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.

Otitis Media Practice During the COVID-19 Pandemic.

The global coronavirus disease-2019 (COVID-19) pandemic has changed the prevalence and management of many pediatric infectious diseases, including acute otitis media (AOM). Coronaviruses are a group of RNA viruses that cause respiratory tract infections in humans. Before the COVID-19 pandemic, coronavirus serotypes OC43, 229E, HKU1, and NL63 were infrequently detected in middle ear fluid (MEF) specimens and nasopharyngeal aspirates in children with AOM during the 1990s and 2000s and were associated with a mild course of the disease. At times when CoV was detected in OM cases, the overall viral load was relatively low. The new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative pathogen responsible for the eruption of the COVID-19 global pandemic. Following the pandemic declaration in many countries and by the World Health Organization in March 2020, preventive proactive measures were imposed to limit COVID-19. These included social distancing; lockdowns; closure of workplaces; kindergartens and schools; increased hygiene; use of antiseptics and alcohol-based gels; frequent temperature measurements and wearing masks. These measures were not the only ones taken, as hospitals and clinics tried to minimize treating non-urgent medical referrals such as OM, and elective surgical procedures were canceled, such as ventilating tube insertion (VTI). These changes and regulations altered the way OM is practiced during the COVID-19 pandemic. Advents in technology allowed a vast use of telemedicine technologies for OM, however, the accuracy of AOM diagnosis in those encounters was in doubt, and antibiotic prescription rates were still reported to be high. There was an overall decrease in AOM episodes and admissions rates and with high spontaneous resolution rates of MEF in children, and a reduction in VTI surgeries. Despite an initial fear regarding viral shedding during myringotomy, the procedure was shown to be safe. Special draping techniques for otologic surgery were suggested. Other aspects of OM practice included the presentation of adult patients with AOM who tested positive for SARS-2-CoV and its detection in MEF samples in living patients and in the mucosa of the middle ear and mastoid in post-mortem specimens.

General anesthesia risk across pediatric surgical specialties: Low in otolaryngology.

PURPOSE: To determine the relevance of the Food and Drug Administration (FDA) warning regarding general anesthesia (GA) in children under 3 years of age for procedures lasting longer than 3 h, by surgical specialty and for otolaryngology specifically. METHODS: A one-year retrospective review was conducted at a tertiary-care medical center for all children younger than 3 years undergoing surgical procedures with durations greater than 3 h. De-identified data related to age, surgical service, procedure types, American Society of Anesthesiologists (ASA) physical status classification, and general anesthesia time were collected and examined. RESULTS: During 2017, 430 of 11,757 patients (3.7%) met the age and duration of anesthesia criteria. Procedures performed by the cardiothoracic surgery service were mostly likely to result in duration of surgery greater than 3 h (46.6%), followed by neurosurgery (12.9%), cardiology (9.3%), plastic surgery (7.1%), general surgery (6.6%), and urology (5.1%). Less than 2% of patients undergoing ophthalmology (1.9%), orthopedic surgery (1.7%), and otolaryngology (0.5%) procedures required anesthesia greater than 3 h. CONCLUSION: Less than 4% of patients younger than 3 years undergoing surgery required general anesthesia for longer than 3 h. The theoretical risks of general anesthesia per the FDA warning are discussed and must be balanced against the known functional and neurodevelopmental consequences of not performing critical and time-sensitive surgery on children in this age group. A strategy for addressing parental and provider concerns is discussed.

Post-transplant lymphoproliferative disease of the larynx.

Laryngeal post-transplant lymphoproliferative disease (PTLD) is rare. Here, we describe two pediatric cases. The first, a 15-month-old who underwent liver transplantation at 5 weeks, presented with airway distress. Airway evaluation identified epiglottic and arytenoid infiltrate, and biopsy was consistent with polymorphic PTLD. The second, a 23-month-old who underwent liver transplantation at 13 months, presented with progressive stridor. Airway evaluation revealed sub-mucosal infiltrate of the epiglottis, arytenoids, post-cricoid region, and uvula. Biopsy was consistent with monomorphic PTLD. Airway findings and symptoms resolved for both after immunosuppression reduction. PTLD diagnosis requires a high index of suspicion in post-transplant patients with airway obstruction.

