A Protocol for Resection and Immediate Reconstruction of Pediatric Mandibles Using Microvascular Free Fibula Flaps.

PURPOSE: The use of a vascularized free fibula graft (FFF) for the reconstruction of a mandible in a child with a mandibular tumor is infrequent. The purpose of this study is to report our protocol for resection of mandibular jaw tumors and immediate reconstruction using FFF in pediatric patients. METHODS: This was a retrospective case series of children with a mandibular tumor, which was resected and immediately reconstructed with FFF. All patients were treated via the same staged protocol: 1) presurgical digital planning, 2) surgical intervention (resection and immediate reconstruction), 3) postoperative care in the pediatric intensive unit, and 4) prosthodontic dental rehabilitation. Outcomes were complications and recurrence. Medical records were reviewed to document demographic information, tumor details, surgical interventions, postoperative course, and prosthodontic rehabilitation. RESULTS: Fifteen patients (10 males, average age of 13.7 years) met inclusion criteria. Ten patients had mandibular ameloblastoma. All patients were treated by a dedicated pediatric team and followed the same protocol. The average tumor size was 4.87 × 3.22 × 2.03 cm. Most fibulas (n = 12) had one osteotomy to reestablish mandibular continuity and create appropriate contour. The most common microvascular anastomosis was with a facial artery (n = 13) and the external jugular vein (n = 9). At an average follow-up of 15.5 months, there were only 3 minor donor site complications. Eight implants were placed without complications. No tumors recurred. CONCLUSIONS: The results of this study suggest that pediatric mandibular tumors can be successfully treated using a specific protocol involving resection and immediate reconstruction using FFF with minimal complications and without recurrence.

Comparative effectiveness of surgical and nonsurgical therapy for advanced laryngeal cancer.

BACKGROUND: The treatment of patients with advanced stage laryngeal cancer includes surgery or concurrent chemoradiation (CRT). Although CRT has become more common in recent years, to the authors' knowledge, the effectiveness of complete CRT in improving survival over surgery has not been studied. METHODS: The authors examined patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare claims-linked data set with locoregional laryngeal cancer who were diagnosed between 1997 and 2007. Multivariate Cox proportional hazard analyses were conducted to compare overall and cause-specific 5-year survival rates between treatment modalities, adjusting for patient sociodemographic and clinical characteristics. A propensity score-matched subcohort also was used to compare survival. RESULTS: Of the 3212 patients in the study cohort, 42% underwent surgery and 18% underwent CRT. Only approximately one-quarter of patients who were treated with CRT completed the courses. In adjusted analyses, the authors were unable to reject the null hypothesis of no difference in 5-year all-cause or cause-specific mortality risk between patients treated with surgery and patients undergoing complete CRT (hazards ratio, 1.25 [95% confidence interval, 0.91-1.71; P = .16] and hazard ratio, 1.41 [95% confidence interval, 0.9-2.2; P = .14], respectively). Older age, not currently married, Medicaid eligibility, and prior cancer history were found to be associated with a higher risk of mortality (P<.05). CONCLUSIONS: Patients with advanced laryngeal cancer who underwent complete CRT were found to have overall and cause-specific survival rates similar to those of patients undergoing surgery. However, a substantial percentage of patients who initiated CRT did not complete the course. Although CRT provides organ preservation, the benefits and trade-offs of CRT and total laryngectomy should be discussed fully with patients. The importance of completing the full course of CRT should be emphasized. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2845-2856. © 2016 American Cancer Society.

Long-Term Functional Outcomes in Pediatric Head and Neck Cancer Patients: A Systematic Review.

