Climate change and environmental sustainability in otolaryngology: A state-of-the-art review.

BACKGROUND: Climate change has been identified by the World Health Organization (WHO) as the greatest existing threat to human health. Given the direct exposure of the upper aerodigestive system to pollutants, patients in otolaryngology are at high risk for increased disease burden in the setting of climate change and worsening air quality. Given this and the environmental impact of surgical care, it is essential for surgeons to understand their role in addressing climate health through quality-driven clinical initiatives, education, advocacy, and research. METHODS: A state-of-the-art review was performed of the existing literature on the otolaryngologic health impacts of climate change and environmental sustainability efforts in surgery with specific attention to studies in otolaryngology - head and neck surgery. FINDINGS: Climate variables including heat and air pollution are associated with increased incidence of allergic rhinitis, chronic rhinosinusitis and head and neck cancer. A number of studies have shown that sustainability initiatives in otolaryngology are safe and provide direct cost benefit. CONCLUSION: Surgeons have the opportunity to lead on climate health and sustainability to address the public health burden of climate change.

Impact of a postgraduate year one (PGY-1) otolaryngology bootcamp on procedural skill development.

Background: To measure the impact of an intensive eight-week postgraduate year one (PGY-1) otolaryngology bootcamp on the acquisition and retention of otolaryngology residents' procedural skills compared to the traditional method of skill acquisition through clinical exposure. Methods: Residents at our institution were evaluated on their performance of flexible laryngoscopy, suture ligature, and rigid bronchoscopy setup at three time points: pre-bootcamp, one-week post-bootcamp, and one-year post-bootcamp. Video recordings were scored by two blinded faculty reviewers using a multipoint rating system. A control group of rising postgraduate year two (PGY-2) residents who did not participate in bootcamp were recorded performing these same skills. Scores in the three skills were compared between groups via t-tests. The eight-week bootcamp curriculum for PGY-1s was held at the Montefiore Einstein Center for Innovation in Simulation at Albert Einstein College of Medicine/Montefiore Medical Center. The participants were two classes of PGY-1 residents (n=8) at our institution who participated in a bootcamp at the beginning of residency, and one class of rising PGY-2 residents (n=3) who did not participate in a bootcamp (control group). Results: A comparison of pre-bootcamp scores to one-week post-bootcamp scores showed significant improvement in suture ligature ( P<0.05) and rigid bronchoscopy ( P<0.05), but no difference in flexible laryngoscopy ( P=0.54). Suture ligature ( P=0.09) and rigid bronchoscopy ( P=0.25) skills were not significantly different from one-week post-bootcamp to one-year post-bootcamp; however, a significant skill improvement was observed in flexible laryngoscopy ( P<0.05). By June of PGY1 year, the two bootcamp cohorts were similar to controls in all three skills: flexible laryngoscopy ( P=0.05), rigid bronchoscopy ( P=0.26), and suture ligature ( P=0.10). Conclusions: Participation in PGY-1 bootcamp was associated with improved acquisition and short-term retention of basic procedural skills, suggesting that bootcamps can be an effective arena to teach basic skills in otolaryngology. PGY-1 bootcamp is a promising arena for multi-institutional development.

Completion of an Individualized Learning Plan for Otology-Related Milestone Subcompetencies Leads to Improved Otology Section Otolaryngology Training Exam Scores.

