Is there an OAHI or O2 nadir that predicts the need for preoperative echocardiogram prior to adenotonsillectomy for children with severe obstructive sleep apnea?

PURPOSE: To investigate threshold values for obstructive apnea-hypopnea index (OAHI) and nadir oxygen saturation (NspO2) in children with severe obstructive sleep apnea (OSA) to identify children most appropriate for preoperative echocardiography. METHODS: A multi-institutional retrospective chart review was performed on children who underwent echocardiography and polysomnogram within a year. Children with severe OSA as defined by OAHI > 10 or NspO2 < 80% were included. Receiver operator curves and Youden's J index were used to assess the discriminatory ability and threshold values of OAHI and NspO2 for right heart strain (RHS) on echocardiography. RESULTS: A total of 173 prepubertal (< 10 years) children and 71 postpubertal (≥ 10 years) children of age were included. RHS was seen in 9 (5%) prepubertal children and 4 (6%) postpubertal children. In prepubertal children, OAHI and NspO2 were poor predictors of RHS (area under the curve [AUC] 0.53 [95%CI 0.45-0.61], p = 0.748; AUC 0.56 [95%CI 0.48-0.64], p = 0.609). In postpubertal children, threshold values of 55 events/hour and 69% were strong predictors for RHS (AUC 0.88 [95%CI 0.78-0.95], p < 0.001; AUC 0.92 [95%CI 0.83-0.97], p < 0.001). CONCLUSION: In children with severe OSA, evidence of RHS is low. Postpubertal children with OAHI > 55 and NspO2 < 69% appear most appropriate for echocardiography. Clinicians should weigh the risks and benefits of preoperative echocardiography for each child with these threshold values in mind.

Cleft Lip and/or Palate Repair in Children With Hypopituitarism: Analysis of the Kids' Inpatient Database.

OBJECTIVE: Children with hypopituitarism (CwHP) can present with orofacial clefting, frequently in the setting of multiple midline anomalies. Hypopituitarism (HP) can complicate medical and surgical care; the perioperative risk in CwHP during the traditionally lower risk cleft lip and/or palate (CL/P) repair is not well described. The objective of this study is to examine the differences in complications and mortality of CL/P repair in CwHP compared to children without hypopituitarism (CwoHP). DESIGN: A retrospective cross-sectional analysis. SETTING: The 1997 to 2019 Kids' Inpatient Databases (KID). PATIENTS: Children 3 years old and younger who underwent CL/P repair. MAIN OUTCOME MEASURE(S): Complications and mortality. RESULTS: A total of 34 106 weighted cases were analyzed, with 86 having HP. CwHP had a longer length of stay (3.0 days [IQR 2.0-10.0] vs 1.0 day [IQR 1.0-2.0], P < .001) and higher rates of complications and mortality (12.8% vs 2.9%, P < .001) compared to CwoHP. Controlling for demographic factors, CwHP had 6.61 higher odds of complications and mortality than CwoHP (95% CI 3.38-12.94, P < .001). CONCLUSIONS: CwHP can present with a CL/P and other midline defects that can increase the complexity of their care. These data show a significant increase in length of stay, complications, and mortality in CwHP undergoing CL/P repair. Increased multidisciplinary attention and monitoring may be needed for these children peri- and postoperatively, especially if additional comorbidities are present. Further studies on perioperative management in this population are warranted to reduce morbidity and mortality.

Impact of auditory environments on language outcomes in children with a cochlear implant.

