Post-extubation laryngitis in children: diagnosis, management and follow-up.

OBJECTIVES: To describe the occurrence of post-extubation laryngitis, analyze its one-year evolution, and correlate laryngeal lesions with clinical outcomes. METHODS: Retrospective study including children up to 13 years old at a tertiary hospital between March 2020 and March 2022 with diagnosis of post-extubation laryngitis confirmed by endoscopic examination. Exclusion criteria were prior history of intubation or anatomical airway abnormalities. Medical records were reviewed to characterize patients, underlying diagnosis, laryngeal lesions, treatment, and outcomes at 12-month follow-up. RESULTS: The study included 38 endoscopically confirmed post-extubation laryngitis cases, corresponding to 86.4% of suspected cases. The mean age was 13.24 months, and 60.5% were male. Acute respiratory failure was the leading cause of intubation. Initial treatment was clinical, and initial diagnosis was defined by nasopharynoglaryngoscopy and/or Microlaryngoscopy and Bronchoscopy (MLB) findings. Initial diagnostic MLB was performed in 65.7% of the patients. Approximately half (53%) of the patients exhibited moderate or severe laryngeal lesions. When compared to mild cases, these patients experienced a higher rate of extubation failures (mean of 1.95 vs. 0.72, p = 0.0013), underwent more endoscopic procedures, and faced worse outcomes, such as the increased need for tracheostomy (p = 0.0001) and the development of laryngeal stenosis (p = 0.0450). Tracheostomy was performed in 14 (36.8%) children. Patients undergoing tracheostomy presented more extubation failures and longer intubation periods. Eight (21%) developed laryngeal stenosis, and 17 (58.6%) had complete resolution on follow-up. CONCLUSION: Post-extubation laryngitis is a frequent diagnosis among patients with clinical symptoms or failed extubation. The severity of laryngeal lesions was linked to a less favorable prognosis observed at one-year follow-up. Otolaryngological evaluation, follow-up protocols, and increased access to therapeutic resources are essential to manage these children properly. LEVEL OF EVIDENCE: Level 4.

Role of fiberoptic endoscopic evaluation of swallowing (FEES) in children with suspected dysphagia.

OBJECTIVE: To assess FEES findings in defining oral feeding safety in children with suspected dysphagia, comparing them with clinical feeding evaluation results. METHODS: This study comprised a case series involving children with suspected dysphagia, referred for evaluation by otolaryngologists and speech-language pathologists (SLPs) at a Brazilian quaternary public university hospital. These children underwent both clinical evaluations and fiberoptic endoscopic evaluation of swallowing (FEES), with a comprehensive collection of demographic and clinical data. Subsequently, the authors performed a comparative analysis of findings from both assessments. RESULTS: Most patients successfully completed the FEES procedure (93.7%), resulting in a final number of 60 cases included in the study. The prevalence of dysphagia was confirmed in a significant 88% of these cases. Suspected aspiration on clinical SLP evaluation was present in 34 patients. Of these, FEES confirmed aspiration or penetration in 28 patients. Among the 35 patients with aspiration or penetration on FEES, 7 (20%) had no suspicion on SLP clinical assessment. All seven patients in whom clinical SLP evaluation failed to predict penetration/aspiration had neurological disorders. The median age of the children was 2.8 years, and 49 (81.6%) had neurological disorders, while 35 (58.3%) had chronic pulmonary disease. The most prevalent complaints were choking (41.6%) and sialorrhea (23.3%). CONCLUSION: FEES can diagnose structural anomalies of the upper aerodigestive tract and significantly contribute to the detection of aspiration and penetration in this group of patients with suspected dysphagia, identifying moderate and severe dysphagia even in cases where clinical assessment had no suspicion.

Position paper of diagnosis and treatment of post-extubation laryngitis in children: a multidisciplinary expert-based opinion.