Dyskeratosis Congenita and Oral Cavity Squamous Cell Carcinoma: Report of a Case and Literature Review.

Dyskeratosis congenita is a rare genetic condition of telomerase dysfunction in which patients are at an increased risk of squamous cell carcinoma (SCCa) of the oral cavity. We present here the youngest patient in the literature with a diagnosis of SCCa. We discuss the literature and management of this advanced presentation of SCCa in a child, stressing the importance of palliative care involvement in facilitating medical decision making.

Palliation in pediatric otorhinolaryngology.

Palliation in pediatric otorhinolaryngology is a rarely discussed but important aspect of care. This review encapsulates current thinking on pediatric palliative care (PC) and demonstrates, through one case, the impact of integrating PC into clinical care. We encourage early consideration of pediatric palliative care approaches for children with complex otorhinolaryngologic disorders.

Risk factor analysis for mortality among infants requiring tracheostomy.

INTRODUCTION: An increasing number of tracheostomies are performed in infants with complex comorbidities including bronchopulmonary dysplasia (BPD) and congenital heart disease (CHD). With this shift in indications, there is an urgent need to characterize outcomes in this population. METHODS: This 5-year retrospective chart review assessed rates of 12-month mortality in infants who were ≤12 months of age at the time of tracheostomy at a tertiary care pediatric hospital and risk factors associated with death. Patient characteristics evaluated included chronologic age and post-menstrual age at tracheostomy placement, gestational age and weight, sex, ethnicity, indication for tracheostomy, and comorbidities including BPD, CHD, subglottic stenosis (SGS), craniofacial syndromes, and chromosomal trisomy syndromes. Subgroup analysis was performed in infants with CHD. RESULTS: One hundred thirty-two tracheostomies were performed during the study period with an overall 12-month mortality of 14.4% (19/132). Mortality was increased in patients with CHD (35%) and decreased in patients with SGS (3.7%). No other patient characteristics were associated with differences in mortality. There was a trend towards improved mortality outcomes among patients born at earlier gestational ages. CONCLUSIONS: Among infants with tracheostomy in this cohort, overall mortality rates were relatively low but not insignificant. CHD was associated with increased mortality; however, children with SGS showed more favorable outcomes. Other patient characteristics were not associated with differences in mortality. These data clarify outcomes in a group of infants with tracheostomy.

Complications Following Pediatric Tracheotomy.

IMPORTANCE: Pediatric tracheotomy is a complex procedure with significant postoperative complications. Wound-related complications are increasingly reported and can have considerable impact on clinical course and health care costs to tracheotomy-dependent children. OBJECTIVE: The primary objective of this study was to identify the type and rate of complications arising from pediatric tracheotomy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of medical records of 302 children who underwent tracheotomy between December 1, 2000, and February 28, 2014, at a tertiary care pediatric referral center. Records were reviewed for preoperative diagnoses, gestational age, age at tracheotomy, tracheotomy technique, and incidence of complication. MAIN OUTCOMES AND MEASURES: Main outcome measures included incidence, type, and timing of complications. Secondary measures included medical diagnoses and surgical technique. RESULTS: Of the 302 children who underwent tracheotomy, the median (SD) age at time of tracheotomy was 5 months (64 months) and the range was birth to 21 years. The most frequent diagnosis associated with performance of a tracheotomy was ventilator-associated respiratory failure (61.9%), followed by airway anomaly or underdevelopment (25.2%), such as subglottic or tracheal stenosis, laryngotracheomalacia, or bronchopulmonary dysplasia. The remaining indications for tracheotomy included airway obstruction (11.6% [35 of 302]) and vocal fold dysfunction (1.3% [4 of 302]). No statistical significance was found associated with diagnosis and incidence of complications. Sixty children (19.9%) had a tracheotomy-related complication. Major complications, such as accidental decannulation (1.0% [3 of 302]). There were no deaths associated with tracheotomy. Minor complications, such as peristomal wound breakdown or granuloma (12.9% [39 of 302]) and bleeding from stoma (1.7% [5 of 302]), were more common. Of all complications, 70% (42 of 60) occurred early (≤7 days postoperatively) and 20% (12 of 60) were late (>7 days postoperatively). CONCLUSIONS AND RELEVANCE: Pediatric tracheotomy at our institution is associated with an overall 19.9% incidence of complications. Although the rate of major complications such as accidental decannulation or death is low, rates of peristomal skin breakdown and development of granuloma are more frequently reported and can occur at any point following tracheotomy. Further work is necessary to understand and mitigate wound care issues in post-tracheotomy care.

