Salivary gland surgery and nonviral respiratory-related hospitalizations in children with neurodevelopmental impairment.

OBJECTIVES: Neurodevelopmentally impaired (NI) children with chronic sialorrhea are at elevated risk for aspiration and respiratory tract infections. Direct resection or ligation ("DROOL") of the submandibular glands (SMG) with parotid duct ligation are surgical interventions intended to decrease salivary output. The objective of this study is to determine the impact of DROOL surgery on the incidence of nonviral respiratory-related (NVR) post-procedure hospital encounters including emergency department visits and admissions. METHODS: Retrospective case series of NVR related outcomes after DROOL surgery in children performed at a single institution, tertiary referral center. RESULTS: A total of 35 gastrostomy tube-dependent patients (60% male, average age 8.2 [SD 6.0] years) with NI underwent DROOL surgery (86% SMG excision). Pre- and post-surgical follow-up time was 3.6 and 3.2 years, respectively. Presurgical and postsurgical NVR hospital encounters occurred in 28 (80%) and 14 (40%) patients, respectively (p < 0.01). Mean (SD) postoperative NVR hospital encounters occurred less frequently when compared to presurgical period (0.4 [0.6] vs. 1.0 [1.2] per year, p < 0.01) with average change of -0.7 encounters per year (SD 1.4, 95% CI -1.0 to -0.2). Patients with encounters within a year preceding DROOL (OR 4.9, p = 0.04, 95% CI 1.1-22.8), or those with at least 3 preoperative encounters (OR 8.0, p = 0.01, 95% CI 1.6-40.3) were significantly associated with a postsurgical NVR event. Fewer patients used anti-sialorrhea medication postoperatively compared to preoperatively (60% vs. 17%, p < 0.01). No patient developed surgical site complications requiring operative interventions. CONCLUSIONS: DROOL surgery for chronic sialorrhea in patients with NI was associated with decreased hospitalization and ED visits for NVR respiratory events post-procedurally. Sialorrhea may be an actionable source of recurrent respiratory illnesses requiring hospitalizations.

Pediatric sleep outcomes after endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy.

BACKGROUND: The purpose of this study was to evaluate the efficacy of sleep endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy in patients with sleep disordered breathing (SDB), including polysomnography (PSG) and swallowing outcomes. METHODS: A retrospective review was performed of all patients undergoing simultaneous lingual tonsillectomy and epiglottopexy over the study period. PSG objective measures were recorded pre- and postoperatively, along with demographic data, comorbidities, and descriptive data of swallowing dysfunction in the postoperative setting. RESULTS: A total of 24 patients met inclusion criteria for consideration, with 13 having valid pre- and postoperative PSG data. Successful surgery was achieved in 84.6% of patients, with no difference based on presence of medical comorbidities including Trisomy 21. Median reduction in obstructive apnea-hypopnea index (oAHI) with the procedure was 69.9%. Four patients (16.7%) had postoperative concern for dysphagia, but all objective swallowing evaluations were normal and no dietary modifications were necessary. CONCLUSION: Combination lingual tonsillectomy and epiglottopexy in indicated patients has a high rate of success in this single-institutional study without new dysphagia in this population. These procedures are amenable to a combination surgery in appropriately selected patients determined by sleep state endoscopy in the setting of SDB evaluated with drug-induced sleep endoscopy.

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.

Age based evaluation of nut aspiration risk.

OBJECTIVE: To identify an age at which initiation of whole nut into the pediatric diet could be considered safe, by evaluating the age distribution of children undergoing bronchoscopy with removal of nut or seed material from the airway. METHOD: A retrospective chart review over a ten-year period identifying children age 0-18 that have undergone bronchoscopy with retrieval of airway foreign bodies. A statistical analysis of demographic data was carried out to identify age distribution of aspiration events. RESULTS: Sixty-four cases of foreign body aspiration were identified, of which 43 (67%) were of organic origin, specifically nuts. A Fisher's exact test was carried out on the cumulative percentage of organic foreign body aspirations to identify the age distribution of nut aspiration events. A statistically significant decrease in organic foreign body aspirations occurred at approximately 36 months of age (p = 0.004). CONCLUSION: Foreign body aspiration is a leading cause of accidental injury or death in children. Nut and other small organic foreign bodies account for a significant portion of accidental aspiration events, however, no guidelines exist regarding appropriate age of whole nut introduction into the diet. Our study suggests that 90% of pediatric nut aspiration events occur under the age of 36 months. We suggest supervised introduction of whole nuts between the ages of 3 and 4 years. Official guidelines regarding this should be considered by professional pediatric societies. LEVEL OF EVIDENCE: 4.

