Influence of Economic Connectedness on Pediatric Obstructive Sleep Apnea Severity and Adenotonsillectomy Outcomes.

OBJECTIVE: To examine the influence of economic connectedness (EC), a measure of social capital, on obstructive sleep apnea (OSA) severity and adenotonsillectomy outcomes in children. STUDY DESIGN: Retrospective study. SETTING: Single tertiary medical center. METHODS: The study population included 286 children who were referred for full-night polysomnography for OSA and underwent adenotonsillectomy. The primary outcome was the relationship between EC and the presence of severe OSA, and secondary outcomes included postoperative emergency room visits and residual OSA after adenotonsillectomy. Linear regression, Kruskal-Wallis test, Pearson's χ2 test, and multiple logistic regression were used for categorical and continuous data as appropriate. RESULTS: In this population, the median age was 9.0 (interquartile range [IQR] = 6.9-11.7) and 144 (50.3%) were male. The majority were white (176, 62.0%), black (60, 21.1%), and/or of Hispanic ethnicity (173, 60.9%). The median EC of this population was 0.64 (IQR = 0.53-0.86). Higher EC was associated with decreased odds of having severe OSA (odds ratio: 0.17, 95% confidence interval = 0.05-0.61). However, EC was not associated with either postoperative emergency room visits or residual OSA. CONCLUSION: EC was significantly associated with severe OSA (ie, apnea-hypopnea index ≥ 10) but not with postoperative emergency room visits or residual OSA after adenotonsillectomy. Further research is needed to understand the effects of various social capital measures on pediatric OSA and adenotonsillectomy outcomes.

Injection Laryngoplasty for Children with Dysphagia after Cardiac Surgery.

Objective: To determine whether injection laryngoplasty (IL) resolves thin liquid aspiration among children with unilateral vocal cord paralysis (UVCP) after cardiac surgery. Study Design: Retrospective case-control. Setting: Tertiary children's hospital. Methods: Consecutive children (<5 years) between 2012 and 2022 with UVCP after cardiac surgery were included. Resolution of thin liquid aspiration after IL versus observation was determined for children obtaining videofluoroscopic swallow studies (VFSS). Results: A total of 32 children with left UVCP after cardiac surgery met inclusion. Initial surgeries were N = 9 (28%) patent ductus arteriosus ligations, N = 7 (22%) aortic arch surgeries, N = 9 (28%) surgeries for hypoplastic left heart syndrome, and N = 7 (22%) other cardiac surgeries. The mean age at initial surgery was 1.8 months (SD: 3.7). All children had a VFSS obtained after surgery that confirmed aspiration. There were 17 children that obtained an IL at 33.6 months (SD: 20.9) after cardiac surgery and 15 children observed without IL procedure. No surgical complications after IL were noted. The rate of aspiration resolution based on postoperative VFSS was N = 14 (82%) for the IL group and N = 9 (60%) for the control group P = .24. Documented VFSS aspiration resolution after cardiac surgery occurred by 9.6 months (SD: 10.0) in the observation group and 47.4 months (SD: 24.1) in the IL group (P < .001). Conclusion: IL can help treat aspiration in children with UVCP after cardiac surgery but the benefit beyond observation remains unclear. Future studies should continue to explore the utility for IL in managing dysphagia in this pediatric population.

Adherence to Reporting Guidelines in Major Otolaryngology Publications.

The aim of this study is to determine the adherence rate to reporting guidelines in published otolaryngology research. We performed an evidence-based review of all original clinical research published in 2021 in five otolaryngology journals for adherence to the appropriate guideline for the study type by evaluating whether the corresponding reporting guideline was mentioned in the body of the published manuscript. There were 1140 original research articles included in this study. Most studies were observational, for which the STROBE reporting guidelines are recommended (n = 791, 70.3%). All studies had an average adherence rate of 16.8% (n = 192/1140). The STROBE adherence rate was 4.9%, with JAMA Otolaryngology having the highest proportion of observation studies using the STROBE guidelines (23/49, 46.9%). Reporting guidelines are important tools to use in presenting original research. The use of these guidelines varies in the otolaryngology literature and highlights the ongoing need to support research reproducibility and usefulness.

Perioperative Delta Weight and Pediatric Obstructive Sleep Apnea Resolution after Adenotonsillectomy.