OBJECTIVE: To examine the relationships among self-assessment of knowledge in otology via an individualized learning plan (ILP), otology milestone achievement rate, and otolaryngology training exam (OTE) otology scores. STUDY DESIGN: Prospective study. SETTING: One otolaryngology residency covering a tertiary care facility, trauma and hospital center, outpatient ambulatory surgery center, and outpatient clinics. PARTICIPANTS: Twenty otolaryngology residents, four from each class. METHODS: Residents identified four milestones from otology-related sub-competencies to achieve in a 3-month rotation via an ILP. During the same rotation, the residents sat for the OTE, and their overall and otology scores were analyzed. MAIN OUTCOME MEASURES: Completion of an ILP before and at the end of the rotation, self-reported achievement of otology milestones, and OTE score components including total percent correct, scaled score, group stanine, national stanine, and residency group weighted scores. RESULTS: Group stanine OTE otology scores were higher for those residents who completed pre- and post-rotation ILPs compared with those who did not, 4.0 (±0.348) versus 2.75 (±0.453), respectively (p = 0.04). Residents who self-reported achieving all four otology milestones had significantly higher otology group stanine scores than the residents who achieved less, 4.1 (±0.348) versus 2.9 ±â€Š0.433, respectively (p = 0.045). Residents who performed well in their PGY program cohort on the otology OTE 1 year were less inclined to complete an ILP for otology in the subsequent year (Pearson correlation -0.528, p = 0.035). CONCLUSION: In the otology subspecialty, residents who completed ILPs scored better on OTE examinations independent of resident class. Consequently, programs may find ILPs useful in other otolaryngology subspecialties and across residencies.

Evaluating butterfly inlay tympanoplasty.

OBJECTIVE: To compare closure rate, reduction in air-bone-gap, and operative time of butterfly tympanoplasty (BT) to underlay tympanoplasty (UT). METHODS: Retrospective cohort study of children (age <18y) undergoing Type I tympanoplasty between 2009 and 2017. Patients were excluded if they had <6 months of follow up, mastoidectomy, fat graft or cholesteatoma. RESULTS: Twenty-one patients (mean age 13.4) underwent BT while forty-one patients (mean age 13.5) underwent UT. The mean size of perforation in 30.6% in BT patients and 43.6% in UT patients (p = 0.01). Preoperative audiogram showed a similar air-bone-gap between the two groups of 31.7, 22.7, and 17.9 dB in BT vs 29.6, 24.8, and 17.6 dB in UT at 500, 1000, and 2000 Hz, respectively (p = 0.65, 0.63, and 0.94). Operative time was reduced in BT as compared to UT (94.0 min vs. 150.9, p = 0.01). Closure rate was similar at 85.7% in BT vs 75.6% in UT patients (p = 0.40). Average reductions in air-bone gap were similar with 19.2, 11.7, and 13.2 dB for BT vs 16.6, 12.1, and 10.3 dB for UT at 500, 1000, and 2000 hz, respectively (p = 0.66, 0.93, 0.40). CONCLUSION: BT has become a reliable tool for the pediatric otolaryngologist. This retrospective study shows that pediatric BT results in similar outcomes with reduced operative time.

The Prevalence of Ultrarapid Metabolizers of Codeine in a Diverse Urban Population.

OBJECTIVE: To examine the prevalence of ultrarapid metabolizers of codeine among children in an ethnically diverse urban community. STUDY DESIGN: Cross-sectional study. SETTING: A tertiary care academic children's hospital in the Bronx, New York. SUBJECTS AND METHODS: In total, 256 children with nonsyndromic congenital sensorineural hearing loss were analyzed. DNA was assessed for 63 previously described single-nucleotide polymorphisms (SNPs) and copy number variants (CNVs) known to alter the function and expression of the CYP2D6 gene primarily responsible for codeine metabolism. The rate of CYP2D6 metabolism was predicted based on participants' haplotype. RESULTS: Ethnic distribution in the study subjects paralleled recent local census data, with the largest portion (115 children, 45.8%) identified as Hispanic or Latino. A total of 154 children (80.6%) had a haplotype that corresponds to extensive codeine metabolism, 18 children (9.42%) were identified as ultrarapid metabolizers (UMs), and 16 children (8.37%) were intermediate metabolizers. Only 3 children in our cohort (1.57%) were poor metabolizers. Patients identifying as Caucasian or Hispanic had an elevated incidence of UMs (11.3% and 11.2%, respectively) with extensive variability within subpopulations. CONCLUSIONS: The clinically significant rate of ultrarapid metabolizers reinforces safety concerns regarding the use of codeine and related opiates. A patient-targeted approach using pharmacogenomics may mitigate adverse effects by individualizing the selection and dosing of these analgesics.

