Laryngeal cancers in paediatric and young adult patients: epidemiology, biology and treatment.

PURPOSE OF REVIEW: The aim of thi study was to review the recent literature on epidemiology, biology and treatment of laryngeal cancer in paediatric and young adult patients. RECENT FINDINGS: Epidemiological studies reported that 2-10% of patients with laryngeal cancer are younger than 40-year-old, while the prevalence of laryngeal cancer remains unknown in the paediatric population. The development of laryngeal cancer in young adults is multifactorial and may be linked to common carcinogens (tobacco and alcohol), occupational factors, laryngopharyngeal reflux, immunosuppression, human papillomavirus infection and genetic polymorphism. A substantial number of cohort studies reported a significant lower proportion of drinkers and smokers in young populations with laryngeal cancer, supporting the higher prevalence of chromosomal losses or abnormalities predisposing to cancer in this group. The development of laryngeal cancer in paediatric patients is strongly associated with genetic syndromes with DNA repair abnormalities. The pathological, clinical and survival outcome differences between young and old patient groups vary significantly between studies, depending on epidemiological, genetic features and therapeutic strategies used. SUMMARY: Paediatric and adult populations with laryngeal cancer present different clinical, pathological and survival outcomes. In the adult population, the patient age at the time of disease development underlies genetic and etiological differences with different mutation patterns between young and old patients, the latter being more frequently individuals with a history of tobacco and alcohol abuse. The differences between age groups regarding stage of cancer at initial presentation, as well as clinical and survival outcomes, are unclear, which may be due to demographic, ethnicity and population genetic differences.

Transoral Laser Microsurgical Excision of a Laryngeal Schwannoma Located in the Paraglottic Space.

OBJECTIVES/HYPOTHESIS: To report the first case of transoral excision of a paraglottic laryngeal schwannoma. METHODS: Case report. RESULTS: Laryngeal schwannomas are rare tumors, with approximately 75 cases reported to date worldwide. Most cases involve superficial supraglottic tumors excised transorally, and some have been found in deeper compartments and treated using transcervical approaches. This report describes the first excision of a schwannoma of the paraglottic space via endoscopic laser laryngotomy. The procedure allowed return to normal function, without recurrence within 8 months, after which the patient was lost to follow-up. CONCLUSIONS: Transoral excision of benign paraglottic tumors is safe and feasible. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2729-2731, 2021.

Prospective Evaluation of Safety of Singing on Steroids: Testing the Truth of Received Wisdom.

OBJECTIVES/HYPOTHESIS: Performing while on steroids is widely considered to increase risk of vocal injury. This study aims to determine incidence and type of injury, and changes in performers' voices after treatment of vocal fold edema (VFE) with glucocorticoids. STUDY DESIGN: Prospective Cohort. METHODS: Fifty-five performers (34 female; 21 male) treated for acute VFE with short-course oral glucocorticoids were prospectively evaluated pre- and post-treatment. Subjects underwent videostroboscopy, acoustic/aerodynamic assessment, and functional assessment with the Singing Voice Handicap Index-10 (SVHI-10) and Evaluation of the Ability to Sing Easily (EASE). Blinded reviewers rated videostroboscopic examinations and performed audio-perceptual assessment. Chi-square tests and Wilcoxon signed rank tests were applied for analyses of treatment changes. RESULTS: Following glucocorticoid treatment, two instances of vocal fold hemorrhage (3.6%) and three instances of glottic thrush (5.5%) were observed. These resolved without consequence. Mucosal wave dynamics and edema improved. Nearly all subjects completed scheduled performances, and significant improvement was noted on the EASE, reflecting improved function after treatment. These were further supported by statistically significant improvements in CAPE-V and some acoustic and aerodynamic outcomes (semitone pitch range for females, airflow measures for males). CONCLUSIONS: Oral glucocorticoids appear to be generally safe for performers presenting with acute VFE. The incidence of adverse effects, specifically hemorrhage and thrush, was low and the effects transient. Vocal fold examination should be considered obligatory before prescribing glucorticoids to working performers. A treatment strategy for acute VF edema incorporating glucocorticoids when appropriate appears to result in significant improvements in measures of glottal function including videostroboscopic appearance, subject perception, and auditory perception. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2298-2304, 2021.

Phonotraumatic Injury in Fitness Instructors: Risk Factors, Diagnoses, and Treatment Methods.