OBJECTIVE: The multimodal treatments for pediatric head and neck (H&N) malignancies can have significant long-term functional consequences for growing patients. This systematic review aims to analyze the current knowledge of functional outcomes for pediatric H&N cancer survivors. DATA SOURCES: PubMed, Embase, Web of Science. REVIEW METHODS: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed, and 1356 papers were reviewed by 3 team members with conflict resolution by a senior member. RESULTS: Fourteen studies were included. Nine of 14 (64%) papers reported issues with swallowing, characterized as either dysphagia, odynophagia, oropharyngeal fibrosis, esophageal stenosis, xerostomia, trismus, or general issues with the throat and mouth. Six of 14 papers noted nutritional and feeding deficiencies, and 5 of 14 additionally noted issues with speech and voice changes. Four of 14 (29%) reported hearing impairments and/or loss. A majority of papers (9/14) reported long-term functional characteristics as a secondary outcome. Three of 14 (21%) reported a quality of life (QoL) measure. Heterogeneity in methodology and reporting precluded analysis of any relationship between treatment type and functional outcomes. Recommendations include integration of objective measures of feeding support and swallowing, as well as regular measurements of function and QoL parameters during treatment to better understand the evolution of QoL and function throughout care. CONCLUSION: Relatively few studies focus on functional outcomes following the treatment of pediatric H&N cancer. Swallowing difficulty is the most frequently reported deficit, but objective data is rarely reported. Standardization of functional outcome assessment could improve the quality of evidence for pediatric patients treated for H&N cancer.

A Mobile Application for Child-Focused Tonsillectomy Education: Development and User-Testing.

OBJECTIVE: Patient education is central to Enhanced Recovery After Surgery protocols, but child-focused materials are lacking. We developed and piloted a mobile application to support accessible, interactive patient and caregiver education about pediatric tonsillectomy. METHODS: Thirty children ages 5-12 who were preparing for tonsillectomy, their caregivers, and six attending otolaryngologists participated in a user-testing trial of a web-based prototype. The trial measured feasibility, fidelity, and patient-centered outcomes. Patients and caregivers rated usability/likeability on the mHealth App Usability Questionnaire. Otolaryngologists rated quality on the Mobile App Rating Scale. The full mobile application, "Ready for Tonsillectomy," was then developed for iOS and Android. RESULTS: Enrollment was 88.2%, retention was 90.0%, and use was 96.3%. Mean (SD) patient ratings for usability/likeability were 6.3 (1.1) out of 7; caregiver ratings were 6.5 (1.1). In common themes from open-ended feedback, patients described the application as helpful and appealing, and caregivers described it as informative, easy to understand, calming, and easy to use. Among caregivers who used the application during recovery, 92.3% reported that it helped them manage their child's pain. Providers would recommend the application to many or all of their patients (mean [SD]: 4.7 [0.5] out of 5). Mean provider ratings for domains of engagement, functionality, aesthetics, information quality, subjective quality, and app-specific value ranged from 4.1 to 4.8 out of 5. CONCLUSION: Feasibility and fidelity were high. Families and otolaryngologists endorsed the resource as an engaging, informative tool that supports positive coping. Our mobile application offers a patient-centered solution readily scalable to other surgeries. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2455-2463, 2024.

Opioid Prescribing Trends After Major Pediatric Ear Surgery: A 12-Year Analysis.

OBJECTIVE: Postoperative opioid prescriptions tend to exceed children's analgesic needs, but awareness of the opioid epidemic may have driven changes in prescribing behaviors. This study evaluated opioid prescribing patterns after major pediatric ear surgery. METHODS: This study reviewed all cases of tympanoplasty, tympanomastoidectomy, mastoidectomy, cochlear implantation, otoplasty, and aural atresia repair at a pediatric hospital during 2010-2021. Regressions were conducted to identify opioid prescribing trends over time. Potential covariates were assessed. Returns to the system were reviewed as a balancing measure. RESULTS: Even without a targeted protocol, opioid prescribing declined significantly. After prescribing peaked in 2012-2013, significant negative trends yielded lower rates of opioid prescriptions, fewer doses per prescription, smaller patient-weight-standardized dose sizes, and less variability (all p < 0.001). In 2012, 96.1% of patients received opioid prescriptions; the rate fell to 13.5% by 2021. For patients ages, 0-6, the annual rate of opioid prescriptions dropped from a maximum of 96.3% in 2012 to 0.0% in 2021. The annual average supply of doses per prescription decreased by 68% between 2013 and 2021, reducing the total days' supply to an evidence-based 3.1 ± 1.6 days. Regressions did not detect changes in returns to the system. Pain-related returns were rare (0.9%) and did not vary by opioid prescriptions (p = 0.37). Prescribing trends were closely correlated with a tonsillectomy-focused protocol that our institution implemented in 2019. CONCLUSION: Surgeon-driven opioid stewardship has improved with no resultant change in revisit rates. Procedure-specific quality improvement interventions may have broader off-target effects on prescribing behaviors. LEVEL OF EVIDENCE: IV Laryngoscope, 133:1987-1992, 2023.

