on homeostasis, the functional interaction between the circadian clock and hypoxia-inducible factors, and the role of circadian dysregulation in the progression of cardiopulmonary disease in obstructive sleep apnea (OSA). DATA SOURCES: The MEDLINE database was accessed through PubMed. REVIEW METHODS: A general review is presented on molecular pathways disrupted in OSA, circadian rhythms and the role of the circadian clock, hypoxia signaling, crosstalk between the circadian and hypoxia systems, the role of the circadian clock in cardiovascular disease, and implications for practice. Studies included in this State of the Art Review demonstrate the potential contribution of the circadian clock and hypoxia in animal models or human disease. CONCLUSIONS: Molecular crosstalk between the circadian clock and hypoxia-inducible factors has not been evaluated in disease models of OSA. IMPLICATIONS FOR PRACTICE: Pediatric OSA is highly prevalent and, if left untreated, may lead to cardiopulmonary sequelae. Changes in inflammatory markers that normally demonstrate circadian rhythmicity are also seen among patients with OSA. Hypoxia-inducible transcription factors interact with core circadian clock transcription factors; however, the interplay between these pathways has not been elucidated in the cardiopulmonary system. This gap in knowledge hinders our ability to identify potential biomarkers of OSA and develop alternative therapeutic strategies. A deeper understanding of the mechanisms by which OSA impinges on clock function and the impact of clock dysregulation on the cardiopulmonary system may lead to future advancements for the care of patients with OSA. The aim of this review is to shed light on this important clinical topic.

Comparison of Patient- and Parent-Reported Quality of Life for Patients Treated for Persistent Obstructive Sleep Apnea.

Objectives To evaluate the impact of the treatment of persistent pediatric obstructive sleep apnea (OSA) on quality of life (QOL) with patient-reported outcomes tools and to compare parent- and self-reported Pediatric Quality of Life Inventory (PedsQL) scores. Study Design Prospective case series. Setting Multidisciplinary upper airway center at a tertiary pediatric institution. Subjects and Methods Children with persistent OSA referred to our multidisciplinary upper airway center from 2014 to 2016. Patients and their families completed validated questionnaires for QOL, including the Family Impact Questionnaire, the Obstructive Sleep Apnea-18, the PedsQL, and the Epworth Sleepiness Scale for Children and Adolescents. They completed the same surveys after treatment. Results Twenty-three children (7 females) and their families were included in the study. Patients had a mean age of 12.7 years. Pretreatment, the mean obstructive apnea-hypopnea index was 15.0 events/hour (95% CI, 8.7-21.3); after treatment, the mean was 3.9 events/hour ( P = .003). The mean PedsQL score for children improved from 60.5 to 74.2 ( P = .04). The PedsQL score for parents did not significantly improve (61.6 to 63.8, P = .39). There was a significant though weak association between OSA severity ( R2 = 0.25, P = .03) and PedsQL scores. The Family Impact Questionnaire negative subscore and Epworth Sleepiness Scale for Children and Adolescents scores did not change with treatment. Conclusions For children treated for persistent OSA, we found that self-reported QOL significantly improved after treatment; however, parent-reported QOL did not significantly change. It is unclear if parents underestimate or patients overestimate QOL after treatment. We suggest that patient-reported outcomes be obtained when feasible.

Temporal trends in inpatient pediatric sleep apnea surgery: 1993-2010.