Fitness instructors are at risk for phonotraumatic injury caused by a combination of occupation-driven environmental and physiologic factors. OBJECTIVES: This study analyzes phonotraumatic injury in a cohort of fitness instructors to define the spectrum of disease, inform treatment, and make educational recommendations. STUDY DESIGN: Retrospective chart review. METHODS: Fitness instructors seen over a 2-year period comprised the study population. Stroboscopic findings, recommended treatment modalities, and treatment outcomes, including postoperative recurrence (when applicable) were analyzed. Demographic information (gender, age), past medical history, VHI-10 scores, and concurrent relevant vocal demands (performer vs. non-performer) were reviewed. Descriptive statistics and bivariate analyses with Fisher's exact test and Wilcoxon rank sum test were used to determine statistical significance of various factors in relation to phonotraumatic injury and response to treatment. Cochran-Armitage trend tests were performed to analyze trends in injuries across fitness types in relation to increased vocal demand. Occupational concerns reported by subjects were analyzed descriptively. RESULTS: The subject cohort consisted of 24 fitness instructors (20F; 4M) who taught a variety of fitness methods. Thirteen subjects (54.2%) were diagnosed with pseudocysts (five unilateral, eight bilateral), five (20.8%) with bilateral midfold masses, five (20.8%) with polyps (four unilateral, one bilateral), and one (4.2%) with cyst. Fourteen subjects (58.3%) were prescribed medication (oral steroids, reflux medication, and/or allergy medication). All were referred for behavioral management. Ten (41.7%) chose surgical intervention after failure to return to satisfactory function with behavioral management; Four (40%) experienced postoperative lesion recurrence. There were no statistically significant findings in relation to demographic information, past medical history, concurrent relevant vocal demands, or occupational vocal demands with choice for surgery. Trend test analysis found that lesions that are typically more likely to require surgical intervention (eg, polyps) tended to be found more frequently as vocal demand increased. The primary occupational concerns reported by subjects were related to amplification (lack of amplification, inadequate amplification/amplification problems) and scheduling (too many consecutive classes without adequate breaks). CONCLUSION: Fitness instructors are subject to a variety of phonotraumatic vocal fold injuries, nearly half which require surgical treatment. One in four recurs after such intervention. Instructors could benefit greatly from education on vocal health, strategies to improve and/or reduce voice use while in the fitness environment, and to help aid in recognizing early "red flags" for phonotraumatic injury. Occupational factors that place fitness instructors at risk for phonotraumatic injury (scheduling, environment, amplification) may be improved with education directed to studio owners and managers.

Contemporary Management of Benign Parapharyngeal Lesions Using Minimally Invasive Techniques: Case Discussion and Review of the Literature.

Branchial anomalies can present in the parapharyngeal space, creating unique challenges in management. Historically, this approach warranted an open approach, including transcervical, transparotid with total parotidectomy and retromandibular dissection, or transmandibular dissection with mandibulotomy. However, the advent of minimally invasive transoral techniques and laser resection have allowed for successful resection of masses in this anatomical region without an external approach. We illustrate these advancements with the case of a 30-year-old man with globus sensation and throat discomfort, found to have a mass of the right posterolateral oropharynx causing severe airway obstruction. Imaging showed a parapharyngeal mass with extension to the carotid sheath and retropharyngeal space, which was successfully resected with potassium-titanyl-phosphate (KTP) laser using a minimally invasive transoral approach with no major complications. Transoral excision offers decreased morbidity and a cosmetically favorable outcome compared to transcervical excision. KTP laser may be safely used for transoral excision of a benign parapharyngeal mass.

Type I Posterior Glottic Stenosis: Natural History and In-Office Management.

OBJECTIVES: To review the natural history of type I posterior glottic stenosis (PGS-I) and its treatment outcomes through a case presentation and demonstrate the feasibility of in-office management of PGS-I. METHODS: The case of a middle-aged woman who developed PGS-I after prolonged intubation is presented. A review of the literature on management and treatment outcomes of PGS-I is also performed. RESULTS: Initially presenting with a large granuloma that failed conservative management, the patient deferred surgical intervention and developed unilateral vocal fold hypomobility with posterior glottic synechia. The adhesion was successfully ablated in the office with potassium-titanyl-phosphate (KTP) laser; however, vocal fold hypomobility persisted after treatment. CONCLUSIONS: This case illustrates the natural history of the development of PGS-I, demonstrates the feasibility of office-based management of this condition, and provides further evidence that lysis of PGS-I synechia does not uniformly lead to restoration of normal laryngeal function and mobility.