OBJECTIVES: To analyse the effects of auditory environments on receptive and expressive language outcomes in children with a CI. DESIGN: A single-institution retrospective review was performed. The auditory environments included Speech-Noise, Speech-Quiet, Quiet, Music, and Noise. Hearing Hour Percentage (HHP) and percent total hours were calculated for each environment. Generalised Linear Mixed Models (GLMM) analyses were used to study the effects of auditory environments on PLS Receptive and Expressive scores. STUDY SAMPLE: Thirty-nine children with CI. RESULTS: On GLMM, an increase in Quiet HHP and Quiet percent total hours were positively associated with PLS Receptive scores. Speech-Quiet, Quiet, and Music HHP were positively associated with PLS Expressive scores, with only Quiet being significant for percent total hours. In contrast, percent total hours of Speech-Noise and Noise had a significant negative association with PLS Expressive scores. CONCLUSIONS: This study suggests that more time spent in a quiet auditory environment positively influences PLS Receptive and Expressive scores and that more time listening to speech in quiet and music positively influences PLS Expressive scores. Time spent in environments recognised as Speech-Noise and Noise might negatively impact a child's expressive language outcomes with a CI. Future research is needed to better understand this association.

Impact of Syndromes on Sleep-Disordered Breathing in Children After Cleft Palate Repair.

OBJECTIVE: Prior research suggests that children with cleft palate (CP) are at increased risk of obstructive sleep-disordered breathing (SDB). However, few studies differentiate the effects of CP repair on SDB based on syndrome status. The goal of this study was to evaluate differences in SDB after palatoplasty among children with nonsyndromic CP, syndromic CP, and isolated Robin sequence (RS). DESIGN: Retrospective chart review. SETTING: Tertiary academic children's hospital. PATIENTS/PARTICIPANTS: A total of 145 children who underwent primary CP repair from 2014 to 2021. MAIN OUTCOME MEASURE: Post-palatoplasty SDB is defined as parent-reported symptoms and/or evidence of obstructive sleep apnea (OSA). RESULTS: Median age at palatoplasty was 11.1 [IQR 10.2-13.6] months. Most patients (61.4%) had nonsyndromic CP, 26.9% had a syndrome, and 11.7% had RS. Children with syndromic CP and RS had more post-palatoplasty SDB symptoms (56.4% vs 58.8% vs 30.3%, P = .006) and higher rates of OSA (25.6% vs 29.4% vs 5.6%, P = .001) compared to children with nonsyndromic CP after palatoplasty. Children with syndromic CP and RS had nearly 3 to 4 higher odds of post-palatoplasty SDB than children with nonsyndromic CP (adjusted odds ratio [aOR] 2.88, 95% CI 1.29-6.47, P = .010; aOR 3.73, 95% CI 1.19-11.70, P = .024). CONCLUSION: This study showed that children with CP experience higher rates of SDB after palatoplasty than the general pediatric population. Within the cohort, children with syndromic CP and isolated RS were more likely to have obstructive sleep disorders than nonsyndromic children after palatoplasty. Clinicians should counsel caregivers accordingly and closely monitor these groups for SDB after palate repair.

Evaluating Prenatal Diagnostic Imaging for Micrognathia: A Systematic Review and Meta-Analysis.

OBJECTIVE: Studies evaluating the ability to diagnose and accurately predict the severity of micrognathia prenatally have yielded inconsistent results. This review aimed to evaluate reliability of prenatal diagnostic imaging in the diagnosis and characterization of micrognathia. DESIGN: Systematic review and meta-analysis. SETTING: Studies with a prenatal diagnosis of micrognathia via ultrasound with a confirmatory postnatal examination were included. Prenatal severity was defined with and without mandibular measurements. Extent of airway obstruction at birth was defined by level of intervention required. Meta-analyses of proportions and relative risk were performed. PATIENTS: A total of 16 studies with 2753 neonates were included. MAIN OUTCOME MEASURES: Primary outcome was the efficacy of characterizing the degree of micrognathia on prenatal imaging as it relates to respiratory obstruction at birth. Secondary outcome was the accuracy of prenatal diagnosis with the utilization of mandibular measurements versus without. RESULTS: Performing meta-analysis of proportions, the proportion of missed prenatal diagnoses of micrognathia made without mandibular measurements was 11.62% (95%CI 2.58-25.94). Utilizing mandibular measurements, the proportion of cases missed were statistically lower (0.20% [95%CI 0.00-0.70]). Patients determined to have severe micrognathia by prenatal imaging did not have a statistically significant increase in risk for more severe respiratory obstruction at birth (RR 3.13 [95%CI 0.59-16.55], P = .180). CONCLUSION: The proportion micrognathia cases missed when prenatal diagnosis was made without mandibular measurements was over 1 in 10, with mandibular measures improving accuracy. This study highlights the need for a uniform objective criterion to improve prenatal diagnosis and planning for postnatal care.