OBJECTIVES: To make recommendations on the diagnosis and treatment of post-extubation laryngitis (PEL) in children with or without other comorbidities. METHODS: A three-iterative modified Delphi method was applied. Specialists were recruited representing pediatric otolaryngologists, pediatric and neonatal intensivists. Questions and statements approached topics encompassing definition, diagnosis, endoscopic airway evaluation, risk factors, comorbidities, management, and follow-up. A consensus was defined as a supermajority >70%. RESULTS: Stridor was considered the most frequent symptom and airway endoscopy was recommended for definitive diagnosis. Gastroesophageal reflux and previous history of intubation were considered risk factors. Specific length of intubation did not achieve a consensus as a risk factor. Systemic corticosteroids should be part of the medical treatment and dexamethasone was the drug of choice. No consensus was achieved regarding dosage of corticosteroids, although endoscopic findings help defining dosage and length of treatment. Non-invasive ventilation, laryngeal rest, and use of comfort sedation scales were recommended. Indications for microlaryngoscopy and bronchoscopy under anesthesia were symptoms progression or failure to improve after the first 72-h of medical treatment post-extubation, after two failed extubations, and/or suspicion of severe lesions on flexible fiberoptic laryngoscopy. CONCLUSIONS: Management of post-extubation laryngitis is challenging and can be facilitated by a multidisciplinary approach. Airway endoscopy is mandatory and impacts decision-making, although there is no consensus regarding dosage and length of treatment.

Initial evaluation of a multidisciplinary pediatric aerodigestive program in a Brazilian hospital: challenges and mitigation strategies.

OBJECTIVE: To identify clinical and epidemiological characteristics of children evaluated by the pediatric aerodigestive program at the beginning of its activity, describe challenges in follow-up, and suggest mitigation strategies. METHODS: A case series was conducted describing the first 25 patients discussed by the aerodigestive team from a Brazilian quaternary public university hospital between April 2019 and October 2020. The median follow-up was 37 months. RESULTS: During the study period 25 children were seen by the group and the median age at first assessment was 45.7 months old. Eight children had a primary airway abnormality, five had a tracheostomy. Nine children had genetic disorders and one had esophageal atresia. Dysphagia was present in 80% of the patients, 68% had a history of chronic or recurrent lung disease, 64% had a gastroenterological diagnosis and 56% had neurological impairment. Moderate to severe dysphagia was identified in 12 children and 7 of these had an exclusive oral diet at the time. The majority of children (72%) had 3 or more comorbidities. Following team discussion, a change in feeding strategy was suggested in 56% of the children. The most frequently ordered exam was pHmetry (44%) and gastrostomy was the surgical procedure with the longest waiting list. CONCLUSIONS: Dysphagia was the most frequent issue encountered in this initial group of aerodigestive patients. Pediatricians caring for these children must be involved in aerodigestive team discussions and hospital policies must be revised to facilitate access to exams and procedures needed for this population.

Oral Teratoma with Hairy Polyp-Like Features: A Brief Report of a Rare Presentation.

We present a 21-day-old female child presenting with a large oral epithelialized tumor implanted at the rhinopharynx and ethmoid plate through a cleft palate, associated with feeding and respiratory difficulties. The histopathological exam showed mature central adipose tissue, hair follicles, sebaceous glands, and neurovascular structures, lined by keratinized stratified squamous epithelium. Proliferative cartilaginous, glandular, lymphatic, bony, and immature myxoid tissue was seen at the posterior region and insertion. Despite the characterization of the tumor as a teratoma containing structures derived from the three embryonic leaflets, the anterior portion presented a microscopic bigeminal pattern fully compatible with hairy polyp.

Voice outcomes and its impact on quality of life after open airway surgery in children.