OBJECTIVES/HYPOTHESIS: We sought to characterize changes in the patterns of inpatient surgical sleep care over time and ascertain if these changes were consistent with previously reported trends in adult surgical sleep care. STUDY DESIGN: Repeated cross-sectional study. METHODS: Discharge data from the U.S. Nationwide Inpatient Sample for 125,691 nasal, palatal, or hypopharyngeal procedures in children for sleep-disordered breathing or obstructive sleep apnea (OSA) from 1993 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. RESULTS: Inpatient surgical sleep procedures increased from 45,671 performed in 1993 to 2000 (study period 1) to 80,020 in 2001 to 2010 (study period 2). Overall, patients were commonly male (61.3%), privately insured (46.8%), 2 to 6 years old (39.4%), and white (36.4%). Obesity was reported in 4.6% and 6.7% of children during study periods 1 and 2, respectively (P < .0001). Tonsillectomy (with and without adenoidectomy) was the most commonly performed procedure in both study periods. With the exception of uvulopalatopharyngoplasty and tracheostomy, all sleep procedures increased over time; however, multilevel surgery did not significantly increase (P = .28). Children who underwent sleep surgery during study period 2 were more likely to receive a supraglottoplasty (P = .0125) and to undergo procedures at high-volume hospitals (P = .0311), and less likely to undergo a tracheostomy (P < .0001). CONCLUSIONS: These data reflect changing trends in the surgical management of pediatric OSA, with significant increases in nasal and hypopharyngeal procedures, particularly lingual tonsillectomy and supraglottoplasty. Unlike the trend in adults, multilevel surgery in children with sleep disordered breathing or OSA has not yet been integrated into routine clinical practice. LEVEL OF EVIDENCE: 2C Laryngoscope, 127:1235-1241, 2017.

Subglottic stenosis.

Subglottic stenosis (SGS) is a congenital or acquired condition characterized by a narrowing of the upper airway extending from just below the vocal folds to the lower border of the cricoid cartilage. With the introduction of prolonged intubation in neonates (mid 1960s), acquired SGS became the most frequent cause of laryngeal stenosis; unlike congenital SGS, it does not improve with time. Laryngeal reconstruction surgery evolved as a consequence of the need to manage these otherwise healthy but tracheotomized children. Ongoing innovations in neonatal care have gradually led to the salvage of premature and medically fragile infants in whom laryngeal pathology is often more severe, and in whom stenosis often involves not only the subglottis, but also the supraglottis or glottis-causing significant morbidity and mortality. The primary objective of intervention in these children is decannulation or preventing the need for tracheotomy. The aim of this article is to present a more detailed description of both congenital and acquired SGS, highlighting the essentials of diagnostic assessment and familiarizing the reader with contemporary management approaches.

Obstructive Sleep Apnea Resolution in Hypopnea- versus Apnea-Predominant Children after Adenotonsillectomy.

OBJECTIVE: Given that 30% to 40% of children have persistent obstructive sleep apnea (OSA) after adenotonsillectomy, we evaluated whether children with hypopnea-predominant OSA were more likely to have complete disease resolution after adenotonsillectomy than those with apnea-predominant disease. We also identified risk factors that might modify the relationship between disease resolution and polysomnographic event type (ie, hypopnea vs apnea). STUDY DESIGN: Case series with chart review. SETTING: Tertiary pediatric hospital. SUBJECTS/METHODS: Consecutive 1- to 18-year-old typically developing children diagnosed with OSA from March 2011 to December 2012 underwent adenotonsillectomy and completed pre- and postoperative polysomnography within 1 year of surgery. RESULTS: Fifty-eight children were included (27 female; mean ± SD: age, 5.6 ± 3.1 years; body mass index z score, 1.1 ± 1.7). Overall, adenotonsillectomy resulted in significant improvement in obstructive apnea-hypopnea index (oAHI) from 23.3 ± 40.0 to 4.3 ± 8.2 events per hour (P < .001), obstructive apnea index (5.1 ± 7.4 to 0.4 ± 0.8, P < .001), and obstructive hypopnea index (oHI; 18.1 ± 37.5 to 3.7 ± 8.1, P < .001). There was complete response (oAHI <1.0 event/h) in 24 of 58 patients (41%) but no difference by event type (P = .11). On univariate analysis, only race, sex, oxygen saturation nadir, and oHI were predictive of response to adenotonsillectomy, while multivariate analysis found that prematurity, age, oxygen saturation nadir, oHI, obstructive apnea index, and oAHI were predictive. Event type was not significant, even in a model controlling for age, race, sex, prematurity, asthma, body mass index, and baseline polysomnographic variables. CONCLUSION: This small study demonstrated no difference in disease resolution between children with hypopnea- and apnea-predominant OSA who underwent adenotonsillectomy. Additionally, adenotonsillectomy significantly improved OSA in most children, and high preoperative oAHI was associated with persistent postoperative OSA.