Complications After Pediatric Temporal Bone Fractures by Classification System: A Systematic Review and Meta-analysis.

OBJECTIVE: To analyze the rates of complications after pediatric temporal bone fractures (TBF) and the utility of the longitudinal, transverse, and mixed versus the otic capsule sparing (OCS) and otic capsule violating (OCV) classification systems in predicting these complications. DATA SOURCES: PubMed, Scopus, and CINAHL. REVIEW METHODS: Per PRISMA guidelines, studies of children with TBFs were included. Meta-analyses of proportions were performed. RESULTS: A total of 22 studies with 1376 TBFs were included. Children with TBF had higher rates of conductive hearing loss (CHL) than sensorineural hearing loss (SNHL) (31.3% [95% confidence interval [CI] 23.2-40.1] vs 12.9% [95% CI 8.9-17.5]). No differences in both CHL and SNHL were seen between longitudinal and transverse TBFs; however, OCV TBFs had higher rates of SNHL than OCS TBFs (59.3% [95% CI 27.8-87.0] vs 4.9% [95% CI 1.5-10.1]). Of all patients, 9.9% [95% CI 7.2-13.1] experienced facial nerve (FN) paresis/paralysis, and 13.4% [95% CI 5.9-23.2] experienced cerebrospinal fluid otorrhea. Transverse TBFs had higher rates of FN paresis/paralysis than longitudinal (27.7% [95% CI 17.4-40.0] vs 8.6% [95% CI 5.2-12.8]), but rates were similar between OCS and OCV TBFs. CONCLUSION: CHL was the most common complication after TBF in children; however, neither classification system was superior in identifying CHL. The traditional system was more effective at identifying FN injuries, and the new system was more robust at identifying SNHL. While these results suggest that both classification systems might have utility in evaluating pediatric TBFs, these analyses were limited by sample size. Future research on outcomes of pediatric TBFs stratified by type of fracture, mainly focusing on long-term outcomes, is needed.

Comparison of trigeminal lateralization with differing stimulants.

Trigeminal-specific stimulants have been shown to activate different receptors preferentially and this likely accounts for variation in sensory perception. It is unclear whether trigeminal sensitivity is similar across different transient receptor potential (TRP) receptors or if dysfunction of different receptors results in differing patient symptoms. Therefore, a prospective cohort study was conducted, consisting of trigeminal lateralization testing with three different stimulants (eucalyptol, isothiocyanate, acetic acid), olfaction testing with Sniffin' Sticks, and measurement of various patient-reported outcome measures (PROMs). A total of 50 participants were enrolled across the olfactory spectrum. Mean TDI score was 27.1 ± 8.3 (range 7.0-39.5) with 38% normosmic and 62% dysosmic. Mean trigeminal lateralization scores out of 20 in the overall cohort were 16.18 (2.78) for eucalyptol, 14.94 (3.49) for mustard oil, and 15.28 (3.68) for vinegar. Eucalyptol showed a significant correlation with threshold scores of Sniffin' Sticks. A significant correlation was found between acetic acid and various PROMs. None of the lateralization scores of the trigeminal stimulants correlated to each other significantly and there was no correlation to age. The lack of correlation suggests that the measured sensitivity of one type of TRP receptor may not translate to similar sensitivity of the other receptors. Additional investigations with TRPV1 and TRPA1 agonists are needed to corroborate our findings.

Does REM AHI Predict Persistent OSA After Pediatric Adenotonsillectomy?