INTRODUCTION: Open airway surgery is used to treat severe grades of laryngotracheal stenosis in children. Scarring of the airway following these procedures may lead to voice impairment and impact quality of life. This study was designed to characterize vocal outcome in children submitted reconstructive airway surgery and verify how this correlates to voice related quality of life in this population. MATERIAL AND METHODS: Children submitted to open airway surgery that had been decannulated for a minimum of 30 days and had functional speech were invited to participate. Pediatric Voice-Related Quality-of-Life survey (PVRQoL) was applied, consensus auditory perceptive of voice (CAPE-V) protocol was used for perceptual voice evaluation and acoustic analysis was performed using Praat software. RESULTS: Twenty children were enrolled in the study with an average age of 4 years and 8 months. Averages for PVRQoL exceeded normative values in 80% of the children. Half of the children had normal voice or mild dysphonia and half had moderate dysphonia, according to perceptual evaluation. Measures of F0, jitter and particularly shimmer were abnormal in most of the children. CONCLUSION: Voice quality varies from normal to moderately impaired in children following reconstructive airway surgery. Voice quality impacts quality of life in the majority of cases and the degree of dysphonia does not always correlate with voice related quality of life scores.

Congenital laryngeal webs: from diagnosis to surgical outcomes.

INTRODUCTION: Congenital laryngeal webs are rare, may be associated with other airway abnormalities and be one of many features of microdeletion 22q11. Meticulous evaluation is imperative when deciding which surgical technique to use. The choice of appropriate stenting may be decisive to avoid persistent anterior commissure synechia and poor voice results. OBJECTIVE: To report outcomes for endoscopic and open surgical approaches in the treatment of congenital laryngeal webs and the challenges one may encounter while applying the current classification and deciding for the best treatment option. METHODS: Retrospective review of medical and surgical charts for congenital laryngeal webs treated in two tertiary university centers. RESULTS: Seven patients were included; following Cohen's classification there were: three type II webs, one of them with an atypical posterior synechia, two type III webs and two type IV webs. Six patients were submitted to laryngotracheal reconstruction and one was treated with an endoscopic approach. Description of precise glottic and subglottic involvement and tailored surgical options are presented. The LT mold® stent was used for long-term stenting that varied between 40 to 60 days. All patients were successfully decannulated with good voice quality and after follow-up of over one year, there were no complications associated with the surgeries. CONCLUSION: Congenital laryngeal webs should be suspected and thoroughly evaluated in the presence of neonatal dysphonia and early onset of laryngitis. Otolaryngologists must be familiar with associated lesions and genetic conditions that may be associated to congenital laryngeal webs. Congenital laryngeal webs may be successfully treated at an early age. The correct choice of surgical technique after meticulous evaluation of glottic and subglottic components of the web, presence of concomitant lesions and appropriate stenting, is imperative to avoid persistent scarring and poor voice quality.

Evaluation of Voice After Open Airway Surgery in Children: A Systematic Review.

Objective: This review aims to describe the methods used to assess the vocal quality and quality of life of children after airway reconstruction and their limitations. Data Sources: A systematic review was carried out in 10 databases for articles published between 2000 and 2021 following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Review Methods: Articles were included that described perceptual voice assessment with or without acoustic measures and/or voice quality impact questionnaires. Articles with no description of a specific voice assessment were excluded. Results: A total of 12 studies were included, yielding 263 patients. The mean age at evaluation was 9 years. Follow-up varied from 5 months to 20 years with most patients being evaluated at least a year after surgery. Methods used to evaluate voice were perceptual, aerodynamic, and acoustic analysis and quality of life questionnaires. CAPE-V (Consensus Auditory Perceptual Evaluation-Voice) was the most used auditory-perceptual instrument (72.7%). Of the acoustic parameters, fundamental frequency and maximum phonation time were the most described (58.3%), and among the quality of life assessment questionnaires, pVHI (Pediatric Voice Handicap Index) was the most used (54.5%). Conclusion: Multidimensional evaluations tailored to the individual child can be recommended after open airway surgery. CAPE-V scale, fundamental frequency, maximum phonation time, and pVHI are the most frequently used methods; therefore, their use may help broaden communication among authors. In the multitude of methods available, cognitive ability and degree of voice disturbance should be considered since they are the most important limiting factors in this population.