OBJECTIVE(S): The first-line treatment for pediatric obstructive sleep apnea (OSA) is adenotonsillectomy. Post-operative weight gain is a well-documented phenomenon. We hypothesized that higher peri-adenotonsillectomy delta weight correlates with lower rates of OSA resolution in pediatric patients. METHODS: This was a retrospective cohort study consisting of 250 patients from 2 to 17 years of age at a tertiary academic medical center between January 2021 and December 2022. Polysomnography results and body mass index (BMI) changes were collected through the electronic health record. Univariate and multivariate logistical regression analyses were performed, adjusting for confounding factors. RESULTS: Perioperative delta weight and pre-operative baseline AHI values were significant predictors of residual OSA. For every 1-kilogram gain in weight, the odds of residual OSA (AHI >5) increase by 6.0% (OR = 1.06, 95% CI = 1.02-1.10, p < 0.002), and the odds of residual severe OSA (AHI > 10) increase by 8% (OR = 1.08, 95% CI = 1.04-1.12, p < 0.001). Increased AHI, Black/African American race, and male sex were also factors associated with incomplete OSA resolution. CONCLUSIONS: Increased peri-adenotonsillectomy delta weight is associated with higher rates of residual OSA in children. Patients and families should be counseled about appropriate weight loss and control methods before adenotonsillectomy. LEVEL OF EVIDENCE: IV Laryngoscope, 2024.

Surgical Outcomes by Early Airway Endoscopy Findings after Pediatric Staged Laryngotracheoplasty.

OBJECTIVES: To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP. METHODS: A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal. RESULTS: Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63). CONCLUSIONS: Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:963-967, 2024.

Outcomes of Injection Laryngoplasty for Deep Interarytenoid Groove

Abstract Introduction Deep interarytenoid groove (DIG) may cause swallowing dysfunction in children; however, the management of DIG has not been established. Objective We evaluated the subjective and objective outcomes of interarytenoid augmentation with injection in children with DIG. Methods Consecutive children under 18 years of age who underwent injection laryngoplasty for DIG were reviewed. Data pertaining to demographics, past medical history, past surgical history, and results of pre and postoperative video fluoroscopic swallow study (VFSS) were obtained. The primary outcome measure was the presence of thin liquid aspiration or penetration on postoperative VFSS. The secondary outcome measure was caregiver-reported improvement of symptoms. Results Twenty-seven patients had VFSS before and after interarytenoid augmentation with injection (IA). Twenty (70%) had thin liquid penetration and 12 (44%) had thin liquid aspiration before the IA. Thin liquid aspiration resolved in 9 children (45%) and persisted in 11 (55%). Of the 12 children who had thin liquid aspiration prior to IA, 6 (50%) had resolution of thin liquid aspiration after IA. Conclusions Injection laryngoplasty is a safe tool to improve swallowing function in children with DIG. Further studies are needed to assess the long-term outcomes of IA and identify predictors of successful IA in children with DIG.

Risk-adjusted analysis of perioperative outcomes after the Sistrunk procedure.

Objectives: Thyroglossal duct cyst (TGDC) is the most common pediatric congenital neck mass. The Sistrunk procedure is the standard method of excision and is associated with low rates of recurrence. This study aimed to review our institution's outcomes following the Sistrunk procedure, specifically the rates of wound complications and cyst recurrence. Methods: This was a retrospective case series of pediatric patients undergoing the Sistrunk procedure from June 2009 to April 2021. Results: A total of 273 patients were included. Of these, 139 (53%) patients were male and 181 (66%) were white. The average age at the time of surgery was 7.1 years. The overall cyst recurrence rate was 11%. The most common wound complications were seroma (14%) and surgical site infections (SSIs) (12%). Wound complications were associated with prior history of cyst infection (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.07-3.60, z-test 2.2, p = .03). Pediatric surgery was associated with fewer wound complications (OR 0.18; 95% CI 0.05-0.6, z-test -2.78, p = .005). However, pediatric surgery operated on fewer patients with a history of cyst infection (36% vs. 55%, p = .012). Drain placement and postoperative antibiotics did not affect rates of wound complications. Conclusions: Prior cyst infection is associated with increased rates of postoperative wound complications. Postoperative antibiotics and drain placement did not significantly affect complication rates. Level of Evidence: 4.

Assessment of neighborhood-level disadvantage and pediatric obstructive sleep apnea severity.