OBJECTIVE: The utility of REM AHI in managing pediatric obstructive sleep apnea (OSA) is not fully understood. This study aimed to evaluate the relationship of preoperative REM AHI to postoperative persistence of OSA in children who underwent adenotonsillectomy. METHODS: This retrospective chart review identified children under the age of 18 years that received an adenotonsillectomy for OSA and a preoperative and postoperative polysomnogram. Children with craniofacial or neuromuscular disorders or a tracheostomy were excluded. The primary outcome was the postoperative persistence of OSA, defined as a postoperative obstructive apnea-hypopnea index (oAHI) ≥ 1.5 events/hour. REM-predominant OSA was defined as a ratio of REM/NREM AHI ≥ 2. REM AHI minus NREM AHI and REM AHI minus oAHI helped to identify patients with a larger distribution of REM AHI. RESULTS: A total of 353 patients were included. Postoperative persistent OSA was seen in 232 (65.7%) children. The preoperative REM AHI, REM AHI minus NREM AHI, and REM AHI minus oAHI of children with persistent OSA did not differ significantly from children with resolution of OSA. Rates of persistence were not different between those with REM-predominant OSA and REM-independent OSA (63.8% vs 70.7%, P = .218). CONCLUSION: This study suggests that preoperative REM AHI may be a poor predictor of OSA persistence after adenotonsillectomy. Further study is needed to help characterize how pre-operative REM AHI should impact clinicians' decision making, family counseling and recommendations.

Outcomes of Tympanoplasty After Cleft Palate Repair: A Systematic Review and Meta-analysis.

OBJECTIVE: To analyze graft success rates and hearing outcomes in patients with a history of cleft palate (CP) repair undergoing tympanoplasty. DATA SOURCES: PubMed, Scopus, and CINAHL. REVIEW METHODS: Per PRISMA guidelines, the databases were searched from date of inception through December 14, 2021. Studies of patients with previous CP repair who underwent tympanoplasty were included. Meta-analysis of proportions, continuous measures, odds ratios (ORs), and meta-regression were used to analyze graft success and hearing outcomes after tympanoplasty. RESULTS: A total of 323 patients with CP repair and 1169 controls were included. The proportion of graft success was 86.7% (95% CI, 76.1%-94.5%) in patients with CP repair and 88.8% (95% CI, 76.9-96.8) in controls. There was no difference in odds of graft success between patients with CP repair and controls (OR, 1.0 [95% CI, 0.5-1.8]; P = .870). Age was not a significant moderator of graft success in patients with CP repair (r = 0.1 [95% CI, -0.2 to 0.3]; P = .689) or controls (r = -0.0 [95% CI, -0.1 to 0.1]; P = .952). Comparing mean differences between pre- and postoperative air-bone gap was not statistically significant in patients with CP repair and controls (0.2 dB [95% CI, -3.1 to 3.4]; P = .930). Odds of functional success (postoperative air-bone gap <20 dB) were not different between the groups (OR, 0.8 [95% CI, 0.5-1.4]; P = .450). CONCLUSION: This meta-analysis does not endorse anatomic or functional differences between patients with CP repair and controls after tympanoplasty. However, there is a paucity of evidence for younger children. Further studies are warranted to elucidate specific risk factors for tympanoplasty outcomes in young patients with previous CP repair.

Improving Pneumococcal Vaccination Rates in Cochlear Implant Programs: A Systematic Review and Meta-analysis.