Management of laryngopharyngeal reflux in Brazil: a national survey.

INTRODUCTION: Studies assessing the management of laryngopharyngeal reflux by otolaryngologists have reported an important heterogeneity regarding the definition, diagnosis, and treatment, which leads to discrepancies in the management of the patient. Information about the current knowledge and practices of Brazilian otolaryngologists in laryngopharyngeal reflux is lacking. OBJECTIVE: To investigate the trends in management of laryngopharyngeal reflux disease among Brazilian otolaryngologists. METHODS: A survey was sent by email to the members of the Brazilian Association of Otolaryngology-Head Neck Surgery. This survey has initially been conducted by the laryngopharyngeal reflux study group of young otolaryngologists of the International Federation of Otolaryngological Societies. RESULTS: According to the survey responders, the prevalence of laryngopharyngeal reflux was estimated to be 26.8% of patients consulting in otolaryngology and the most common symptoms were globus sensation, throat clearing, cough and stomach acid reflux. Nasal obstruction, Eustachian tube dysfunction, acute and chronic otitis media, vocal fold nodules and hemorrhage were considered not associated with laryngopharyngeal reflux by the majority of responders. About 2/3 of Brazilian otolaryngologists based the diagnosis of laryngopharyngeal reflux on the assessment of both symptoms and findings and a positive response to empiric therapeutic trials. Proton pump inhibitor utilized once or twice daily, was the most commonly used therapeutic scheme. Only 21.4% of Brazilian otolaryngologists have heard about nonacid and mixed laryngopharyngeal reflux and the awareness about the usefulness of multichannel intraluminal impedance pH monitoring (MII-pH) was minimal; 30.5% of responders did not consider themselves as well-informed about laryngopharyngeal reflux. CONCLUSION: Although the laryngopharyngeal reflux-related symptoms, main diagnostic and treatment approaches referred by Brazilian otolaryngologists are consistent with the literature, the survey identified some limitations, such as the insufficient awareness of the role of laryngopharyngeal reflux in many otolaryngological conditions and of the possibility of non-acid or mixed reflux in refractory cases. Future studies are needed to establish international recommendations for the management of laryngopharyngeal reflux disease.

IVORY Guidelines (Instructional Videos in Otorhinolaryngology by YO-IFOS): A Consensus on Surgical Videos in Ear, Nose, and Throat.

OBJECTIVES/HYPOTHESIS: Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology. STUDY DESIGN: DELPHI survey. METHODS: Twenty-seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained. RESULTS: The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high-definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ-specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre- and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery. CONCLUSIONS: International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E732-E737, 2021.

Pediatric airway reconstruction: results after implementation of an airway team in Brazil.

INTRODUCTION: Since development of pediatric intensive care units, children have increasingly and appropriately been treated for complex surgical conditions such as laryngotracheal stenosis. Building coordinated airway teams to achieve acceptable results is still a challenge. OBJECTIVE: To describe patient demographics and surgical outcomes during the first 8years of a pediatric airway reconstruction team. METHODS: Retrospective chart review of children submitted to open airway reconstruction in a tertiary university healthcare facility during the first eight years of an airway team formation. RESULTS: In the past 8 years 43 children underwent 52 open airway reconstructions. The median age at surgery was 4.1 years of age. Over half of the children (55.8%) had at least one comorbidity and over 80% presented Grade III and Grade IV subglottic stenosis. Other airway anomalies occurred in 34.8% of the cases. Surgeries performed were: partial and extended cricotracheal resections in 50% and laryngotracheoplasty with anterior and/or posterior grafts in 50%. Postoperative dilatation was needed in 34.15% of the patients. Total decannulation rate in this population during the 8-year period was 86% with 72% being decannulated after the first procedure. Average follow-up was 13.6 months. Initial grade of stenosis was predictive of success for the first surgery (p=0.0085), 7 children were submitted to salvage surgeries. Children with comorbidities had 2.5 greater odds (95% CI 1.2-4.9, p=0.0067) of unsuccessful surgery. Age at first surgery and presence of other airway anomalies were not significantly associated with success. CONCLUSIONS: The overall success rate was 86%. Failures were associated with higher grades of stenosis and presence of comorbidities, but not with patient age or concomitant airway anomalies.