Objectives: To examine the relationship between neighborhood-level advantage and severe obstructive sleep apnea (OSA) in children. Methods: A retrospective case-control study was conducted on 249 children who underwent adenotonsillectomy and had full-night polysomnography conducted within 6 months prior. Patients were divided into more or less socioeconomically disadvantaged groups using a validated measure, the area deprivation index (ADI). The primary outcomes were the relationship between the apnea-hypopnea index (AHI) and the presence of severe OSA, and the secondary outcome was residual moderate or greater OSA after tonsillectomy. Results: Of the 249 children included in the study, 175 (70.3%) were socially disadvantaged (ADI > 50). The median (interquartile range [IQR]) age was 9.4 (7.3-12.3) years, 129 (51.8%) were male, and the majority were White (151, 60.9%), Black (51, 20.6%), and/or of Hispanic (155, 62.5%) ethnicity. A total of 140 (56.2%) children were obese. The median (IQR) AHI was 8.9 (3.9-20.2). There was no significant difference in the median AHI or the presence of severe OSA between the more and less disadvantaged groups. Severe OSA was found to be associated with obesity (odds ratio [OR] = 3.13, 95% confidence interval [CI] = 1.83-5.34), and residual moderate or greater OSA was associated with older age (OR = 1.20, 95% CI = 1.05-1.38). Conclusions: The ADI was not significantly associated with severe OSA or residual OSA in this cohort of children. Although more neighborhood-level disadvantage may increase the risk of comorbidities associated with OSA, it was not an independent risk factor in this study. Level of Evidence: Level 4.

Long-Term Outcomes of Tracheostomy-Dependent Children.

OBJECTIVE: To estimate the 1-, 5-, and 10-year survival and decannulation rates of children with a tracheostomy. STUDY DESIGN: Ambidirectional cohort. SETTING: Tertiary children's hospital. METHODS: All patients (<18 years) that had a tracheostomy placed between 2009 and 2020 were included and followed until 21 years of age, decannulation, or death. The Kaplan-Meier method estimated cumulative probabilities of death and decannulation. RESULTS: A total of 551 children underwent tracheostomy at a median age of 7.2 months (interquartile range [IQR]: 3.8-49.2). Children were followed for a median of 2.1 years (IQR: 0.7-4.2, range 0-11.5). The cumulative probability of mortality at 1 year was 11.9% (95% confidence interval [CI]: 9.4-15.1), at 5 years was 26.1% (95% CI: 21.6-31.3), and at 10 years was 41.6% (95% CI: 32.7-51.8). Ventilator dependence at index discharge (hazard ratio [HR]: 2.04, 95% CI: 1.10-3.81, p = .03), severe neurologic disability (HR: 2.79, 95% CI: 1.61-4.84, p < .001), and cardiac disease (HR: 1.69, 95% CI: 1.08-2.65, p = .02) were associated with time to death. The cumulative probability of decannulation was 10.4% (95% CI: 8.0-13.5), 44.9% (95% CI: 39.4-50.9), and 54.1% (95% CI: 47.4-61.1) at 1 year, 5 years, and 10 years, respectively. Ventilator dependence (HR: 0.43, 95% CI: 0.31-0.60, p < .001), severe neurologic disability (HR: 0.20, 95% CI: 0.14-0.30, p < .001), and tracheostomy indicated for respiratory failure (HR: 0.68, 95% CI: 0.48-0.96, p = .03) correlated with longer decannulation times. CONCLUSION: After tracheostomy, estimated mortality approaches 42% by 10 years and decannulation approaches 54%. Children with ventilator support at discharge and severe neurological disability had poorer long-term survival and longer times to decannulation.

Estimations of Inpatient and Ambulatory Pediatric Tonsillectomy in the United States: A Cross-sectional Analysis.