OBJECTIVE: To review the literature on pneumococcal vaccination compliance rates among cochlear implant (CI) patients and to examine the utility of intervention programs on increasing vaccination rates. DATA SOURCES: PubMed, Scopus, and CINAHL. REVIEW METHODS: A systematic review was performed following PRISMA guidelines. Studies of pneumococcal vaccination rates at baseline and before and after the implementation of a quality improvement (QI) intervention were included. A total of 641 studies were screened, and 13 studies met inclusion criteria. Meta-analyses of pneumococcal vaccination rates pre- and post-QI intervention in CI patients were performed. RESULTS: A total of 12,973 children and adults were included. The baseline PCV13 and PPSV23 vaccination rates were 53.45% (95% CI, 37.02%-69.51%) and 42.53% (95% CI, 31.94%-53.48%), respectively. Comparing children and adults, PCV13 and PPSV23 baseline vaccination rates were not statistically significant. The PPSV23 vaccine rate after QI initiatives was significantly higher than the baseline rate at 83.52% (95% CI, 57.36%-98.46%). After these interventions, patients had a 15.71 (95% CI, 4.32-57.20, P < .001) increased odds of receiving PPSV23 vaccination compared to before QI implementation. CONCLUSIONS: The baseline rates of PCV13 and PPSV23 are highly variable and lower than expected, given current vaccination recommendations for CI patients. QI programs appear successful in increasing compliance rates with the PPSV23 vaccination; however, they are still far from full compliance. Further intervention programs with stricter surveillance, monitoring, and follow-up systems are needed to achieve improved compliance with the PCV13 and PPSV23 vaccination in CI recipients.

Preoperative Imaging in Patients with 22q11 Deletion Syndrome Undergoing Velopharyngeal Surgery.

OBJECTIVE: To evaluate the utility of preoperative imaging before velopharyngeal dysfunction (VPD) surgery in children with 22q11 Deletion Syndrome (22qDS) in evaluating internal carotid artery (ICA) medialization. DATA SOURCES: PubMed, Scopus, and CINAHL. REVIEW METHODS: Following PRISMA guidelines, a systematic review was performed. Studies of children with 22qDS who underwent preoperative imaging (MRA or CTA) to identify ICA anomalies were included. High-risk medialized ICAs were defined as either submucosal, retropharyngeal, Pfeiffer Grade III-IV, or <3 mm from the pharyngeal mucosa. Meta-analyses of proportions were performed. RESULTS: Eleven studies met inclusion criteria, comprising 398 patients with 22qDS (weighted mean age 7.6 years). In 372 patients with imaging, the rate of ICA medialization on imaging was 47.1% (95%CI 29.2-65.5), of which 46.3% (95%CI 27.4-65.8) were determined high risk. Operative plans were modified in 19.4% (95%CI 5.7-38.8) of 254 surgeries due to medialized ICA. In studies attempting to use nasopharyngoscopy pulsations to identify medialization for 214 patients, the true-positive rate was 53.9% (95%CI 27.5-79.2) and the false-positive rate was 16.2% (95%CI 7.9-26.8). Nine of eleven studies (81.8%) recommended universal preoperative imaging of the ICAs in children with 22qDS undergoing VPD surgery. No cases of perioperative bleeding secondary to ICA injury were identified. CONCLUSION: Although most studies endorse routine preoperative imaging to assess for ICA medialization in children with 22qDS undergoing VPD surgery, only a minority of these cases led to surgical modification. Additional studies are needed to compare outcomes in children with and without preoperative imaging given the low rates of ICA injury in the literature. LEVEL OF EVIDENCE: N/A Laryngoscope, 2023.

Sociodemographic Factors Affecting Loss to Follow-Up After Newborn Hearing Screening: A Systematic Review and Meta-Analysis.