Sirolimus-induced pulmonary hemorrhage of an infant with massive cervicofacial lymphatic malformation: A case report.

Lymphatic malformations (LMs) are uncommon congenital abnormalities of the lymphatic system. As more than half of these lesions develop in the head and neck, LMs can be life-threatening if associated with airway involvement. LMs necessitate a multidisciplinary treatment approach, frequently including surgery and sclerotherapy. We present a case report of a 32-week pre-term male infant with a massive cervicofacial LM necessitating delivery via ex-utero intrapartum treatment (EXIT). The patient was treated with numerous rounds of sclerotherapy, systemic sirolimus, and surgical debulking, but ultimately died at 4 months of age due to acute pulmonary hemorrhage, which may have been related to sirolimus due to the absence of any other associable organ involvement or derangement. We document the patient's clinical course and treatment regimen, highlighting the myriad modalities employed to treat these challenging lesions, and describe a potentially lethal complication of sirolimus therapy not previously described in the treatment of pediatric LM.

Outcomes in pediatric total thyroidectomy following implementation of a two-surgeon operative approach.

PURPOSE: Pediatric total thyroidectomy is an uncommon procedure. Higher rates of complication are reported for pediatric patients compared to adults which may be secondary to lower case volume. In this study, we examine the effect of a two-surgeon operative approach on outcomes in pediatric total thyroidectomy. METHODS: A retrospective review of 152 pediatric patients undergoing total thyroidectomy at a single institution was performed. A control group of 89 patients, with one attending surgeon present, was compared to a cohort of 63 pediatric patients who underwent total thyroidectomy with two attendings present. Primary outcomes included rates of permanent hypoparathyroidism and recurrent laryngeal nerve (RLN) injury. The secondary outcomes included postoperative hematoma, length of stay (LOS), LOS greater than 1 day (>1d) secondary to hypocalcemia, and readmissions secondary to hypocalcemia. RESULTS: One RLN injury was documented in each cohort and no postoperative hematomas were documented. Rates of permanent hypoparathyroidism decreased in the two-surgeon cohort (11.48%) when compared to the control group (15.73%) but was not significant. There was a statistically significant decrease in LOS >1d secondary to hypocalcemia in the two-surgeon cohort. LOS >1d attributable to hypocalcemia was seen in 38.2% in the control group versus 15.87% in the 2-surgeon cohort (p = 0.003). CONCLUSIONS: Implementation of a two-surgeon operative approach was shown to lead to a significant decrease in length of stay >1d attributable to hypocalcemia. However, this change was in the setting of multidisciplinary thyroid team and postoperative protocol implementation, and concentration of surgeons performing the operation. Further studies are needed to investigate the effects of the two-surgeon operative approach further.

Predictive value of 6 h postoperative parathyroid hormone level on permanent hypoparathyroidism in pediatric total thyroidectomy: a pilot study.

OBJECTIVES: Transient hypocalcemia is a common complication after pediatric total thyroidectomy, while permanent hypoparathyroidism (PH) is relatively uncommon. To date there is no model to predict which patients will develop PH based on post-operative makers. We aim to identify pediatric patients who are at high risk of PH following thyroidectomy based on 6 h post-operative parathyroid hormone (PTH) value. METHODS: A retrospective review of 122 pediatric patients undergoing total thyroidectomy between 2016 and 2022 following implementation of a multidisciplinary team was performed. Outcome of interest was permanent hypoparathyroidism, defined as need for calcium supplementation at 6 months postoperatively. Receiver operating characteristic (ROC) analysis was used to determine PTH value at 6 h post-operative that was predictive of permanent hypoparathyroidism. RESULTS: Rates of permanent hypoparathyroidism reported are similar to those described in the literature with 12 patients (10.9%) developing PH. In patients who developed PH, mean 6 h postoperative PTH was 5.12 pg/mL. Mean 6 h postoperative PTH level in those who did not develop PH was 31.34 pg/mL (p<0.0001). The 6 h post-operative PTH value predictive for PH was ≤11.3 pg/mL. PTH cutoff of ≤11.3 pg/mL had a sensitivity of 100%, specificity of 72.2%, positive predictive value (PPV) of 27.0%, and negative predictive value (NPV) of 100%. CONCLUSIONS: 6 h postoperative PTH values were found to be predictive of permanent hypoparathyroidism in pediatric total thyroidectomy: a 6 h postoperative PTH level of >11.3 pg/mL excludes permanent hypoparathyroidism, but if PTH is ≤11.3 pg/mL at 6 h, approximately 1/3 of patients may persist with permanent hypoparathyroidism.