Time Course of Recovery of Iatrogenic Vocal Fold Paralysis.

OBJECTIVE: To clarify the time course of recovery in patients with iatrogenic vocal fold paralysis. STUDY DESIGN: Retrospective chart review. METHODS: Medical records for all patients with iatrogenic vocal fold paralysis over a 10-year period were reviewed to obtain demographic and clinical information, including onset of disease and recovery of vocal function. Stroboscopic exams of patients who recovered voice were reviewed blindly to assess return of vocal fold motion. RESULTS: One hundred and two patients of 114 (89%) recovered vocal function. Time to recovery could be assessed in 39 patients who did not undergo injection augmentation. The mean time to recovery was 181.8 ± 109.3 days (left: 166.4 ± 106.7 days; right: 221.8 ± 115.6 days; P value = 0.095). Patients were analyzed according to anatomical site of surgery (skull base, carotid endarterectomy, thoracic, neck and intubation); there was no significant difference in time to recovery (P value = 0.60). Twelve of the 39 patients had recovery of vocal fold motion. The mean time to vocal recovery did not differ between patients with return of motion versus no return of motion (140.6 ± 118.0 days vs. 200.1 ± 102.2 days; P value = 0.147). CONCLUSION: Age, gender, laterality, and anatomical site of injury do not influence recovery rate in iatrogenic vocal fold paralysis. The probability of recovery decreases over time but more slowly in comparison with idiopathic vocal fold paralysis, reflecting the greater heterogeneity of injury type in the iatrogenic population. Commonly available aggregate recovery rates overstate the potential for recovery. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1159-1163, 2019.

Granulomas of the membranous vocal fold after intubation and other airway instrumentation.

OBJECTIVES/HYPOTHESIS: We describe the clinical features of granulomas of the membranous vocal fold secondary to endotracheal intubation, bronchoscopy or esophagogastroduodenoscopy. STUDY DESIGN: Retrospective case series. METHODS: Review of cases at a single tertiary institution with evaluation of patient demographic characteristics, time to presentation, time to treatment, and clinical outcomes. RESULTS: Thirteen adult patients were identified with postintervention granuloma of the membranous vocal fold. All patients were female, with a mean age of 60 years (range, 28-81 years). None noted hoarseness prior to the intervention, and all noted significant hoarseness postoperatively. Conservative treatment with proton pump inhibitors and vocal rest was initially implemented in all patients. Four cases resolved without further intervention. Nine underwent surgical management because of airway symptoms, failure to improve, or patient request. One patient had injury to the contralateral vocal fold upon intubation. None experienced recurrence. Five had complete recovery of voice postoperatively, four did not. CONCLUSION: Iatrogenic granulomas of the membranous vocal fold after intubation or other upper airway instrumentation are rare complications presenting in the early postprocedure period with worsening hoarseness. Initial conservative treatment may be sufficient to yield resolution, and surgical treatment is effective for those failing medical management. Permanent voice damage may result from the original injury. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:441-447, 2019.

In-office procedures for the treatment of benign vocal fold lesions in the awake patient: A contemporary review.

OBJECTIVES: To review available information regarding in-office procedures for benign vocal fold lesions (BVFL). METHODS: PubMed term search on office/awake laryngeal procedures for any of the following specific lesions: Reinke's edema (RE), polyps, nodules, varices, vocal process granuloma, and vocal fold (VF) scar. RESULTS: In-office ablative and nonablative laser procedures have been described for BVFL, including RE, polyps, varices, and granuloma. Fiber-based lasers used include potassium titanyl phosphate, pulsed dye laser, and more recently CO2 . In-office intralesional steroid injection (ISI) for BVFL targets the inflammatory process involved with the lesion and may induce regression of polyps, nodules, RE, and granuloma. Botulinum toxin-induced "voice rest" has been described as adjunctive treatment for refractory VF nodules or vocal process granuloma. Most in-office techniques for treating BVFL rely on induction of lesion regression rather than complete lesion removal, as in conventional operative microsurgery. When treating VF scarring, in-office procedures aim to alter the wound-healing process; ISI targets the inflammatory phase and angiolytic lasers target the proliferative phase. CONCLUSION: In-office procedures for BVFL apply new technology that can potentially lower risk and cost. Although numerous case series have shown the potential of these procedures, data that thoroughly compares outcomes with those of microlaryngoscopic techniques is needed. Laryngoscope, 129:2131-2138, 2019.