OBJECTIVE: Universal newborn hearing screening (NBHS) has been widely implemented as a part of early hearing detection and intervention (EHDI) programs worldwide. Even with excellent provider knowledge and screening rates, many infants do not receive definitive hearing testing or intervention after initial screening. The objective of this study was to identify sociodemographic factors contributing to loss of follow-up. DATA SOURCES: PubMed, Scopus, and CINAHL. REVIEW METHODS: Per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the databases were searched from the date of inception through December 28, 2021. Studies containing sociodemographic information on patients who were referred to NBHS were included. Meta-analysis of odds ratios (ORs) was performed comparing rates of sociodemographic variables between patients adherent and nonadherent to follow-up. RESULTS: A total of 169,238 infants from 19 studies were included. Low birth weight (OR 1.6 [95% confidence interval, CI 1.2-2.2, p < .001), racial minority (OR 1.4 [95% CI 1.2-1.6], p < .001), rural residence (OR 1.5 [95% CI 1.1-1.9], p = .005), lack of insurance (OR 1 [95% CI 1.4-2.5], p < .001), and public or state insurance (OR 1.7 [95% CI 1.2-4.2], p = .008) were associated with missed follow-up after referred NBHS. Associated maternal factors included low maternal education (OR 1.8 [95% CI 1.6-2.0], p < .001), young maternal age (OR 1.5 [95% CI 1.5-1.6], p < .001), unmarried maternal status (OR 1.5 [95% CI 1.1-1.9], p = .003), and current or former maternal smoking status (OR 1.8 [95% CI 1.4-2.2], p < .001). CONCLUSION: Both infant and maternal sociodemographic factors influence follow-up compliance after referred NBHS. Focused efforts should be made by medical providers and policymakers to address these factors to ensure appropriate newborn hearing care and interventions are achieved.

Unique Measurements of Intranasal Trigeminal Function: A Pilot Study.

OBJECTIVE: To investigate novel methods of measuring intranasal trigeminal function and correlate to validated measures of trigeminal function. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary medical center. METHODS: Forty-one subjects without nasal congestion were assessed. The trigeminal temperature function of the cool/warmth detection threshold and cold/heat pain threshold was measured with the Thermal Sensory Analyzer (TSA) device, as previously validated at buccal mucosa and infraorbital skin. Identical temperature sensory function was assessed at the anterior septum and inferior turbinate. Lateralization of trigeminal odorants eucalyptol, isothiocyanate, and acetic acid was conducted. Visual analog scales (VAS) of trigeminal function were collected. RESULTS: Extraoral cheek site and oral site thermal measures were moderately correlated, suggesting consistent assessment of trigeminal function. Nearly all intranasal thermal measures correlated between the septum and turbinate (significant correlations [ρ] ranged from .3 to .8). Oral and extraoral cheek sites had modest correlations to intranasal cold and heat pain (ρ = .4-.5). The oral site had modest correlations of cold and heat detection to intranasal sites, with turbinate appearing to have the most correlations. Isothiocyanate lateralization was the most closely correlated to intranasal thermal scores for cold and heat pain. Turbinate thermal measures had weak correlations with trigeminal VAS scores (ρ = .3-.4). CONCLUSION: Intranasal trigeminal measures of thermal function correlate to validated extraoral and intraoral thermal measures. The turbinate appears to have stronger correlations to the septum than found in the mouth and face. TSA testing might provide a rapid, novel method of intranasal trigeminal function assessment.

Pediatric obesity education and counseling in otolaryngology clinics: A survey of ASPO members.

BACKGROUND: Adenotonsillectomy can cure pediatric obstructive sleep apnea (OSA) in 80% of children without obesity but only 20-30% of children with obesity. Despite this, there is a current lack of consistent guidelines and practices around pediatric obesity management in otolaryngology. This study evaluated the extent of counseling, referrals, confidence, and barriers in addressing childhood obesity in pediatric otolaryngology. METHODS: A 20-question electronic survey assessing pediatric obesity practice patterns regarding sleep-disordered breathing (SDB) and OSA was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were performed. Pediatric otolaryngologists were compared using logistic regression models based on their practice type and frequency of counseling and referral. RESULTS: Of all ASPO members, 19.6% (114/583) completed the survey. Half (50.0%) of physicians counsel and 14.0% refer to obesity management >75% of the time. Only 8.8% of physicians are confident their counseling helps reduce their patient's obesity, and 35.9% of physicians are satisfied with their services available for referral. Most physicians cite time/clinical workload (81.6%) and parent/rearing habits (50.0%) as barriers to obesity counseling. Non-academic physicians had lower odds of counseling and referring their patients >50% of the time (aOR 0.23 [95%CI 0.06-0.81], aOR 0.23 [95%CI 0.06-0.83]). Almost all (92.1%) physicians counsel on residual SDB or OSA after adenotonsillectomy >75% of the time if the child is obese. CONCLUSIONS: Most pediatric otolaryngologists do not regularly counsel or refer patients to available obesity management programs, with differences seen between academic and non-academic surgeons. Confidence is low in currently available measures to reduce pediatric obesity. These results highlight the challenges of pediatric obesity and provide context for guideline implementation and additional resource development for pediatric otolaryngologists.