An update on COVID-19 for the otorhinolaryngologist - a Brazilian Association of Otolaryngology and Cervicofacial Surgery (ABORL-CCF) Position Statement.

INTRODUCTION: We are facing a pandemic with a great impact worldwide, as a result of the rapid spread of the novel coronavirus (COVID-19). The medical community is still getting to know behavior of this virus and the consequences from a population point of view. All this knowledge is extremely dynamic, so some behaviors are still not well established. Otorhinolaryngologists have a central role in the management of this situation, in which they must assess the patient, avoid contamination to and by health professionals and other patients. Thus, the recommendations of the Brazilian Association of Otorhinolaryngology and Cervical-Facial Surgery (ABORL-CCF) have the main objective of reducing the spread of the new coronavirus during otorhinolaryngological care and assisting in the management of these patients. METHODS: Review of the main recommendations of national and international scientific societies, decisions by government agencies and class councils. The topics will be related to the general aspects of COVID-19, personal protective equipment, care in patient assistance, endoscopic exam routines and the management of sinonasal, otological and pediatric evaluations related to COVID-19. RESULTS: The use of personal protective equipment is considered crucial in routine ENT care. We recommend postponing appointments, exams and elective surgeries to reduce the spread of COVID-19. Similarly, we recommend changing routines in several areas of otolaryngology. Additionally, guidance is provided on the use of telemedicine resources during the pandemic period. CONCLUSIONS: We are still at the beginning of the COVID-19 pandemic and scientific evidence is still scarce and incomplete, so these ABORL-CCF recommendations for otorhinolaryngologists may be updated based on new knowledge and the pattern of the new coronavirus spread.

Pediatric airway tumors: A report from the International Network of Pediatric Airway Teams (INPAT).

OBJECTIVE: Primary tracheobronchial tumors (PTTs) are rare heterogeneous lesions arising from any part of the tracheobronchial tree. Nonspecific symptoms may lead to delayed diagnosis that requires more aggressive surgical treatment. An analysis of cases collected by the International Network of Pediatric Airway Team was undertaken to ensure proper insight into the behavior and management of PTTs. METHODS: Patients <18 years of age with a histological confirmation of PTT diagnosed from 2000 to 2015 were included in this multicenter international retrospective study. Medical records, treatment modalities, and outcomes were analyzed. The patient presentation, tumor management, and clinical course were compared between malignant and benign histotypes. Clinical and surgical variables that might influence event-free survival were considered. RESULTS: Among the 78 children identified, PTTs were more likely to be malignant than benign; bronchial carcinoid tumor (n = 31; 40%) was the most common histological subtype, followed by inflammatory myofibroblastic tumor (n = 19; 25%) and mucoepidermoid carcinoma (n = 15; 19%). Regarding symptoms at presentation, wheezing (P = 0.001) and dyspnea (P = 0.03) were more often associated with benign growth, whereas hemoptysis was more frequently associated with malignancy (P = 0.042). Factors that significantly worsened event-free survival were age at diagnosis earlier than 112 months (P = 0.0035) and duration of symptoms lasting more than 2 months (P = 0.0029). CONCLUSION: The results of this international study provide important information regarding the clinical presentation, diagnostic workup, and treatment of PTTs in children, casting new light on the biological behavior of PTTs to ensure appropriate treatments. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E243-E251, 2020.