Pediatric foreign body aspiration: A nidus for Aspergillus colonization.

We describe an immunocompetent child with bronchial fungus following foreign body aspiration. A two-year-old male presented with cough. Workup revealed air trapping and bronchoscopy showed aspirated foreign material in the right mainstem bronchus. Histopathology revealed fungal organisms suggestive of Aspergillus within an ulcer of the adjacent bronchial mucosa. Foreign body aspiration has been posited as a nidus for aspergilloma formation but is not yet described in the available English-language pediatric literature. Here, the foreign body provided a site for fungal growth in the bronchus of an otherwise healthy child. This case suggests that bronchial foreign body may pose risk of fungal colonization even in immunocompetent children.

Tracheotomy after laryngotracheoplasty: risk factors over 10 years. [Corrected].

BACKGROUND: Subglottic stenosis (SGS) is the most common congenital and/or acquired laryngotracheal anomaly requiring tracheotomy in infants. We sought to determine factors associated with a greater likelihood of tracheotomy in symptomatic infants with SGS who underwent laryngotracheoplasty (LTP). METHODS: Retrospective case series with chart review of patients undergoing single-stage LTP for SGS over a 10-year period (2001-2010) in a tertiary-care pediatric hospital. RESULTS: Twenty-two children (15 boys, 7 girls), with a mean gestational age of 32.5weeks, underwent LTP with and without interpositional grafting, at a median age of 89days. Ten patients (43%) required postoperative tracheotomy. Of patients weighing <2.5kg, 7 of 8 eventually required tracheotomy, while none weighing >5kg needed tracheotomy (p=0.003). The average length of stay for patients with a tracheotomy was 125days, while those without tracheotomy required only 58days (p=0.011). The grade of SGS (p=0.809), gender (p=0.968), age at surgery (p=0.178), and gestational age (p=0.117) were not significantly associated with the need for tracheotomy. Weight at surgery was significantly correlated with the likelihood of needing tracheotomy (p=0.003). CONCLUSIONS: Patients who weighed less than 2.5kg at the time of LTP procedures were more likely to require a postoperative tracheotomy. Children who required tracheotomy had longer lengths of hospital stay.

Risk factors associated with postoperative tympanostomy tube obstruction.

IMPORTANCE: Myringotomy and tympanostomy tube placement for chronic otitis media with effusion is the most common reason for a child to undergo anesthesia in the United States. Postoperative tube obstruction occurs in 1.4% to 36.0% of cases and remains a challenge in achieving middle ear ventilation. OBJECTIVE: To identify risk factors associated with tube obstruction. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 248 patients, mean age 2.54 years, seen between March 2007 and June 2011 in a tertiary care pediatric hospital. INTERVENTIONS: Tympanostomy tube placement and postoperative otic drop therapy. MAIN OUTCOMES AND MEASURES: Tube patency at postoperative visit, number of tube removals and revisions, age, sex, body mass index (BMI), middle ear fluid type at time of surgery, and time between surgery and first postoperative visit were examined. Type of surgery (tympanostomy tube placement alone, adenoidectomy + tympanostomy tube placement, tympanostomy tube placement + adenoidectomy + tonsillectomy) and its effect on tube patency were also reviewed. RESULTS: At first follow-up, 10.6% of patients had occlusion of one or both tubes. No significant association was found between tube patency and a patient's BMI percentile, sex, or procedure type. Patients with no middle ear fluid were more likely to have patent tubes than those who had serous fluid (odds ratio [OR], 3.5; 95% CI, 1.2-10.6; P = .02). A significant inverse correlation was found between patency and time between surgery and follow-up in that patients who had longer follow-up after surgery were less likely to have patent tubes (OR per day of follow-up delay, 0.990; 95% CI, 0.981-0.999; P = .01). CONCLUSIONS AND RELEVANCE: Tympanostomy tube obstruction was seen in 10.6% of patients. Serous fluid and increased time to postoperative visit were statistically significant indicators for tube occlusion.