Time course of recovery of idiopathic vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: To clarify the time course of recovery in patients with idiopathic vocal fold paralysis. STUDY DESIGN: Retrospective chart review. METHODS: Medical records for all patients with idiopathic vocal fold paralysis over a 10-year period were reviewed to obtain demographic and clinical information, including onset of disease and recovery of vocal function. Stroboscopic exams of patients who recovered voice were reviewed blindly to assess return of vocal fold motion. RESULTS: Thirty-eight of 55 patients (69%) recovered vocal function. Time course of recovery could be assessed in 34 patients who did not undergo injection augmentation. The mean time to recovery was 152.8 ± 109.3 days (left, 179.8 ± 111.3 days; right, 105.3 ± 93.7 days; P = .088). Two-thirds of patients recovered within 6 months. Probability of recovery declined over time. Five of 22 patients who recovered voice had return of vocal fold motion; 17 did not. The mean time to recovery did not differ between these groups (return of motion, 127.4 ± 132.3 days; no return of motion, 160.1 ± 105.1 days; P = .290). CONCLUSIONS: Sixty-nine percent of patients with idiopathic vocal fold paralysis recovered vocal function, two-thirds doing so within 6 months of onset. Age, gender, laterality, use of injection augmentation did not influence recovery rate. Declining probability of recovery over time leads us to consider framework surgery after 6 months in patients with idiopathic paralysis. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:148-152, 2018.

The Voice of Autoimmunity: Antisynthetase Syndrome Manifesting as Vocal Fold Bamboo Nodes.

OBJECTIVES: To describe a case of vocal fold bamboo nodes leading to the diagnosis of antisynthetase syndrome, a rare autoimmune disorder. To highlight the link between these laryngeal lesions and autoimmunity. METHODS: A case of vocal fold bamboo nodes in a patient with long-standing interstitial lung disease is presented. The presence of these characteristic lesions prompted a rheumatologic workup that led to the diagnosis of a rare autoimmune disorder. RESULTS: The patient was ultimately diagnosed with antisynthetase syndrome, a rare condition characterized by inflammatory myositis and interstitial lung disease. She was treated with steroids and immunosuppressive agents with improvement in her symptoms and clinical findings. CONCLUSIONS: Vocal fold bamboo nodes are pathognomonic signs of autoimmunity. Management consists primarily of medical treatment of the underlying systemic disorder. Intralesional steroid injection or phonomicrosurgical excision may be considered for refractory cases.

Laryngoscopic and stroboscopic signs in the diagnosis of vocal fold paresis.

OBJECTIVES/HYPOTHESIS: To identify strobolaryngoscopic findings significant in the diagnosis of paresis. STUDY DESIGN: Retrospective cohort study. METHODS: Fellowship-trained laryngologists reviewed 34 videostroboscopic examinations (24 with paresis, eight without paresis, two repeat). They indicated presence or absence of paresis, including side and type, degree of confidence in diagnosis, and ranked clinical findings that influenced diagnosis by order of importance. Fleiss's κ was used to assess inter-rater agreement for paresis presence, side, and type. Clinical findings compelling in diagnosis were tabulated and described. Confidence levels for side and type were compared by analysis of variance/Kruskal-Wallis tests and post hoc pairwise comparisons. RESULTS: Thirty-one laryngologists completed the review. Inter-rater agreement on presence or absence of paresis was fair at 0.334 (Fleiss's κ). Fourteen examinations were diagnosed with paresis by >70% of raters and considered strong paresis-candidate exams. Diagnosis of paresis side and type were inconsistent, although with statistically significant differences in confidence ratings (unilateral vs. bilateral, recurrent laryngeal nerve [RLN] vs. superior laryngeal nerve [SLN], RLN vs. mixed RLN/SLN). Laryngoscopic and stroboscopic findings with the strongest association with paresis were vocal fold motion anomalies, vocal fold degeneration, glottic insufficiency, and mucosal wave anomalies. CONCLUSIONS: Most laryngologists use strobolaryngoscopy for diagnosis of paresis. Although certain clinical findings were found to be associated with diagnosis, most commonly vocal fold motion anomalies, these varied among raters, especially when determining sidedness and nerve involvement. Future studies should expand the discussion and consideration of strobolaryngoscopic factors and adjunct functional and objective measures to develop a heuristic algorithm for diagnosis of paresis. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2100-2105, 2017.