Impact of a Formal Patient Safety and Quality Improvement Curriculum: A Prospective, Controlled Trial.

OBJECTIVE: To assess the impact of implementing a dedicated Patient Safety and Quality Improvement (PSQI) curriculum for otolaryngology residents. METHODS: Residents in two otolaryngology residency programs were recruited to participate in the study. Residents at institution A (intervention group) participated in a formal, newly developed, year-long PSQI curriculum. Residents at institution B (control group) participated in traditional, morbidity, and mortality conference-based PSQI education, with no formal curriculum in place. Curriculum participants completed anonymous surveys to assess learner satisfaction. Validated instruments were administered to assess for changes in resident confidence in the ability to develop PSQI projects, their attitudes toward patient safety, and PSQI-related knowledge. The number and quality of PSQI-related resident projects were also assessed. RESULTS: Survey responses demonstrated excellent learner satisfaction with the curriculum. Based on validated instrument-based responses, both programs demonstrated similar confidence scores (P = 0.05), safety attitudes (P = 0.82), and PSQI knowledge (P = 0.29) at the beginning of the year. The residents of institution A demonstrated significant improvement in confidence (P = 0.00009) and knowledge (P = 0.0006) after completing the curriculum, with no improvement noted for residents at institution B in either confidence (P = 0.06) or knowledge (P = 0.79). Neither program demonstrated improvement in attitudes toward patient safety at the end of the year-long curriculum. CONCLUSION: Implementing a formal curriculum dedicated to PSQI led to an improvement in PSQI-related project development confidence and PSQI knowledge. Attitudes toward safety did not improve over the course of a year. Longer-term studies involving multiple institutions and other interventions are needed to evaluate the impact and duration of changes that occur. LEVEL OF EVIDENCE: 1b Laryngoscope, 129:1100-1106, 2019.

Individualized Learning Plan (ILP) Is an Effective Tool in Assessing Achievement of Otology-related Subcompetency Milestones.

OBJECTIVE: To investigate the individualized learning plan (ILP) as a tool in assessment of residents' milestone achievements as they pertain to Otology subcompetencies: Chronic Ear Disease, Pediatric Otitis Media, and Hearing Loss. STUDY DESIGN: Prospective study. METHODS: Twenty otolaryngology residents were instructed to use an ILP and identify six milestones from three otology-related subcompetencies to focus on during the course of a 3-month rotation. They were also asked to plan out specific activities which would help them achieve these milestones, to specify whether or not they successfully achieved them, by what instructional or learning methods and to identify any barriers. The completed ILPs were reviewed by a faculty member. MAIN OUTCOME MEASURES: The effectiveness of the ILP was assessed by response compliance rate, corroboration of self-reported milestone achievement with faculty evaluations and the ability to set attainable milestones. RESULTS: There was 95% compliance in using an ILP to achieve milestones. Self-reported milestone scores corresponded to the faculty evaluations in a large majority (89.6%) of patients, and tended to be underestimated by the residents. Out of 114 total milestones identified, 44 (38.6%) were not achieved, with particular overestimation in the use of independent study as a learning method. CONCLUSION: The ILP is an effective tool in measuring residents' achievement of otology-related milestones, and could possibly be used to supplement or replace faculty assessment. The ILP provides valuable information on barriers to achieving milestones and informs trainees on how to set attainable goals as they pertain to patient care and medical knowledge in otology.

An app to enhance resident education in otolaryngology.