Outcome measures for pediatric laryngotracheal reconstruction: International consensus statement.

OBJECTIVES: Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies. METHODS: Standard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site-specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria. RESULTS: Thirty-three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative-/intraoperative-/procedure-related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site-specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable. CONCLUSION: This consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta-analyses, quality improvement, transfer of information, and surgeon self-assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient. LEVEL OF EVIDENCE: 5 Laryngoscope, 129:244-255, 2019.

Outcomes of tympanoplasty in children with down syndrome.

INTRODUCTION: The prevalence of chronic otitis media with effusion (COME), and Eustachian tube dysfunction (ETD) is high in Down syndrome (DS) patients. This often necessitates multiple tympanostomy tube (TT) placements resulting in a higher rate of persistent tympanic membrane (TM) perforation requiring tympanoplasty for repair. OBJECTIVES: To assess risk factors for persistent perforation and outcomes of tympanoplasty in DS patients. METHODS: Retrospective case series of 91 ears in 69 DS patients with TM perforations, who were either observed or underwent tympanoplasty. Clinical features, surgical outcomes, and hearing outcomes were assessed. RESULTS: 91 ears were evaluated. Sixty perforations were observed, and 31 perforations were repaired. The closure rate was 54.8% for primary surgery, and 70.9% after secondary surgical interventions in the Tympanoplasty Group, compared to 33.0% spontaneous closure rate in the Observation Group (p < 0.001). The only risk factor for failed tympanoplasty repair was persistent COME/ETD (OR 27.2, p = 0.001). In the Observation Group perforations diagnosed at an older age, with >3 TT insertions, and with persistent COME/ETD were less likely to close spontaneously. Patients undergoing tympanoplasty had worse preoperative pure tone averages than those being observed, but significant improvement in air-bone gaps were noted in the Tympanoplasty Group (p = 0.02) post-operatively. Patients were often rehabilitated with hearing aids regardless of intervention (53.3% Observation Group, 48.4% Tympanoplasty Group). CONCLUSIONS: Persistent TM perforation in children with Down syndrome was associated with a history of COME/ETD, and multiple prior TT insertions. Tympanoplasty was successful for repair in most patients who underwent surgical intervention, but residual hearing loss was common.

Pediatric stridor.

Pediatric stridor is an important symptom of upper airway obstruction, and must be recognized early by evaluating physicians. Proper evaluation and management, both acutely and chronically, can provide improved outcomes and better quality of life for patients. This article discusses the physiology of stridor and its intimate relation to airway anatomy, the work-up of the stridorous child, and recent advances in treatment, and provides illustrative examples of common lesions.

Upper airway complications of junctional epidermolysis bullosa.

OBJECTIVE: To assess the incidence of upper airway pathology in patients with junctional epidermolysis bullosa (JEB). STUDY DESIGN: We conducted a retrospective chart review of all patients with JEB who came to an interdisciplinary epidermolysis bullosa center at a tertiary care institution between 2004 and 2010. RESULTS: Twenty-five patients with JEB were identified, and 12 patients were seen in the otolaryngology clinic (age range, 2 months-15 years; 8 male, 4 female). Of the 12 patients, 8 underwent rigid laryngoscopy and bronchoscopy for upper respiratory tract symptoms; 7 of these patients displayed laryngeal pathology, and 5 of them underwent surgical intervention with successful resolution of symptoms. Furthermore, none of these patients had any short- or long-term complications from their surgery. A strict protocol and a precise problem-focused cold surgical technique were used in these cases to protect skin and mucus membranes. CONCLUSION: With appropriate precautions, endoscopic laryngeal surgery can be safe and effective in patients with JEB and larygnotracheal disease. Endoscopic laryngeal surgery is feasible when indicated for these patients.