Early glottic cancer involving the anterior commissure treated by transoral laser cordectomy.

OBJECTIVES/HYPOTHESIS: Anterior commissure involvement is considered to be a risk factor for poorer outcomes after transoral laser cordectomy (TLC) for early glottic cancer. The objective of this study was to determine the outcomes and relevance of the tumor-node-metastasis (TNM) classification in a large series of patients with early glottic cancer involving the anterior commissure treated by TLC. METHODS: The clinical and surgical parameters, as well as follow-up results, of the patients treated consecutively for early-stage glottic squamous cell carcinoma involving the anterior commissure (Tis, T1a, T1b, and T2) by transoral CO2 laser cordectomy in an urban academic medical center from January 2001 to March 2013 were analyzed retrospectively. The main outcomes measures were: 5-year disease free survival (DFS), ultimate local control with laser alone, laryngeal preservation, overall-survival (OS) rates, and disease-specific survival (DSS) rates (Kaplan-Meier). RESULTS: Ninety-six patients treated from January 2001 to March 2013 were included. The 5-year DFS and ultimate local control with laser alone rates were 61.7% and 74.4%, respectively. The laryngeal preservation rate was 93.4%; and the OS and DSS rates were 79.2% and 91.5%, respectively. Postoperative T classification (pT) status was not found to be a significant predictor of recurrences, but was predictive of more severe recurrences requiring other treatments than laser. CONCLUSION: TLC is an effective treatment for early stage glottic cancer involving the anterior commissure. The TNM classification is a relevant prognosis factor for severe recurrences. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1817-1822, 2016.

Identifying outcome predictors of transoral laser cordectomy for early glottic cancer.

BACKGROUND: The purpose of this study was to determine the predictors of outcomes in patients with early glottic cancer treated by transoral laser cordectomy. METHODS: This was an inception cohort study of 201 patients with early glottic cancer who were treated by transoral laser cordectomy. Five-year Kaplan-Meier analyses were realized. RESULTS: Patients with anterior commissure involvement (n = 75) had a significantly lower disease-free survival (DFS) rate (54.6% vs 79.8%; p = .0004), ultimate local control with laser alone rate (71.0% vs 95.7%; p < .0001), laryngeal preservation rate (91.6% vs 100%; p = .0003), and disease-specific survival (DSS) rate (90.8% vs 99.0%; p = .03). There was no significant difference in overall-survival (OS) rates (76.9% vs 88.5%; p = .29). Surgical margin status was not found to be a significant predictor of outcomes in this series. CONCLUSION: Although anterior commissure involvement has a significant impact on outcomes, laser cordectomy remains a valuable option considering its high organ preservation and survival rates. In cases of local recurrence, all standard further treatment options remain available. © 2015 Wiley Periodicals, Inc. Head Neck 38: E406-E411, 2015.

Transcervical Conservation Laryngeal Surgery: An Anatomic Understanding to Enhance Functional and Oncologic Outcomes.

The goal of this review is to facilitate an improved understanding of the indications and contraindications to transcervical conservation laryngeal surgery in the treatment of glottic and supraglottic carcinoma. An overview of seminal anatomic principles is presented to provide guidance for clinicians contemplating open partial laryngectomy options.

Quality of Life After Conservation Surgery for Laryngeal Cancer.

Quality of life preservation has become an essential goal of treatment in the management of laryngeal carcinoma. Although established treatments of reference such as total laryngectomy and chemoradiation protocols have focused on survival and anatomic preservation of the larynx, they still generate considerable functional morbidity with detrimental effects on quality of life. Transoral and transcervical partial laryngectomy techniques can offer significant advantages when used prudently after proper patient selection. The growing relevance of those techniques in the management of advanced and recurrent laryngeal carcinoma deserves particular attention, with potential for improved quality of life without compromising oncologic outcomes.

Dysphonia in performers: toward a clinical definition of laryngology of the performing voice.