OBJECTIVE: Technological change is leading to an evolution in medical education. The objective of our study was to assess the impact of a medical knowledge app, called PulseQD, on resident education within our otolaryngology-head and neck surgery department at Montefiore Medical Center, Albert Einstein College of Medicine (Bronx, NY). METHODS: A prospective cohort study was conducted within the Department of Otolaryngology-Head and Neck Surgery from July 2016 to June 2017. All faculty attendings and residents were asked to participate in the study and were included. A Web and mobile-based app, PulseQD, that allowed for collaborative learning was implemented. Questionnaires were given at the beginning and end of the academic year. Otolaryngology Training Exam (OTE) scores were collected RESULTS: A total of 20 residents and 13 faculty members participated in the study. Residents used online sources of medical information significantly more often than faculty (90% and 54%, respectively, P = 0.0179). Residents and faculty felt that PulseQD offered a valuable perspective on clinically relevant medical information (P = 0.0003), was a great way to test clinical and medical knowledge (P = 0.0001), and improved the sharing and discussing of medical knowledge (P < 0.0001). There was a statistically significant 5.8% improvement in OTE scores (P = 0.0008) at the end of the academic year. CONCLUSION: The implementation of a novel mobile app, PulseQD, was well received by residents and faculty in the Department of Otolaryngology-Head and Neck Surgery. Preliminary data suggest that app-based learning may lead to improved performance on knowledge-based assessments. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1340-1345, 2018.

Sleep and Breathing the First Night After Adenotonsillectomy in Obese Children With Obstructive Sleep Apnea.

STUDY OBJECTIVES: There are few studies measuring postoperative respiratory complications in obese children with obstructive sleep apnea (OSA) undergoing adenotonsillectomy (AT). These complications are further compounded by perioperative medications. Our objective was to study obese children with OSA for their respiratory characteristics and sleep architecture on the night of AT. METHODS: This was a prospective study at a tertiary pediatric hospital between January 2009-February 2012. Twenty obese children between 8-17 years of age with OSA and adenotonsillar hypertrophy were recruited. Patients underwent baseline polysomnography (PSG) and AT with or without additional debulking procedures, followed by a second PSG on the night of surgery. Demographic and clinical variables, surgical details, perioperative anesthetics and analgesics, and PSG respiratory and sleep architecture parameters were recorded. Statistical tests included Pearson correlation coefficient for correlation between continuous variables and chi-square and Wilcoxon rank-sum tests for differences between groups. RESULTS: Baseline PSG showed OSA with mean obstructive apnea-hypopnea index (oAHI) 27.1 ± 22.9, SpO2 nadir 80.1 ± 7.9%, and sleep fragmentation-arousal index 25.5 ± 22.0. Postoperatively, 85% of patients had abnormal sleep studies similar to baseline, with postoperative oAHI 27.0 ± 34.3 (P = .204), SpO2 nadir, 82.0 ± 8.7% (P = .462), and arousal index, 24.3 ± 24.0 (P = .295). Sleep architecture was abnormal after surgery, showing a significant decrease in REM sleep (P = .003), and a corresponding increase in N2 (P = .017). CONCLUSIONS: Obese children undergoing AT for OSA are at increased risk for residual OSA on the night of surgery. Special considerations should be taken for postoperative monitoring and treatment of these children. COMMENTARY: A commentary on this article appears in this issue on page 775.

Leadership Training in Otolaryngology Residency.

Although residency training offers numerous leadership opportunities, most residents are not exposed to scripted leadership instruction. To explore one program's attitudes about leadership training, a group of otolaryngology faculty (n = 14) and residents (n = 17) was polled about their attitudes. In terms of self-perception, more faculty (10 of 14, 71.4%) than residents (9 of 17, 52.9%; P = .461) considered themselves good leaders. The majority of faculty and residents (27 of 31) thought that adults could be taught leadership ability. Given attitudes about leadership ability and the potential for improvement through instruction, consideration should be given to including such training in otolaryngology residency.

From Morbidity and Mortality to Quality Improvement: Effects of a Structured and Interactive Otolaryngology Conference.