OBJECTIVE: To estimate the incidence of inpatient and ambulatory pediatric tonsillectomies in the United States in 2019. STUDY DESIGN: Cross-sectional analysis. SETTING: Healthcare Cost and Utilization Project databases. METHODS: We determined national incidences of hospital-based ambulatory procedures, inpatient admissions, and readmissions among pediatric tonsillectomy patients, ages 0 to 20 years, using the Kids Inpatient Database, Nationwide Ambulatory Surgery Sample, and Nationwide Readmission Database. We described the demographics, commonly associated conditions, complications, and predictors of readmission. RESULTS: An estimated 559,900 ambulatory and 7100 inpatient tonsillectomies were performed in 2019. Among inpatients, the majority were male (59%) and the largest ethnic group was white (37%). Adenotonsillar hypertrophy (ATH), 79%, and obstructive sleep apnea (OSA), 74%, were the most frequent diagnosis and Medicaid (61%) was the most frequent primary payer. The majority of ambulatory tonsillectomy patients were female (52%) and white (65%); ATH, OSA, and Medicaid accounted for 62%, 29%, and 45% of cases, respectively, (all p < .001 when compared to inpatient cases). Common inpatient complications were bleeding (2%), pain/nausea/vomiting (5.6%), and postprocedural respiratory failure (1.7%). On the other hand, ambulatory complications occurred in less than 1% of patients. The readmission rate was 5.2%, with pain/nausea/vomiting and bleeding accounting for 35% and 23% of overall readmissions. All Patient Refined Diagnosis Related Groups severity of illness subclass predicted readmission (odds ratio = 2.18, 95% confidence interval = 1.73-2.73, p < .001). CONCLUSION: A total of 567,000 pediatric ambulatory and inpatient tonsillectomies were performed in 2019; the majority were performed in ambulatory settings. The index admission severity of illness was associated with readmission risk.

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.

Pathogenic bacteria in bronchoalveolar lavage cultures and pediatric laryngotracheal reconstruction outcomes.

OBJECTIVE: The primary objective was to determine if treating pathogenic bacteria in bronchoalveolar lavage (BAL) cultures improves outcomes after pediatric double stage laryngotracheal reconstruction (dsLTR). STUDY DESIGN: Case series with chart review. SETTING: Tertiary children's hospital. METHODS: All children (<18 years) obtaining flexible bronchoscopy with BAL cultures before dsLTR between 2016 and 2022 were included. Cultures identified abnormal bacterial growth or normal respiratory flora. Thirty-day postoperative surgical site or lung infections were captured and tracheostomy decannulation rates were obtained for children with at least 12 months of follow-up. RESULTS: Twenty-seven children obtained presurgical BAL cultures before dsLTR. Median age at reconstruction was 2.9 years (interquartile range: 2.3-3.5) and 89% (24/27) had high grade subglottic stenosis. Positive cultures were obtained in 56% of children (N = 15) with Pseudomonas aeruginosa (40%, 6/15) and methicillin-resistant Staphylococcus aureus (33%, 5/15) the most frequent organisms. All children with positive cultures were treated based on culture and sensitivity data. Postoperative infections developed in 22% (6/27) of children with equal distribution of surgical site and respiratory infections among children with pathogenic bacteria and normal respiratory flora. At 12 months after surgery, the decannulation rate was no different between those treated and not treated for a presurgical positive BAL culture (47% vs. 58%, p = 0.70). CONCLUSION: Pathogenic bacteria are common in BAL cultures from tracheostomy-dependent children before dsLTR. Treatment keeps respiratory infections and decannulation rates similar to children with negative cultures, suggesting continued benefit of flexible bronchoscopy and BAL in preparation for these surgeries.

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.

Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea.

OBJECTIVES/HYPOTHESIS: To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA). METHODS: Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared. RESULTS: There were 887 patients included in this study. 14.8% (n = 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O2  < 90% (tb90) (95% CI = 1.07-1.14, OR = 1.10, p < 0.001), Black race (95% CI = 1.53-3.58, OR = 2.34, p < 0.001), primary neurologic co-morbidity (1.67-6.32, OR = 3.27, p < 0.001), Down syndrome (1.25-5.94, OR = 2.72, p = 0.01), and age (0.84-0.94, OR = 0.88, p < 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90. CONCLUSIONS: Our results demonstrate that there are other potential risk factors outside of AHI and O2 nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1251-1256, 2023.

Surgical site infections after pediatric open airway reconstruction-A National Surgical Quality Improvement Program-Pediatric analysis.