The Utility of CTA in Pediatric Oropharyngeal Trauma: A Systematic Review and Meta-Analysis.

OBJECTIVE(S): To analyze the utility of computed tomography angiography (CTA) in identifying internal carotid artery (ICA) injury and reducing cerebrovascular accident (CVA) incidence in children presenting with normal neurologic exams after oropharyngeal trauma (OT). DATA SOURCES: PubMed, Scopus, CINAHL, and Cochrane. REVIEW METHODS: A systematic review and meta-analysis were performed following PRISMA guidelines. Of 1,185 studies screened, 95 studies of pediatric OT met inclusion criteria. Meta-analysis of proportions was performed. RESULTS: A total of 1224 children with OT were analyzed. Excluding case reports, the weighted proportion of a CVA after OT was 0.31% (95% CI 0.06-0.93). If a child presented without neurologic deficits, 0.30% (95% CI 0.05-0.95) returned with new neurologic deficits. An ICA injury was identified in 0.89% (95% CI 0.16-2.74) of screening CTAs. No difference in CVA incidence was seen in children with screening CTA (0.52% [95% CI 0.02-2.15]) compared to children without screening CTA (0.42% [95% CI 0.06-1.37]). Patients who developed CVA had a higher proportion of injuries >2 cm, injuries at the posterior pillar or tonsil, and injuries with a writing utensil or popsicle stick compared to patients without CVA. CONCLUSION: The proportion of children experiencing an ICA injury leading to CVA after sustaining OT is low. CTAs infrequently show ICA changes in children with normal neurological exams. Children who receive CTAs do not have a significantly lower incidence of CVAs than children who do not receive CTAs. Clinicians should weigh the risks and benefits of a CTA based on an individual child's presentation and discuss this with caregivers for shared decision-making. Laryngoscope, 133:25-37, 2023.

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis.

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1-43.3] vs. 7.5% [95%CI 3.3-13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8-1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1-16.5] vs. 8.8% [95% CI 1.5-21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Obstructive sleep apnea in children with nonsyndromic cleft palate: a systematic review.

STUDY OBJECTIVES: To characterize obstructive sleep apnea in children with nonsyndromic cleft palate based on polysomnographic parameters relative to primary palatoplasty. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched: PubMed, Scopus, CINAHL, and Cochrane. Studies were only considered for inclusion if they examined exclusively patients with nonsyndromic cleft palate and reported polysomnogram data. RESULTS: Seven studies met inclusion criteria, providing information on a total of 151 patients with a weighted mean age of 5.2 ± 5.0 years (range 0.1-12 years). Five studies presented data from either the pre- or postoperative period. Two studies investigated both pre- and postpalatoplasty polysomnogram data, and neither observed a significant change in apnea-hypopnea index (AHI) values following surgery (mean preoperative AHI of 2.7 events/h, mean improvement of 0.6 events/h). The entire cohort had a prepalatoplasty weighted mean AHI of 11.4 events/h (range 1.5-16.1) and postpalatoplasty AHI of 1.5 events/h (range 0.2-5.2). Interpretation of polysomnographic data was limited by heterogeneity; however, the AHI values for children with nonsyndromic cleft palate largely demonstrated mild to moderate obstructive sleep apnea following palatoplasty. CONCLUSIONS: The full effect of cleft palate repair on obstructive sleep apnea in children with nonsyndromic cleft palate remains understudied. While published data are heterogenous, few studies support the worsening of obstructive AHI after palatoplasty in children with nonsyndromic cleft palate. Further studies with standardized polysomnographic parameters are needed to provide guidance for management of this population. CITATION: Jungbauer WN Jr, Poupore NS, Nguyen SA, Carroll WW, Pecha PP. Obstructive sleep apnea in children with nonsyndromic cleft palate: a systematic review. J Clin Sleep Med. 2022;18(8):2063-2068.