OBJECTIVE: Measure the effects of a structured morbidity and mortality conference format on the attitudes of resident and faculty participants. STUDY DESIGN: Prospective cohort study. SETTING: Otorhinolaryngology-head and neck surgery residency training program. SUBJECTS AND METHODS: Two changes were implemented to the structure of our morbidity and mortality conference: (1) we adopted a recently described presentation framework called situation-background-assessment-recommendation and (2) appointed a faculty moderator to lead the conference. Surveys were distributed to residents and faculty before and after these modifications were implemented to measure changes in attitude of conference attendees. RESULTS: After implementing the above changes to the morbidity and mortality conference, participant engagement increased from "moderately engaged" to "extremely engaged" (P < .01). Among both faculty and residents, the perceived educational value of conference also improved from "moderately educational" to "extremely educational" (P < .01). Finally in the attending cohort, the impact on future patient care increased from "no change" to "greatly enhanced" (P < .01). CONCLUSION: By implementing the situation-background-assessment-recommendation framework and appointing a faculty moderator to morbidity and mortality conference, participants reported significantly enhanced engagement during the conference, increased educational value of the session, and a positive impact on future patient care.

Tonsillectomies and respiratory complications in children: A look at pre-op polysomnography risk factors and post-op admissions.

OBJECTIVE: To identify predictors of post-operative respiratory complications in children undergoing tonsillectomy. METHODS: Consecutive case series with chart review of children who underwent polysomnography (PSG) and subsequent tonsillectomy with or without adenoidectomy for obstructive sleep apnea (OSA). Patients with craniofacial anomalies or significant cardiopulmonary comorbidities were excluded. Rates of post-surgical respiratory complication were reviewed and compared to patient specific factors and PSG findings to identify possible risk factors. RESULTS: Eighty-six patients (mean age 5.3 ± 2.2 years) were included. There was a statistically significant (p = 0.03) relationship between an AHI ≥40 (AHI40) and post-operative respiratory complications. AHI40 also had the greatest magnitude of association with postoperative respiratory complications (OR = 5.313). An AHI ≥25 (AHI25) was marginally significant (p = 0.067). No significant difference in outcome occurrence was found when analyzing rates of complication in patients with BMI above and below 18 (p = 0.20) or oxygen (O2) nadir above and below 80% (p = 0.09). The AHI ranged from 0 to 112.2, and no postoperative respiratory complications were identified in children with an AHI less than 10. CONCLUSIONS: Our results indicate an association between an AHI ≥40 and respiratory complications following an adenotonsillectomy, but we were not able to observe any significant difference at a cutoff of 25. An association between BMI or O2 nadir and postoperative respiratory complication was not able to be identified. Our results support the importance of AHI as a predictor of postoperative respiratory complications in children undergoing tonsillectomy for OSA.

Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea.

IMPORTANCE: Limited information exists regarding clinical outcomes of children undergoing extracapsular tonsillectomy and adenoidectomy (ETA) or intracapsular tonsillectomy and adenoidectomy (ITA) for treatment of obstructive sleep apnea syndrome (OSAS). OBJECTIVES: To quantify polysomnography (PSG) and clinical outcomes of ETA and ITA in children with OSAS and to assess the contribution of comorbid conditions of asthma and obesity. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using medical records at a tertiary pediatrics inner-city hospital. Medical records from 89 children who underwent ETA or ITA between October 1, 2008, and December 31, 2013, were analyzed. The dates of our analysis were January 6, 2014, to April 11, 2014. Inclusion criteria required no evidence of craniofacial or neurological disorders, confirmation of OSAS by PSG within the 2 years before surgery, and a second PSG within the 2 years after surgery. INTERVENTIONS: Each child underwent ETA or ITA after being evaluated by a pediatric otolaryngologist and obtaining written parental informed consent. MAIN OUTCOMES AND MEASURES: Main primary outcomes were derived from PSG. Secondary outcomes included treatment failure, defined as residual OSAS with an obstructive apnea-hypopnea index of at least 5 events per hour. Comparisons were made between and within groups. Logistic regression was used to identify factors associated with treatment failure. RESULTS: Fifty-two children underwent ETA, and 37 children underwent ITA. Children in the ETA group were older (7.5 vs 5.2 years, P = .001) and more obese (60% [31 of 52] vs 30% [11 of 37], P = .004). However, both groups had similar severity of OSAS, with median preoperative obstructive apnea-hypopnea indexes of 17.0 in the ETA group and 24.1 in the ITA group (P = .21), and similar prevalences of asthma (38% [20 of 52] vs 38% [14 of 37]). After surgery, significant improvement was noted on PSG in both groups, with no differences in any clinical outcomes. There was no association between procedure type, age, or body mass index z score and treatment failure. However, in a subset of patients with asthma and obesity, ITA was associated with residual OSAS (odds ratio, 16.5; 95% CI, 1.1-250.2; P = .04). CONCLUSIONS AND RELEVANCE: Both ETA and ITA are effective modalities to treat OSAS, with comparable surgical outcomes on short-term follow-up. However, when comorbid diagnoses of both asthma and obesity exist, OSAS is likely to be refractory to treatment with ITA compared with ETA.