Objectives: To determine the rate of surgical site infections (SSI) after pediatric open airway reconstruction using a nationwide database. Study Design: Cross-sectional study of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) Database. Methods: The ACS NSQIP-P was queried for open airway surgeries between 2013 and 2019 determining postoperative SSI and wound dehiscence with a random sample of non-airway cases serving as a control group. Results: A total of 637 laryngotracheoplasties (LTP), 411 tracheal resections (TR) and 2100 control procedures were included. LTP and TR were both performed on younger children with more comorbidities than control surgeries (p < .05). Postoperative wound complications occurred more often after airway reconstructions than non-airway cases (6.4% vs. 2.9%, p < .001). Compared to non-airway procedures, LTP (OR: 2.42, 95% CI: 1.62-3.61) and TR (OR: 2.07, 95% CI: 1.28-3.66) developed increased SSI. Multiple logistic regression identified dirty or infected wounds (OR: 4.61, p < .001, 95% CI: 2.35-9.03) and American Society of Anesthesiologists (ASA) Class IV (OR: 3.19, p = .02, 95% CI: 1.12-8.39) as the strongest predictors of SSI after airway reconstruction. Conclusions: SSI after pediatric airway reconstruction occur in 6% of cases and are increased in infected wounds and ASA Class IV surgeries. Recognizing common factors for these complications provide reliable benchmarking to design surgical quality improvement initiatives. Level of Evidence: 4.

Assessment of socioeconomic disadvantage in laryngotracheoplasty outcomes among pediatric patients.

OBJECTIVES: To determine whether socioeconomic disadvantage impacts outcomes after pediatric laryngotracheoplasty. STUDY DESIGN: Case series with chart review. METHODS: All laryngotracheoplasty procedures at a tertiary children's hospital between 2010 and 2019 were included. Primary zip code determined Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure, and children were grouped based on less or more community disadvantage. Primary outcomes included complication and decannulation rates. RESULTS: Eighty-four procedures were included with 69% (58/84) double-stage and 31% (26/84) single-stage reconstructions. Median age at surgery was 3.2 (IQR 2.2-4.9) years, 56% (47/84) were male, and median gestational age was 25 (IQR 24-28) weeks. Children from more disadvantaged communities represented 67% (56/84) of surgeries and were more likely to have higher grade stenosis (89% vs. 64%, P = .02). Postoperative airway complications (20% vs. 18%, P = .99), non-airway complications (14% vs. 18%, P = .75), and total length of stay (7 vs. 6 days, P = .26) were not impacted by ADI grouping. While children from higher community disadvantage were just as likely to be decannulated after double stage surgeries (76% vs. 76%, P = .99), it more often took longer than six months to achieve (90% vs. 61%, P = .04). CONCLUSIONS: Community disadvantage is associated with higher grade airway stenosis and longer times to successful decannulation in children requiring expansion airway surgery. Encouragingly, ADI grouping did not impact complication and decannulation rates. Continued work is needed to understand how socioeconomic metrics influence pediatric open airway surgery.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Evaluation and management of congenital tracheal stenosis.

OBJECTIVES: To outline an expert-based consensus of recommendations for the diagnosis and management of pediatric patients with congenital tracheal stenosis. METHODS: Expert opinions were sought from members of the International Pediatric Otolaryngology Group (IPOG) via completion of an 18-item survey utilizing an iterative Delphi method and review of the literature. RESULTS: Forty-three members completed the survey providing recommendations regarding the initial history, clinical evaluation, diagnostic evaluation, temporizing measures, definitive repair, and post-repair care of children with congenital tracheal stenosis. CONCLUSION: These recommendations are intended to be used to support clinical decision-making regarding the evaluation and management of children with congenital tracheal stenosis. Responses highlight the diverse management strategies and the importance of a multidisciplinary approach to care of these patients.

Impact of Language and Ethnicity on Pediatric Tracheostomy Outcomes.

OBJECTIVE: To compare outcomes after tracheostomy between children from Spanish- and English-speaking families. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary care children's hospital. METHODS: All children <18 years of age who had a tracheostomy placed between 2014 and 2020 were included. Comorbidities and postsurgical outcomes were compared between (1) children whose families preferred speaking Spanish or identified as Hispanic/Latino and (2) children from English-language or non-Hispanic families. RESULTS: A total of 339 children met inclusion, with 11% (37/339) from families identifying Spanish as their primary language and 33% (112/339) identifying as Hispanic. Spanish-speaking families were more likely to have tracheostomy-dependent children with cardiac conditions (65% vs 42%, P = .008) and high complexity (72% vs 49%, P = .007). Outcomes were similar regardless of language preference, with 45% (153/339) still tracheostomy dependent, 28% (94/339) decannulated, and 6.8% (23/339) deceased at a median follow-up of 1.77 years (interquartile range, 0.65-3.43). Severe neurocognitive disabilities were similar between Spanish- and English-language families (P > .05). Spanish language was not associated with times to decannulation or death in univariate or multiple regression models. A sensitivity analysis of self-identified Hispanic or Latino patients did not show significant differences for time to decannulation, death, or neurocognitive disability rates (P > .05). CONCLUSION: Spanish language and Hispanic ethnicity appear to have minimal impact on pediatric tracheostomy outcomes.