Resource analysis of tonsillectomy in children.

OBJECTIVES/HYPOTHESIS: To analyze variables that affect time and cost parameters of pediatric adenotonsillectomy. STUDY DESIGN: Longitudinal 7-month retrospective review of sequential tonsil and adenoid surgery at a university pediatric tertiary care hospital. METHODS: All children aged 2 to 12 years who underwent adenotonsillectomy from May 2008 to October 2008 had charts and billing records analyzed for variations in charges and times of adenotonsillectomy according to patient age, body mass index for age (BMIFA), American Society of Anesthesiologists (ASA) status, surgical indication, technology used, and teaching status of case. A total of 214 children had records reviewed. RESULTS: Statistically significant variations were observed for all measured parameters except for indications for surgery. Children 3 years and younger had shorter procedures (P = .005) and total operating room times (P = .037). Charges for supplies were lower for ASA 1 patients than for ASA 2 patients (P = .010). Obese children with elevated BMIFA required longer procedures (P = .039) and more expensive surgery (P = .003). Procedure times were shorter for Coblation (ArthroCare, Austin, TX) compared with electrocautery (P = .27) and for microdebrider compared with electrocautery (P < .001). Charges for Coblation were substantially higher (P < .001). Teaching cases took longer (P < .001). CONCLUSIONS: Charges and times for adenotonsillectomy surgery varied by patient age, BMIFA, ASA status, tonsillectomy technique, and teaching case status. Clinically salient differences were noted for ASA status, BMIFA, and surgical technique. This method of cost analysis provides useful information for resource management in tonsillectomy.

Castleman disease in the pediatric neck: a literature review.

OBJECTIVE: To investigate the common features of cervical pediatric Castleman disease. DATA SOURCES: Literature review of pediatric patients with cervical Castleman disease. REVIEW METHODS: Online medical journal databases were searched for patients aged 18 years or younger. Eighteen published studies were found, comprising 29 patients. CONCLUSIONS: An asymptomatic or slowly enlarging neck mass was the most common presentation. No sex differences were noted. Magnetic resonance imaging demonstrates a homogeneous, isointense to slightly hyperintense T1-weighted signal and high signal intensity on T2-weighted imaging. Lymphoma was the most common differential diagnosis. All patients were treated with complete surgical excision and diagnosed as hyaline-vascular type on histology, except for 1 patient for whom histologic type was not reported. No reports of multicentric disease, plasma cell, or mixed histology were found. No recurrences were reported. IMPLICATIONS FOR PRACTICE: In this article, we provide the largest known literature review of pediatric patients with cervical Castleman disease. Although Castleman disease is rare, it should be considered on the differential for a pediatric neck mass, particularly when presenting with an asymptomatic posterior neck mass and equivocal workup. Fortunately, our study suggests that if diagnosed as Castleman disease, the most likely diagnosis is hyaline-vascular type, for which the long-term prognosis is good. Surgical excision is both diagnostic and therapeutic.

Low birth weight neonatal choanal atresia repair using image guidance.

This case report demonstrates a novel technique for image-guided choanal atresia repair in the undersized neonate. A surgical navigation system (Stryker, Inc., Kalamazoo, MI) face mask was applied in an "inch-worm" technique facilitating a registration "work-around," also detailed here, to permit intraoperative image guidance despite the patient's small head size. At age 10 days, the premature neonate underwent successful image-guided endoscopic repair of bilateral choanal atresia, permitted by a unique adaptation of face mask application and registration technique. This report presents the smallest weight patient in the literature to date to undergo image guidance during transnasal bilateral choanal atresia repair.