Securing stent during multi-stage laryngotracheoplasty--an evolved technique.

BACKGROUND: Multi-stage laryngotracheoplasty (LTP) typically requires a stent be secured to the airway for 2-6 weeks. Our technique has evolved over time to securing the stent to the strap muscles and tying a series of knots long enough to leave the suture tail protruding through the skin incision, which simplifies stent removal. METHODS: Retrospective chart review. RESULTS: Twenty-four patients underwent multi-stage LTP at our institution from 2007 to 2013. Eight patients were excluded from the study because they either did not have a stent placed (n=4), or they had a t-tube placed which was not sutured in place (n=4). Of the remaining 16 patients, 62.5% (n=10) had their stent secured via sutures which were buried below the skin, and 37.5% (n=6) via a long suture tail which was left protruding through the end of the skin incision. An incision was required for stent removal 100% of buried sutures patients, and 33% of exposed suture patients (p=0.0009). Average operative time for stent removal was 60min in the buried sutures group, and 25min in the exposed sutures group (p=0.0075). CONCLUSIONS: Securing stents via an exposed suture technique decreases the need for making a skin incision during the second stage of the operation, and significantly decreases the operative time of the second stage.

The role of tonsillectomy in the treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

IMPORTANCE: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) in children describes neuropsychiatric symptom exacerbations that relate temporally to streptococcal infections. Recent case reports suggest tonsillectomy may effectively reduce these symptoms; however, no consensus treatment guidelines exist. This study examines whether tonsillectomy improves neuropsychiatric symptoms in children with PANDAS who have incomplete response to antibiotic therapy. OBSERVATIONS: Ten patients met strict diagnostic criteria for PANDAS. Comparisons were made between parental reports of symptom severity at diagnosis, after antibiotic treatment (in 10 patients), and after tonsillectomy (in 9). From a baseline severity score of 10, antibiotics alone improved symptoms to a median (interquartile range [IQR]) score of 8 (6.5-10.0) (P = .03). Nine children who subsequently underwent tonsillectomy reported symptom improvement in comparison with treatment with antibiotics alone, including those with no response to antibiotics. Symptom severity improved at all periods after tonsillectomy compared with antibiotics alone. The median score [IQR] 3 months postoperatively was 3 (0.0-6.5) (P = .01); 6 months postoperatively, 3 (0.0-5.0) (P = .02); 1 year postoperatively, 3 (0.0-5.0) (P = .02); and 3 years postoperatively, 0.5 (0.0-2.3) (P = .03). Four of the 9 had complete resolution after tonsillectomy. CONCLUSIONS AND RELEVANCE: This PANDAS cohort whose neuropsychiatric symptoms did not respond sufficiently to antibiotics may have gained benefit from tonsillectomy.

The use of mitomycin C in pediatric airway surgery: does it work?

PURPOSE OF REVIEW: To describe the efficacy of mitomycin C in combating airway stenosis. RECENT FINDINGS: Recent publications discussing mitomycin C utility have not altered the mixed results previously established by prospective trials. SUMMARY: Mitomycin C has been used for the past 16 years to inhibit pediatric airway fibroblast proliferation. Its benefit remains more hypothetical than proven and its future role remains uncertain.

Tracheal rupture in complicated delivery: a case report and review of the literature.