Reducing Children's Preoperative Fear with an Educational Pop-up Book: A Randomized Controlled Trial.

OBJECTIVE: Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies. STUDY DESIGN: Prospective randomized controlled trial. SETTING: Pediatric outpatient surgery center. METHODS: Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction. RESULTS: In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients' fear of anesthesia induction (Cohen's d effect size = 0.94; P < .001). Intervention patients also expected less pain than control patients from the anesthesia mask and during surgery (d = 0.60-0.80; P < .001). The book encouraged more positive views of the procedure and preoperative explanations (P < .005). Furthermore, the book prepared patients to cope adaptively: intervention patients were significantly more likely to generate positive active coping strategies, distraction strategies, and support-seeking strategies (P < .001). Observer-rated behavioral anxiety at anesthesia induction did not differ between groups (P = .75). Caregivers in the intervention group were significantly more satisfied with each aspect of the surgical experience (P≤ .02). CONCLUSION: The educational pop-up book offers a child-focused resource that helps alleviate children's preoperative fears, encourages positive coping, and improves caregivers' perceptions of the experience. This study was registered at ClinicalTrials.gov (NCT04796077).

Unexpected Benefits in Single Institution Experience With Successful Implementation of a Standardized Perioperative Protocol in Pediatric Thyroidectomy.

Introduction: To illustrate how quality improvement can produce unexpected positive outcomes. Methods: We compared a retrospective review of perioperative management and outcomes of baseline 122 pediatric total thyroidectomies to 121 subsequent total thyroidectomies managed by an Electronic Medical Record protocol in a large, free-standing children's healthcare system. Process measures included serum calcium measurement 6-12 hours postoperatively; parathyroid hormone measurement 6 hours postoperatively; preoperative iodine for Graves disease, and postoperative prophylactic calcium carbonate administration. In addition, we completed 4 Plan-Do-Study-Act (PDSA) cycles, focusing on implementation, refinement, usage, education, and postoperative calcitriol administration. The primary outcome included transient hypocalcemia during admission. Results: All perioperative process measures improved over PDSA cycles. Measurement of postoperative serum calcium increased from 42% at baseline to 100%. Measurement of postoperative PTH increased from 11% to 97%. Preoperative iodine administration for Graves disease surgeries improved from 72% to 94%. Postoperative calcium carbonate administration increased from 36% to 100%. There was a trend toward lower rates of severe hypocalcemia during admission over the subsequent PDSA cycles starting at 11.6% and improving to 3.4%. With the regular review of outcomes, surgical volume consolidated among high-volume providers, associated with a decrease in a permanent hypoparathyroid rate of 20.5% at baseline to 10% by the end of monitoring. Conclusions: In standardizing care at 1 large pediatric institution, implementing a focused quality improvement project involving the perioperative management of transient hypocalcemia in total thyroidectomy pediatric patients resulted in additional, unanticipated improvements in patient care.

Measuring the Impact of a Delay in Care on Pediatric Otolaryngologic Surgery Completion.