Estimating perioperative outcomes after pediatric laryngotracheal reconstruction surgery in accordance with ACS-NSQIP-P reporting.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P) database monitors quality outcomes in pediatric surgery. However, the registry might underreport low-volume procedures. This review describes complications after laryngotracheal reconstruction (LTR) based on ACS-NSQIP-P reporting standards. METHODS: A case series with chart review at a tertiary children's hospital included consecutive LTR procedures between 2010 and 2018. Surgical procedures were grouped into single- or double-stage for comparison of thirty-day complication rates. RESULTS: Eighty-four procedures were reviewed with 70% (59/84) double-stage and 30% (25/84) single-stage. Children requiring double-stage procedures were younger (3.3 vs. 6.0 years, P = .002) and more often Black or African American (51% vs. 24%, P = .03). Double-stage LTR was frequently performed on children with grade 3 or 4 subglottic stenosis (90% vs. 52%, P < 001), with a tracheostomy (97% vs. 68%, P = .001) and with gastroesophageal reflux disease (93% vs. 67%, P = .004). Airway-related complications occurred in 19% (16/84) of children and non-airway complications occurred in 16% (13/84) with similar rates between groups. Unplanned reintubation (20% vs. 0%, P = .002), ventilator support longer than 48 hours (12% vs. 0%, P = .02), and total hospitalization lengths (15.6 vs. 6.5 days, P < .001) were increased after single-stage LTR. Children with non-airway complications had more central nervous system disorders (46% vs. 10%, P = .004). CONCLUSION: Postoperative complications after pediatric LTR occur in nearly 20% of children and single-stage procedures have higher unplanned reintubations, prolonged ventilator support and hospitalization lengths. Surgeons should recognize that these typically minor events should be consistently monitored and reported after surgical expansion of the pediatric airway. LEVEL OF EVIDENCE: IV.

Pediatric Tracheostomy-Related Complications: A Cross-sectional Analysis.

OBJECTIVE: To determine the rate of tracheostomy-related complications in pediatric patients from nationally representative databases. STUDY DESIGN: Cross-sectional analysis. SETTING: 2016 Kids' Inpatient Database and 2016 Nationwide Readmission Database. METHODS: All pediatric tracheostomy procedures were included. Complication type, admission outcomes, and readmission rates were recorded with a logistic regression analysis to determine patient characteristics associated with complications. RESULTS: An estimated 5309 tracheostomies were performed among pediatric patients in 2016, 8% (n = 432) of whom developed tracheostomy-related complications. This group was younger (4.7 vs 8.7 years, P < .001) and required longer hospital admissions (68.7 vs 33.2 days, P < .001) than children without tracheostomy-related complications. Mean costs ($459,324 vs $397,937, P < .001) and mean total charges ($1,573,964 vs $1,099,347, P < .001) were increased if a tracheostomy-related complication occurred. These events occurred more often in those with bronchopulmonary dysplasia (24% vs 12%, P < .001), heart disease (24% vs 12%, P = .001), gastroesophageal reflux disease (31% vs 19%, P < .001), short gestational age (24% vs 14%, P < .001), and subglottic stenosis (9.9% vs 5.4%, P = .001). The estimated 30-day readmission rate was 24% (SE, 1.7%) but did not increase after tracheostomy complications (27% vs 15%, P = .04). Tracheostomy-related complications were predicted by gastroesophageal reflux disease (odds ratio [OR], 1.50; 95% CI, 1.14-1.97; P = .004), younger age (OR, 1.12; 95% CI, 1.04-1.22; P = .002), and lengthier hospitalization (OR, 1.00; 95% CI, 1.00-1.01; P < .001) on multiple logistic regression analysis. CONCLUSION: Tracheostomy-related complications occur in approximately 8% of pediatric patients and are higher in younger children or those with longer admission lengths. These data have implications for benchmarking standards of posttracheostomy complications across institutions.