A case of distal tracheal rupture is described, literature review reveals two previously reported cases of neonatal distal tracheal rupture, as well as 14 cases of anterior subglottic rupture. All patients had shoulder dystocia, and 59% had associated brachial plexus injury. Delayed diagnosis (>3 days) was common in the distal tracheal group (66%), compared to 0% in the anterior subglottic group. The 2 distal tracheal rupture patients were initially managed conservatively, but ultimately required open repair. Distal tracheal rupture is exceedingly rare and more difficult to diagnose and manage than the more common anterior subglottic rupture.

Laryngotracheal reconstruction outcomes in hypotonic children.

IMPORTANCE: Children with poor muscle tone may demonstrate upper airway obstruction due to several mechanisms including obstructive sleep apnea, laryngopharyngeal reflux, and laryngomalacia. Though hypotonia has been shown to compromise the pediatric airway, and some authors suggest that neurologic deficits can compromise the success of laryngotracheal reconstruction (LTR), to our knowledge no studies have evaluated the effect of neurologic diagnoses or hypotonia on outcomes in LTR. OBJECTIVE: To determine whether hypotonic children with subglottic stenosis have lower rates of successful decannulation after LTR compared with children without neurologic deficit. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical chart review was conducted for 27 children aged 0 to 6 years, who underwent LTR for subglottic stenosis between December 2007 and December 2012 at a tertiary care children's hospital. Children were classified based on documented neurologic findings. Group 1 comprised those children without neurologic impairment (n = 16). Group 2 included those children with a documented neurocognitive or neuromuscular diagnosis but without evidence of hypotonia (n = 7). Group 3 comprised hypotonic children (n = 4). INTERVENTIONS Laryngotracheal reconstruction. MAIN OUTCOMES AND MEASURES: The number of procedures performed after LTR to optimize the airway and whether the child was successfully decannulated. RESULTS: All 16 of the neurologically intact patients (100%) were decannulated. Among children with a neurologic deficit, 5 of 7 (71%) were ultimately decannulated. No hypotonic children 0 of 4 were decannulated. The difference in rates of decannulation between unaffected and normotonic children with a neurologic deficit was not statistically significant (P = .08). However, the difference in outcomes between hypotonic children and neurologically intact patients was statistically significant (P < .001). CONCLUSIONS AND RELEVANCE: Findings from this study suggest that hypotonic children may experience poorer rates of post-LTR decannulation compared with children without neurologic deficit. Dynamic upper airway obstruction may be unappreciated in hypotonic children. Future research may be directed at the appropriate evaluation and treatment of children with poor muscle tone and subglottic stenosis.

Adjunctive procedures after pediatric single-stage laryngotracheoplasty.

OBJECTIVES: We report the frequency and success rates of adjunctive airway procedures after pediatric single-stage laryngotracheoplasty (LTP) and review different adjunctive techniques in a prospectively enrolled and retrospectively reviewed case series. METHODS: Of 31 LTP procedures performed from 2008 to 2011 at an academic tertiary care children's hospital, 10 were single-stage LTP procedures. These 10 cases were analyzed to determine the number and type, if any, of adjunctive procedures required after LTP, as well as the subglottic response and decannulation rates. RESULTS: Of the 10 patients with single-stage LTP procedures, 6 patients required a total of 16 postoperative adjunctive airway procedures. The adjunctive procedures included granulation tissue removal with forceps or a carbon dioxide laser, stent placement, mitomycin C application, and triamcinolone acetonide injection. One patient also required tracheotomy placement and, eventually, cricotracheal resection. All 6 patients had significant improvement of subglottic and/ or tracheal stenosis on their most recent endoscopic examination. With a minimum follow-up of 12 months, all 6 patients were decannulated. CONCLUSIONS: In this series, more than half of our pediatric patients who underwent single-stage LTP required 1 or more postoperative adjunctive procedures, and all had successful outcomes.

A randomized trial of adenotonsillectomy for childhood sleep apnea.

BACKGROUND: Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. METHODS: We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. RESULTS: The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). CONCLUSIONS: As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).