OBJECTIVES: To identify causes of dysphonia in performers and compare causes and aspects of treatment of dysphonia in performers and nonperformers. STUDY DESIGN: Case-control study. METHODS: A chart review of all new patients presenting with a chief complaint of dysphonia over a 1-year period was performed. The prevalence of laryngeal disorders was reviewed and differences between performers and nonperformers were analyzed. The odds ratio of the prevalence of each disorder was computed against performer status as a risk factor. RESULTS: Four hundred seventy-six new patients complaining of dysphonia presented over 12 months; 74 were vocal performers. The median duration of symptoms in performers was 90 days. Phonotraumatic lesions were significantly more prevalent in performers (63.5% vs. 28.6%, P < 0.001), particularly bilateral mid-fold swelling (4-fold increase in performers), pseudocysts (3-fold increase), and vocal fold hemorrhage/ectasia. Neurologic disorders (vocal fold paralysis and spasmodic dysphonia), neoplastic pathologies, and age-related phenomena (atrophy/presbyphonia) were significantly more common in nonperformers. Overall and diagnosis-specific rates of surgical intervention were equal between the two groups. CONCLUSIONS: Phonotraumatic injury is responsible for the majority of dysphonia in vocal performers, to a significantly greater extent than in nonperformers and requires the implementation of standard therapeutic strategies. Awareness of the specific risks and management needs of the performer is of paramount importance to the practice of laryngology of the performing voice.

Hoarseness evaluation: a transatlantic survey of laryngeal experts.

OBJECTIVES/HYPOTHESIS: Hoarseness is a symptom of laryngeal dysfunction, without an existing consensus regarding its appropriate evaluation. A survey of laryngeal specialists is proposed to establish expert opinion on the methodology for evaluation of hoarseness, and to identify divergence of opinion regarding appropriate management. STUDY DESIGN: Cross-sectional survey. METHODS: A 13-item questionnaire was submitted electronically to the membership of the American Laryngological Association, the American Broncho-Esophagological Association, and the European Laryngological Society. Responses were collated anonymously and subjected to cross-tabulated data analysis. RESULTS: A total of 195 responses were included for review. The majority of respondents identified themselves as laryngologists/phoniatricians (54.9%). Two-thirds (64.1%) of the providers dedicated more than 25% of their practice to voice management, and 48.8% managed more than 10 dysphonic patients weekly. Most respondents defined hoarseness and dysphonia as symptoms and not diseases. The panel recommended a mandated time to laryngoscopy of 1 week to 1 month from the onset of symptoms for most acutely dysphonic patients, regardless of risk factors for malignancy, while it was not advised to defer laryngoscopy beyond 2 months of symptom persistence in any situation. A majority (96.2%) felt that an otolaryngologist ought to perform the initial laryngoscopy of a newly hoarse patient. CONCLUSION: This survey demonstrates an agreement to expedite specialized laryngeal visualization for cases of hoarseness not subsiding within 1 month, and exemplifies controversies stemming from a recently published clinical practice guideline. Ongoing research and practice evaluation will contribute to set forth improved standards of care and to appropriately counsel dysphonic patients.

Deep cervical lymph node hypertrophy: a new paradigm in the understanding of pediatric obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To determine if adenotonsillar hypertrophy is an isolated factor in pediatric obstructive sleep apnea (OSA), or if it is part of larger spectrum of cervical lymphoid hypertrophy. STUDY DESIGN: Prospective case control study. METHODS: A total of 70 screened patients (mean age 7.47 years) underwent polysomnography to confirm OSA, and then underwent MRI of the upper airway. Seventy-six matched controls (mean age 8.00 years) who already had an MRI underwent polysomnography. Volumetric analysis of lymphoid tissue volumes was carried out. Chi-square analysis and Student's t test were used to compare demographic data and lymph node volumes between cohorts. Fisher's Exact test and Chi-square analysis were used to compare sleep data. RESULTS: Patients and controls demonstrated no significant difference in mean age (7.47 vs. 8.00 yrs), weight (44.87 vs. 38.71 kg), height (124.68 vs. 127.65 cm), or body-mass index (23.63 vs. 20.87 kg/m(2)). OSA patients demonstrated poorer sleep measures than controls (P < 0.05) in all polysomnography categories (sleep efficiency, apnea index, apnea-hypopnea index, baseline SpO2, SpO2 nadir, baseline ETCO2, peak ETCO2 , and arousal awakening index). Children with OSA had higher lymphoid tissue volumes than controls in the retropharyngeal region (3316 vs. 2403 mm(3), P < 0.001), upper jugular region (22202 vs. 16819 mm(3), P < 0.005), and adenotonsillar region (18994 vs. 12675 mm(3), P < 0.0001). CONCLUSIONS: Children with OSA have larger volumes of deep cervical lymph nodes and adenotonsillar tissue than controls. This finding suggests a new paradigm in the understanding of pediatric OSA, and has ramifications for future research and clinical care.