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.

Tracheal and bronchial stenoses and other obstructive conditions.

Although tracheal stenosis and bronchial stenosis are relatively rare in the pediatric population, they are both associated with significant morbidity and mortality. While most cases of congenital tracheal stenosis in children present as complete tracheal rings (CTRs), other congenital tracheal obstructions are also encountered in clinical practice. In addition, acquired obstructive tracheal conditions stemming from endotracheal trauma or previous surgical interventions may occur. Many affected children also have associated cardiovascular malformations, further complicating their management. Optimal management of children with tracheal or bronchial stenoses requires comprehensive diagnostic evaluation and optimization prior to surgery. Slide tracheoplasty has been the operative intervention of choice in the treatment of the majority of these children.

Decision Making for Children with Obstructive Sleep Apnea without Tonsillar Hypertrophy.

OBJECTIVE: Evidence-based medicine is the gold standard practice model for patient management. Our aim was to determine whether decisions made by pediatric subspecialists regarding management of obstructive sleep apnea in children without tonsillar hypertrophy adhered to this model or were based on clinical experiences. STUDY DESIGN: Single-institution prospective study. SETTING: Multidisciplinary upper airway center in an academic pediatric hospital. SUBJECTS AND METHODS: Twelve pediatric subspecialists representing 8 specialties participating in upper airway clinics and management conferences. Real-time decisions made in treatment conferences and upper airway clinics were collected. Physicians were queried regarding the basis of their decisions, and these decisions were then classified into 10 categories. RESULTS: Over 13 days (10 case conferences, 3 half-day clinics), 324 decisions were made for 58 patients (mean age = 8.9 ± 7.4 years, mean body mass index percentile = 75 ± 29); 34% (n = 108) of decisions were evidence based; 59% (n = 193) were nonevidence based; and 7% (n = 23) were based on parental preference. Providers were able to cite specific studies for <20% of these decisions. There was no significant increase in the proportion of evidence-based decisions made over time. CONCLUSIONS: We deemed 34% of decisions regarding the management of obstructive sleep apnea in children without tonsillar hypertrophy to be evidence based and found that sharing the basis for decisions did not improve the percentage of evidence-based decisions over time. These findings reflect significant evidence gaps and highlight the need for a systematic literature evaluation to identify best practice in managing this population. We recommend that these evidence gaps be further characterized and incorporated into an agenda for future research.

Systematic review of site of obstruction identification and non-CPAP treatment options for children with persistent pediatric obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Although adenotonsillectomy is accepted as a first-line therapy for pediatric obstructive sleep apnea (OSA), there is currently no consensus regarding optimal methods for identifying the sites of obstruction or treatment of children with persistent disease after surgery. With this in mind, our aim was to systematically review the English-language literature pertaining to these issues. STUDY DESIGN: Systematic review. METHODS: We searched all indexed years of Pubmed, Cochrane CENTRAL, DynaMed, UpToDate, CINAHL, and Scopus for English-language articles containing original human data, with ≥ 7 participants, all < 18 years old. Data regarding study design, demographics, clinical characteristics/outcomes, level of evidence, and risk of bias were obtained. Articles were independently reviewed by two investigators. RESULTS: Of 758 identified abstracts, 24 articles (combined population = 960) were ultimately included. Seventeen (71%) described methods to identify site(s) of obstruction: drug-induced sleep endoscopy (11/24), cine magnetic resonance imaging (MRI) (3/24), and alternative imaging (3/24). Treatment options included lingual tonsillectomy (n = 6), with success rates of 57% to 88% (Cohen's effect size d = 1.38), as well as supraglottoplasty (n = 4), with success rates of 58% to 72% (d = 0.64). Additional treatments included medications and surgery (e.g., partial midline glossectomy and tongue suspension). CONCLUSIONS: Drug-induced sleep endoscopy and cine MRI are the most commonly reported tools to identify sites of obstruction for children with persistent OSA; however, these techniques have not yet been clearly linked to outcomes. Evidence for treatment is extremely limited and focuses primarily on lingual tonsillectomy and supraglottoplasty. Also, reports regarding appropriate patient selection and outcomes in obese or otherwise healthy children are scant.