Complications in pediatric osseointegrated implantation.

OBJECTIVE: To report an accurate complication rate in pediatric osseointegrated implants in a large cohort of patients from a major center and to characterize the complications observed. SETTING: Tertiary care pediatric hospital. STUDY DESIGN: Case series with chart review of all consecutive patients receiving otologic osseointegrated implants at Cincinnati Children's Hospital since 2001. SUBJECTS AND METHODS: All patients undergoing osseointegrated implant placement were identified at Cincinnati Children's Hospital, and complication rates were tabulated and stratified to major and minor based on the need for surgical revision. Evaluations of syndromic and body mass index associations were performed, along with evaluation of length of follow-up. RESULTS: Forty-three patients were identified with 88 implants placed. Eighteen (42%) children had a diagnosis of a craniofacial syndrome. Overall, 19 (41.9%) returned to the operating suite, with a complication rate of 46.1%. A long duration of follow-up was obtained, and with this was identified an increasing risk of complications over time. Also identified was a significantly increased complication risk associated with a craniofacial syndrome. Body mass index was not found to be associated with complications. CONCLUSION: Osseointegrated implants require frequent maintenance care from the surgeon. Complication rates are higher for children with a diagnosis of a craniofacial syndrome, and the risk of a complication increases significantly over a prolonged period of time.

Laryngeal cancer involving a branchial cleft cyst.

BACKGROUND: Benign secondary neck lesions in the setting of laryngeal cancer have been described, but not with branchial cleft cysts. This article describes a branchial cleft cyst in a laryngectomy/neck dissection specimen. METHODS AND RESULTS: A 44-year-old woman presented to our emergency department with an obstructing laryngeal tumor that was staged as a T4N0M0 squamous cell cancer on the basis of clinical and radiographic findings. After laryngectomy with bilateral neck dissections, the neck specimen contained a right-sided branchial cleft cyst, which was directly invaded by tumor. In addition, the location of the cyst relative to the larynx suggested that this was a third branchial cleft cyst. CONCLUSION: This is the first report of a laryngeal carcinoma invading a branchial cleft cyst. Staging discrepancies may result from concurrent head and neck lesions, altering treatment plans, or changing the prognosis for the patient. Lesions such as this are nearly impossible to diagnose preoperatively, and a high index of suspicion for advanced cancer should be maintained.

Gold laser adenoidectomy: long-term safety and efficacy results.

OBJECTIVES: To report the long-term results of Gold laser adenoidectomy with pressure equalization tube (PET) placement by measuring the incidence of otorrhea and middle ear effusion after tube extrusion. STUDY DESIGN: A prospective study of 50 patients, ages 8-48 months, that underwent Gold laser adenoidectomy with PE tube placement in a pediatric outpatient setting. METHODS: We previously reported the initial results at 4 months post-op of 50 patients treated for adenoid hypertrophy and chronic otitis media with effusion (COME). All patients were then evaluated at 8, 12, and 16 months post-operatively. The incidence of otorrhea, extrusion of the PE tubes, and middle ear status was recorded. RESULTS: The incidence of otorrhea was 3/50 (6%) at 8 months, 0 (0%) at 12 months, and 2 (4%) at 16 months. At 16 months, the PE tubes had extruded in 29 (58%) and 28/29 (97%) of these had clear middle ears. Forty-nine patients (98%) overall had clear middle ears at the last exam. One patient required a second set of tubes. CONCLUSION: The long-term results of Gold laser adenoidectomy with PE tube placement for adenoid hypertrophy and COME compare favorably with the initial report of the technique, as well as with other techniques as reported in other studies.

Obstructive lesions of the pediatric subglottis.

PURPOSE: To compile information regarding obstructive subglottic lesions in children, including anatomy, pathogenesis, prevention, evaluation, and treatment options, required for implementation of a multi-faceted treatment plan. METHOD: Review of the literature. CONCLUSIONS: Although they are infrequent, obstructive subglottic lesions pose significant challenges to treating physicians, from airway management and injury prevention to decannulation and voice rehabilitation. Most patients with these lesions require multidisciplinary care and long-term treatment and can nearly always be treated successfully.