Act to keep patients safe: device-related adverse event reporting.

Primum non nocere- "Above all do no harm." Since the first year of medical school, we have all heard and spoken this dictum countless times. Translating this dictum into action may present challenges in our daily practice. Every day, clinicians must distinguish between scientific evidence, clinical experience, and marketing claims by industry vendors of improved efficacy and safety regarding medical devices. Adverse event reporting and device failure notification are generally laid out well in hospital practice settings. Reporting beyond the local level takes on a new dimension for most surgeons. Perceived stigma from peers and corporations, lack of confidentiality, and cynicism regarding protective actions for patients should not limit one from "raising the alarm" when concerns arise about device safety or performance. This commentary aims to explain the process for reporting device-related adverse events.

Practitioners need corporate compliance education: AAO-HNS survey results.

The environment in which otolaryngologists coexist with device and drug development has become increasingly complex. There are broad implications for both the academic and the private practitioner, with neither group being more or less insulated than the other. From the medical, ethical, and resource-oriented standpoints, otolaryngologists must consider this evolving area very carefully. A survey of the American Association of Otolaryngology-Head and Neck Surgery membership identified areas of education to improve the awareness and knowledge base of these complex considerations. In particular, knowledge of legal proceedings, Food and Drug Administration processes, relevant hospital resources, and conflict of interest considerations were areas in which the membership would benefit from further instruction.

Case report: Langerhans cell histiocytosis presenting as massive cervical adenopathy and retropharyngeal thickening: importance of chest radiography and coordinated airway and anesthetic management.

OBJECTIVE: To demonstrate the importance of chest radiography and special anesthetic management in children with massive cervical adenopathy. METHOD: Case report of an 8-month-old infant who presented to the emergency department with fever, drooling, and massive cervical and mediastinal adenopathy. Safe anesthetic management allowed for cervical lymph node biopsy, which showed Langerhans cell histiocytosis. RESULTS: Chest imaging and special anesthetic techniques (intravenous anesthesia and positioning in the lateral decubitus position) should be considered for children with massive cervical and mediastinal adenopathy. CONCLUSIONS: Interdisciplinary airway, radiographic, and anesthetic management is recommended for children who present with massive and cervical and mediastinal adenopathy.

Case studies in corporate compliance: putting the rubber to the road.

An interdisciplinary, proactive perspective allows providers to engage in productive, long-term collaborative relationships with corporations, while 1) maintaining patient care improvements; 2) maintaining legality; 3) enhancing technical and clinical innovation; and 4) providing fair compensation for work done. The case study approach is used to demonstrate an effective approach to compliant behavior.

Penalties for health care fraud and abuse: January 2007-March 2008.

This commentary details the providers, penalties, and affected regions resulting from US health care fraud and abuse prosecutions from January 2007 to March 2008. Database review found that over $3 billion in fines as well as incarceration in some cases were ordered for 21 convicted providers, 68 percent of whom were physicians, and to 41 nonproviders, most of whom were vendors of durable medical goods (36%), individual citizens (18%) and health care corporations (17%). Fewer claims were found against pharmaceutical firms (7%) and medical equipment manufacturers (4%). Most verdicts were in the state of Florida. False claims accounted for most of the violations for both providers and nonproviders. These severe repercussions of malfeasance should promote careful consideration and construction of the terms of engagement between health care providers, corporations, and payers.

Corporate-physician relationships: a need for education.

Knowledge is lacking among Otolaryngologist-Head and Neck Surgeons (ORL-HNS) regarding basic ethical situations in corporate-provider relationships. A pilot educational program demonstrates the need and potential for improvement by structured intervention. "At risk" areas specifically identified regard acceptable gifts, and payments for meetings and travel. Recommendations are made to educate otolaryngologists in standards for compliant behavior in corporate-physician relationships. Further work to formalize and tailor education to the needs of ORL-HNS is warranted, including continued education through the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF). A checklist is provided here as a first step in enabling more compliant behavior as surgeons engage in corporate relationships.