Laryngotracheal Cleft Repair in Children With Complex Airway Anomalies.

IMPORTANCE: This study provides clinicians with relevant information regarding the surgical outcomes of patients with laryngotracheal cleft in the context of additional airway anomalies. OBJECTIVES: To determine the rates of surgical success in patients who underwent laryngotracheal cleft repair in the context of additional airway anomalies, determine the revision rate for cleft repair, characterize the time to revision among patients who underwent cleft repair, and assess the functional swallowing outcomes after cleft repair. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study was conducted at a quaternary pediatric center of 81 children diagnosed as having laryngotracheal cleft with or without concomitant airway anomalies who underwent laryngotracheal cleft repair between February 1, 2000, and February 28, 2013. Analysis was conducted from October 1, 2012, through March 30, 2013. INTERVENTIONS: Surgical repair of laryngotracheal cleft. MAIN OUTCOMES AND MEASURES: Surgery-specific success, overall surgical success, and revision rate. We defined surgery-specific success as a repair not requiring revision and overall surgical success as absence of a cleft or TEF at the last operative examination, regardless of the number of revisions required. RESULTS: Of 81 patients with laryngotracheal cleft who underwent surgical repair, 48 (59%) had at least 1 additional airway finding; 24 (30%) had tracheomalacia and 21 (26%) had subglottic stenosis. Seventeen patients required a revision of laryngotracheal cleft repair, with a median time to revision of 8.3 months (interquartile range, 4.3-25.1 months). Six patients required a second revision, with a median interval between revisions of 44.2 months (interquartile range, 28.6-53.6 months). The surgery-specific success rate was 77% (37 of 48) in patients with additional airway anomalies and 82% (27 of 33) in those with laryngotracheal clefts alone. The overall surgical success rate was 92% (44 of 48) in patients with additional airway anomalies and 97% (32 of 33) in those with clefts alone. Fourteen (17%) patients demonstrated swallowing dysfunction postoperatively despite closure of the cleft. CONCLUSIONS AND RELEVANCE: Although additional airway findings were common in our cohort of patients with laryngotracheal clefts, these anomalies did not affect surgery-specific or overall surgical success. The overall surgical success rate for those with and without additional airway anomalies was 92% and 97%, respectively. In view of the fact that cleft breakdown after surgical repair is not uncommon and may occur years after the initial repair, we strongly advocate long-term follow-up. Despite successful closure, a significant percentage of children with laryngotracheal cleft will have persistent swallowing dysfunction.

Surgical management of OSA in adults.

OSA is a common, often chronic, condition requiring long-term therapy. Given the prevalence of OSA, as well as its significant health-related sequelae, a range of medical and surgical treatments have been developed and used with varying success depending on individual anatomy and patient compliance. Although CPAP is the primary treatment, many patients cannot tolerate this treatment and require alternative therapies. In this clinical scenario, surgery is often warranted and useful. Surgical management is aimed at addressing obstruction in the nasal, retropalatal, and retroglossal/hypopharyngeal regions, and many patients have multiple levels of obstruction. This review presents a comprehensive overview of research findings on a wide spectrum of surgical approaches currently used by sleep clinicians when other therapeutic modalities fail to achieve positive outcomes.