International registry of otolaryngologist-head and neck surgeons with COVID-19.

BACKGROUND: It has become clear that healthcare workers are at high risk, and otolaryngology has been theorized to be among the highest risk specialties for coronavirus disease 2019 (COVID-19). The purpose of this study was to detail the international impact of COVID-19 among otolaryngologists, and to identify instructional cases. METHODS: Country representatives of the Young Otolaryngologists-International Federation of Otolaryngologic Societies (YO-IFOS) surveyed otolaryngologists through various channels. Nationwide surveys were distributed in 19 countries. The gray literature and social media channels were searched to identify reported deaths of otolaryngologists from COVID-19. RESULTS: A total of 361 otolaryngologists were identified to have had COVID-19, and data for 325 surgeons was available for analysis. The age range was 25 to 84 years, with one-half under the age of 44 years. There were 24 deaths in the study period, with 83% over age 55 years. Source of infection was likely clinical activity in 175 (54%) cases. Prolonged exposure to a colleague was the source for 37 (11%) surgeons. Six instructional cases were identified where infections occurred during the performance of aerosol-generating operations (tracheostomy, mastoidectomy, epistaxis control, dacryocystorhinostomy, and translabyrinthine resection). In 3 of these cases, multiple operating room attendees were infected, and in 2, the surgeon succumbed to complications of COVID-19. CONCLUSION: The etiology of reported cases within the otolaryngology community appear to stem equally from clinical activity and community spread. Multiple procedures performed by otolaryngologists are aerosol-generating procedures (AGPs) and great care should be taken to protect the surgical team before, during, and after these operations.

Correlation between voice and life quality and occupation.

UNLABELLED: Dysphonia may impair the quality of communication and social relations of people, thereby directly affecting quality of life. It is common knowledge amongst professionals involved with the treatment of voice disorders the need for objective protocols to evaluate voice quality and measure its impact on the individual's quality of life. AIM: To associate life quality with the degree of dysphonia and professional voice use in a group of dysphonic patients. MATERIALS AND METHODS: A prospective clinical study was undertaken with a group of dysphonic patients using an internationally validated voice-related quality-of-life protocol. A statistical analysis of the results was carried out, not distinguishing between those who use their voices professionally and those who don't. RESULTS: Dysphonia had an impact on the quality of life of all patients. There was no statistically significant difference between the groups - professional users and non-users of their voices; however, considering the groups separately, this correlation was significant only in the group of patients who do not use their voices professionally. CONCLUSION: Dysphonia affected the quality of life of all subjects regardless of their voice use.

Bilateral Facial Paralysis and Deafness in a Child Treated for Acute Lymphoblastic Leukemia.

Involvement of the ear and temporal bone in acute leukemias are uncommon. We report a case of atypical mastoiditis with bilateral facial paralysis in a child diagnosed with Acute Lymphoblastic Leukemia (ALL). A 20-month-old male child was diagnosed with ALL and developed otorrhea unresponsive to antimicrobial treatment during the first week of chemotherapy followed by hearing loss, loss of balance, and bilateral facial paralysis. A CT scan of the mastoids showed cortical erosion of the temporal bone and presence of soft tissue contents filling the mastoid cells and external auditory canal bilaterally. Mastoidectomy was performed to collect material for analysis. Histopathologic examination of the material revealed an active chronic inflammatory process, with a moderate amount of plasma cells. Chemotherapy was reintroduced 3 weeks after the surgical procedure, and progressive improvement of otorrhea and imbalance was noted. Grade III House-Brackmann peripheral facial paralysis persisted on 6-month follow-up, and the patient is in rehabilitation program.