Objective: To determine if postponement of elective pediatric otorhinolaryngology surgeries results in a change in overall healthcare utilization and if there is any commensurate impact on disease progression. Methods: We identified patients ≤18 years of age whose surgeries were postponed at the onset of the COVID-19 pandemic-related shutdown. We then tracked patients' rate of and patterns of rescheduling surgery. Surveys were also sent to caregivers to better characterize his/her decision regarding moving forward with his/her child's surgery during COVID-19. Results: A total of 1915 pediatric patients had elective surgeries canceled, of which 992 (51.8%) were rescheduled within 4 months. No difference in rates of rescheduling was identified based on race or ethnicity. Patients who were scheduled for tonsillectomies and/or adenoidectomies were 1.22 times more likely to reschedule compared to those patients with other planned procedures (CI: 1.02-1.46). A total of 95 caregivers at two hospitals completed surveys: 44 (47.4%) rescheduled their child's surgery. Most caregivers who rescheduled were concerned their child's disease could impact their future (n = 14, 32%). Conclusions: Just over half of patients who had pediatric otolaryngologic surgery canceled during a period of social distancing went on to have surgery within a 4-month timeframe. This reflects the dependence of pediatric otolaryngologic surgery on environmental exposures and may represent a potential target for prevention and management of some pediatric otolaryngology diseases.

Sustaining standardized opioid prescribing practices after pediatric tonsillectomy.

INTRODUCTION: Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes. METHODS: A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure. RESULTS: From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28). CONCLUSION: An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.

Risk factors for return visits in children discharged with tracheostomy.

STUDY OBJECTIVES: To determine associations between demographic and clinical characteristics and rate of unplanned returns to system (RTS) in pediatric patients discharged with tracheostomy. METHODS: Medical records were examined for pediatric patients discharged after tracheostomy placement between January 1, 2011 and December 31, 2015. Exclusion criteria included death or decannulation prior to discharge and lack of follow-up through 180 days post-discharge. Readmissions were grouped by time interval after discharge (within 30 days or within 31-180 days). Chi-squared analysis and Fisher's Exact Test were utilized to determine associations between patient characteristics, rate and frequency of RTS, and type of admission (Emergency Department [ED] or inpatient [IP]). RESULTS: One hundred twenty-one patients were eligible for the study, and 80 (66.1 %) had an unanticipated RTS during the follow-up period. Patients with early RTS had a higher total number of RTS. Patients with two or more RTS were more likely to be younger, while patients with five or more RTS were more likely to have greater organ system involvement and cardiovascular (CV) disease in particular. Patients presenting with GI diagnoses were more likely to be discharged from the ED. The rate of RTS remained constant throughout the time period examined. CONCLUSION: Pediatric patients discharged with tracheostomy are medically complex and at high risk of RTS, especially for respiratory and GI problems. This risk does not decrease after the initial post-discharge period and long-term follow-up is warranted. Younger patients and patients with history of early RTS are at highest risk for repeat RTS and should be identified for closer outpatient care.

Mortality and Outcomes of Pediatric Tracheostomy Dependent Patients.

Objective: To describe clinical factors associated with mortality and causes of death in tracheostomy-dependent (TD) children. Methods: A retrospective study of patients with a new or established tracheostomy requiring hospitalization at a large tertiary children's hospital between 2009 and 2015 was conducted. Patient groups were developed based on indication for tracheostomy: pulmonary, anatomic/airway obstruction, and neurologic causes. The outcome measures were overall mortality rate, mortality risk factors, and causes of death. Results: A total of 187 patients were identified as TD with complete data available for 164 patients. Primary indications for tracheostomy included pulmonary (40%), anatomic/airway obstruction (36%), and neurologic (24%). The median age at tracheostomy and duration of follow up were 6.6 months (IQR 3.5-19.5 months) and 23.8 months (IQR 9.9-46.7 months), respectively. Overall, 45 (27%) patients died during the study period and the median time to death following tracheostomy was 9.8 months (IQR 6.1-29.7 months). Overall survival at 1- and 5-years following tracheostomy was 83% (95% CI: 76-88%) and 68% (95% CI: 57-76%), respectively. There was no significant difference in mortality based on indication for tracheostomy (p = 0.35), however pulmonary indication for tracheostomy was associated with a shorter time to death (HR: 1.9; 95% CI: 1.04-3.4; p = 0.04). Among the co-morbid medical conditions, children with seizure disorder had higher mortality (p = 0.04). Conclusion: In this study, TD children had a high mortality rate with no significant difference in mortality based on indication for tracheostomy. Pulmonary indication for tracheostomy was associated with a shorter time to death and neurologic indication was associated with lower decannulation rates.