Influence of Tonsillar Size on OSA Improvement in Children Undergoing Adenotonsillectomy.

OBJECTIVE: To determine if pediatric obstructive sleep apnea (OSA) improves after adenotonsillectomy (AT) regardless of tonsil size. STUDY DESIGN: Case series with chart review. SETTING: Pediatric Otolaryngology Department, Johns Hopkins Hospital. SUBJECTS: Seventy children 1 to 18 years of age who underwent polysomnography (PSG) before and after AT. METHODS: Tonsil size was evaluated using the Brodsky grading scale. RESULTS: Children were stratified by tonsil size as 2+ (n = 20), 3+ (n = 36), and 4+ (n = 14). There was a significant improvement in obstructive apnea-hypopnea index (oAHI), apnea index (AI), and saturation nadir across all 3 groups after AT. Preoperative oAHI, AI, and hypopnea index (HI) were similar regardless of tonsil size (P > .05). Overall, oAHI improved from a median of 11.8 ± 21.7 to 2.0 ± 6.1 events/h, with 40% (28/70) of children having complete resolution. The oAHI (P < .0001-0.02), AI (P < .0001-0.017), HI (P < .0001-0.058), and saturation nadir (P < .0001-0.017) significantly improved for the 2+, 3+, and 4+ groups. Only the HI (P = .058) in the 2+ group did not. The median oAHI improvement was 3.4 ± 26.4 events/h in the 2+ group, 8.3 ± 16.6 events/h in the 3+ group, and 12.3 ± 19.5 events/h in the 4+ group, with 25% (5/20), 50% (18/36), and 36% (5/14), respectively, having complete resolution. There was no correlation between OSA severity and tonsil or adenoid size (P > .32). CONCLUSION: Tonsil size did not correlate with OSA severity. While a larger proportion of patients classified as 3+ and 4+ had complete resolution after surgery, significant improvement was seen in AI and saturation nadir even in those classified as 2+.

Does surgery for obstructive sleep apnea improve depression and sleepiness?

OBJECTIVES/HYPOTHESIS: To determine if surgical intervention for OSA (obstructive sleep apnea), particularly multilevel surgery, decreases depression and sleepiness. STUDY DESIGN: Prospective cohort study. METHODS: Chart and prospective outcome database review of patients who underwent surgery from August 2008 through November 2012. Patients were evaluated before and after surgery using the Epworth Sleepiness Scale (ESS), the Beck Depression Index (BDI), and overnight polysomnography. RESULTS: Forty-four patients (12 females; 32 males) met inclusion criteria. Mean age of participants was 44.0 years (SD, 10.2); mean body mass index was 31.9 (SD, 9.3). The mean preoperative obstructive respiratory disturbance index (RDI) was 35.8 events/hour (SD, 21.9; range, 6.6-94.2), which decreased to 17.1 (SD, 19.5; range, 0.8-78.1; P < 0.0001). Mean ESS improved from 10.8 (SD, 4.7) to 6.3 (SD, 3.7; P = 0.0001); whereas BDI scores improved from 8.4 (SD, 8.2) to 4.9 (SD, 6.0; P = 0.0051). There were 22 (50.0%) patients with excessive daytime sleepiness and 12 (27.3%) patients with depression before surgery. Surgery was associated with resolution of sleepiness in 17 patients (77.3%) and depression in 9 patients (75.0%). In multivariable regression analysis, only change in ESS (P = 0.003) and baseline BDI (P < 0.001) were associated with improvement in depression. RDI was not significant (P = 0.15). CONCLUSIONS: Surgical treatment of OSA, especially multilevel surgery, resulted in significantly reduced depression, with resolution in 75% of patients. Similarly, surgery resulted in significantly reduced sleepiness, with resolution in 77% of patients. Reduction in sleepiness scores, but not OSA severity, was predictive of improvement in depression scores. Further evaluation with a larger sample size and a control group is warranted. LEVEL OF EVIDENCE: 4.