The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury.

BACKGROUND: The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population. METHODS: We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database. RESULTS: A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7 g/dl at 48 and 72 hours into admission. CONCLUSIONS: These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.

Regional differences of tracheostomy in extremely premature neonates across the United States.

OBJECTIVE: To identify regional differences in tracheostomy rates and mortality in extremely premature neonates. METHODS: The 1997-2019 Kids' Inpatient Databases (KID) were queried to identify children who completed 27 weeks gestation (27-wk) or less and 23 weeks gestation (23-wk) or less. Multivariable logistic regressions compared odds of tracheostomy and mortality by region (Midwest (MW), Northeast (NE), South (S), and West (W)) while controlling for demographic variables and comorbidities. Trend analyses were performed using Poisson Regressions. RESULTS: There were 2433 27-wk or less infants and 259 23-wk or less who received a tracheostomy. The MW was the only region where higher odds of tracheostomy were seen for 27-wk or less (aOR 1.25 [95%CI 1.12-1.39]) and 23-wk or less (aOR 1.68 [95%CI 1.24-2.27]) neonates when compared to all other regions combined. The S and MW had the highest increase in tracheostomy rates of 27-wk or less (ß = 5.1, r = 0.77, p = 0.025; ß = 3.8, r = 0.93, p = 0.001), and the MW had the highest increased rate of tracheostomy for 23-wk or less (ß = 1.9, r = 0.97, p = 0.008). There were no higher mortality odds by region in 27-wk or less. Mortality was the highest in the S for 23-wk or less (20.8%, p = 0.015). CONCLUSIONS: This study identified regional differences in tracheostomy rates in extremely premature infants. Extremely premature neonates in the MW had higher odds of receiving a tracheostomy with comparable mortality rates to other regions. Further research is needed to analyze regional practice differences that may impact the decision to perform a tracheostomy.

Tissue Doppler echocardiography in children with OSA before and after tonsillectomy and adenoidectomy: A systematic review and meta-analysis.

BACKGROUND: When to order an echocardiogram in children with obstructive sleep apnea (OSA) is debated. Studies evaluating the utility of pre-operative standard echocardiography are inconsistent. Tissue Doppler imaging (TDI) is an additional technique that quantifies the velocity of myocardial motion to assess cardiac function. The utility of TDI in pediatric OSA remains unclear. METHODS: A systematic review and meta-analysis were performed in accordance with PRISMA guidelines using PubMed, Scopus, CINAHL, and Cochrane Library databases. Studies of echocardiographic findings using TDI in children with polysomnogram confirmed OSA before and after tonsillectomy and adenoidectomy (T&A) were included. 1,423 studies were screened, and 4 studies met inclusion criteria. Meta-analysis of echocardiographic findings was performed. RESULTS: Data from 560 children were analyzed. Study groups included pre- and post-T&A children with OSA and non OSA controls. Pre-T&A S' wave at the tricuspid annulus (S' RV) was decreased with a mean difference of -1.04 [95% CI -1.57, -0.52, p < 0.001] and E'/A' ratio at the mitral annulus (E'/A' LV) was decreased with a mean difference of -0.74 [95% CI -0.85, -0.64, p < 0.001] when compared to controls. These variables were not statistically different when comparing post-T&A to controls. CONCLUSIONS: TDI appears to successfully detect subclinical changes in cardiac function in children with OSA. However, echocardiography parameters of post-T&A and non OSA control children were similar. Further prospective studies stratified by OSA severity are needed with both TDI and standard echocardiography to define the utility of pre-operative cardiac imaging.