Targeted Oncogene Therapy Before Surgery in Pediatric Patients With Advanced Invasive Thyroid Cancer at Initial Presentation: Is It Time for a Paradigm Shift?

Importance: Initial data suggest the effectiveness of oncogene-specific targeted therapies in inducing tumor regression of diverse cancers in children and adults, with minimal adverse effects. Observations: In this review, preliminary data suggest that systemic therapy may be effective in inducing tumor regression in pediatric patients with unresectable invasive thyroid cancer. Although most pediatric patients with thyroid cancer initially present with operable disease, some children have extensive disease that poses substantial surgical challenges and exposes them to higher than usual risk of operative complications. Extensive disease includes thyroid cancer that invades the trachea or esophagus or encases vascular or neural structures. Previous efforts to manage extensive thyroid cancer focused on surgery with near-curative intent. With the recent development of oncogene-specific targeted therapies that are effective in inducing tumor regression, with minimal drug-associated adverse effects, there is an opportunity to consider incorporating these agents as neoadjuvant therapy. In patients with morbidly invasive regional metastasis or with hypoxia associated with extensive pulmonary metastasis, neoadjuvant therapy can be incorporated to induce tumor regression before surgery and radioactive iodine therapy. For patients with widely invasive medullary thyroid cancer, in whom the risk of surgical complications is high and the likelihood of surgical remission is low, these agents may replace surgery depending on the response to therapy and long-term tolerance. Conclusions and Relevance: With oncogene-specific targeted therapy that is associated with substantial tumor regression and low risk of adverse reactions, there appears to be an opportunity to include children with advanced invasive thyroid cancer in clinical trials exploring neoadjuvant targeted oncogene therapy before or instead of surgery.

Simulation-based education to improve emergency management skills in caregivers of tracheostomy patients.

INTRODUCTION: Children with tracheostomies are medically complex and may be discharged with limited and variably trained home nursing support. When faced with emergencies at home, caregivers must often take the lead role in management, and many lack experience with troubleshooting these emergencies prior to initial discharge. METHODS: A high-fidelity simulation-based tracheostomy education program was designed using a programmable mannequin (Gaumard HAL S3004 one-year-old pediatric simulator). At the conclusion of our standard education program, caregivers completed three simulation scenarios: desaturation, mucus plugging, and dislodgement. A trained simulation facilitator graded performance. A self-assessment tool was used to analyze comfort with emergency management at the beginning of training, before and after simulation. Caregivers rated confidence using a 10 cm visual analog scale. All participants completed a post-simulation debriefing session. RESULTS: 39 caregivers completed all three scenarios and returned pre- and post-simulation self-assessments. Mean scores from the caregiver self-assessments increased for all three scenarios, with mean increases of 9 mm for desaturation, 16 mm for mucus plugging, and 10 mm for decannulation. Two patterns of responses emerged: caregivers with progressive increase in confidence through training, and caregivers who initially rated confidence highly, and had confidence decrease as the complexity of true emergency management became apparent. All participants found the simulations to be realistic and helpful. DISCUSSION: High-fidelity simulation training allows for realistic exposure to trach-related emergencies. Many caregivers overestimate their ability to handle emergencies and gain important insight through simulation. IMPLICATIONS FOR PRACTICE: Identification of skills and knowledge gaps prior to discharge allows for targeted re-education in emergency management.

Fetal Evaluation and Airway Management.

Congenital causes of airway obstruction once noted at birth are now diagnosed prenatally. The adoption of ex utero intrapartum treatment has allowed for planned airway stabilization on placental support, dramatically decreasing the incidence of hypoxic injury or peripartum demise related to neonatal airway obstruction. Airway access is gained either through laryngoscopy, bronchoscopy, or a surgical airway. In complete airway obstruction, primary resection of the obstructing lesion may be performed before completion of delivery. This article reviews the current and emerging methods of fetal evaluation, indications for ex utero intrapartum treatment, and provides a detailed description of the procedure and necessary personnel.