Position paper of diagnosis and treatment of post-extubation laryngitis in children: a multidisciplinary expert-based opinion

Abstract Objectives To make recommendations on the diagnosis and treatment of post-extubation laryngitis (PEL) in children with or without other comorbidities. Methods A three-iterative modified Delphi method was applied. Specialists were recruited representing pediatric otolaryngologists, pediatric and neonatal intensivists. Questions and statements approached topics encompassing definition, diagnosis, endoscopic airway evaluation, risk factors, comorbidities, management, and follow-up. A consensus was defined as a supermajority >70%. Results Stridor was considered the most frequent symptom and airway endoscopy was recommended for definitive diagnosis. Gastroesophageal reflux and previous history of intubation were considered risk factors. Specific length of intubation did not achieve a consensus as a risk factor. Systemic corticosteroids should be part of the medical treatment and dexamethasone was the drug of choice. No consensus was achieved regarding dosage of corticosteroids, although endoscopic findings help defining dosage and length of treatment. Non-invasive ventilation, laryngeal rest, and use of comfort sedation scales were recommended. Indications for microlaryngoscopy and bronchoscopy under anesthesia were symptoms progression or failure to improve after the first 72-h of medical treatment post-extubation, after two failed extubations, and/or suspicion of severe lesions on flexible fiberoptic laryngoscopy. Conclusions Management of post-extubation laryngitis is challenging and can be facilitated by a multidisciplinary approach. Airway endoscopy is mandatory and impacts decision-making, although there is no consensus regarding dosage and length of treatment.

Pegylated interferon for treating severe recurrent respiratory papillomatosis in a child: case report.

CONTEXT: Recurrent respiratory papillomatosis (RRP) is the most common laryngeal tumor. During childhood, it may present in extremely severe forms defined by the need for frequent surgical procedures to relieve respiratory distress and/or involvement of extralaryngeal sites such as lung involvement. Adjuvant therapies are indicated in these cases and interferon is one of the options. Pegylated interferon is more effective than conventional alpha interferon and, given its reported results in relation to treating hepatitis C over the past decade, we hypothesized that this might be more effective than conventional interferon also for treating respiratory papillomatosis. Use of a treatment strategy that eliminates the need for general anesthesia is particularly appealing, yet obtaining approval for use of medications that are not currently used for this purpose is challenging. CASE REPORT: We report the case of a child with severe RRP that had been followed for the preceding six years, who was treated with pegylated interferon after failure of other adjuvant therapies. There was noticeable improvement in the frequency of surgical procedures, which was regarded very receptively, considering the child's history and previous response to other therapies. CONCLUSION: Pegylated interferon may be a good option for diminishing the need for surgical intervention in severe cases of recurrent respiratory papillomatosis.

Initial evaluation of a multidisciplinary pediatric aerodigestive program in a Brazilian hospital: challenges and mitigation strategies

Abstract Objective: To identify clinical and epidemiological characteristics of children evaluated by the pediatric aerodigestive program at the beginning of its activity, describe challenges in followup, and suggest mitigation strategies. Methods: A case series was conducted describing the first 25 patients discussed by the aerodigestive team from a Brazilian quaternary public university hospital between April 2019 and October 2020. The median follow-up was 37 months. Results: During the study period 25 children were seen by the group and the median age at first assessment was 45.7 months old. Eight children had a primary airway abnormality, five had a tracheostomy. Nine children had genetic disorders and one had esophageal atresia. Dysphagia was present in 80% of the patients, 68% had a history of chronic or recurrent lung disease, 64% had a gastroenterological diagnosis and 56% had neurological impairment. Moderate to severe dysphagia was identified in 12 children and 7 of these had an exclusive oral diet at the time. The majority of children (72%) had 3 or more comorbidities. Following team discussion, a change in feeding strategy was suggested in 56% of the children. The most frequently ordered exam was pHmetry (44%) and gastrostomy was the surgical procedure with the longest waiting list. Conclusions: Dysphagia was the most frequent issue encountered in this initial group of aerodigestive patients. Pediatricians caring for these children must be involved in aerodigestive team discussions and hospital policies must be revised to facilitate access to exams and procedures needed for this population.