EXIT (ex utero intrapartum treatment) in a growth restricted fetus with tracheal atresia.

Congenital high airway obstruction syndrome (CHAOS) encompasses a heterogeneous group of pathologies leading to poor lung development and difficulty oxygenating the newborn after delivery. While previously uniformly fatal, the ex utero intrapartum therapy (EXIT) procedure has provided a method to treat these patients and provide an airway to potentiate survival. We present a patient diagnosed prenatally with CHAOS secondary to tracheal atresia complicated by severe intra-uterine growth restriction (IUGR) who was successfully delivered via an EXIT procedure at 33-weeks. Multidisciplinary care and planning is paramount.

Inpatient observation for elective decannulation of pediatric patients with tracheostomy.

IMPORTANCE: The incidence and timing patterns of decannulation failure in children are unknown. There is substantial variability in the duration of inpatient hospitalization for patients undergoing decannulation, which represents an opportunity for improved resource use. OBJECTIVE: To determine the incidence and timing patterns of elective decannulation failure in the pediatric population and to determine an appropriate interval of inpatient observation following decannulation that optimizes both patient safety and resource use. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of medical records of consecutive patients 18 years or younger hospitalized for elective, inpatient decannulation between January 1, 2012, and October 31, 2013, at a quaternary care pediatric hospital. MAIN OUTCOMES AND MEASURES: Duration of decannulation hospitalization, failure of elective decannulation (decision not to decannulate or reinsertion of tracheostomy tube after decannulation), time interval from decannulation to failure. RESULTS: Forty-six patients completed 50 elective decannulation hospitalizations during the study period. The median duration of hospitalization for decannulation was 3.0 days. The hospitalization-specific failure rate was 16% (8 of 50), and the overall failure rate was 9% (4 of 46). Four patients were not able to tolerate capping of the tracheostomy tube and were discharged with their original tracheostomy tubes in place. Three of these patients were decannulated at a later hospitalization. In 4 patients, decannulation failed and they had to have their tracheostomy tubes replaced prior to discharge. Patients who did not tolerate decannulation were younger (mean [SD] age, 45.7 [17.0] months) than patients whose decannulation was successful (68.2 [48.0] months). All patients with unsuccessful decannulation attempts were symptomatic during capping. The longest interval from decannulation to tracheostomy reinsertion was 11 hours. CONCLUSIONS AND RELEVANCE: Elective decannulation failure occurred in 9% of this population and may be more common in younger patients and those with a diagnosis of vocal fold paralysis. Patients who are symptomatic during predecannulation capping are at high risk for decannulation failure. Inpatient observation for a 24-hour asymptomatic interval after decannulation may be sufficient because late failures were not observed in this sample.

Pediatric Thyroid Carcinoma in Patients with Graves' Disease: The Role of Ultrasound in Selecting Patients for Definitive Therapy.

BACKGROUND/AIMS: Pediatric Graves' disease (GD) accounts for 10-15% of all thyroid disorders in patients ≤18 years and is treated with antithyroid medication or definitive therapy [radioactive iodine (RAI) ablation vs. surgery]. Patients with GD may have concurrent differentiated thyroid cancer (DTC). DTC prevalence in pediatric GD is not well established. We examined the prevalence of DTC in pediatric GD and the role of preoperative thyroid ultrasound (US) in selecting the appropriate definitive therapy. METHODS: This is a single-institution, retrospective, cross-sectional study of 32 GD patients with a median age of 11 years (range 3-18) who underwent total thyroidectomy as the definitive treatment between 2005 and 2014. RESULTS: DTC was identified in 22% of the GD patients. A total of 97% completed preoperative thyroid US, and thyroid nodules were identified in 13/32 patients (41%). Preoperative fine needle aspiration (FNA) biopsy was performed in 6/13 patients, accounting for four preoperative diagnoses of concurrent DTC. Extra-thyroidal extension was present in 4/7 (63%), regional lymph node metastasis in 3/7 (43%), and lung metastasis in 2/7 patients (29%). CONCLUSIONS: Concurrent DTC occurs in pediatric GD patients. Thyroid US is an efficient tool for selecting patients for thyroidectomy. For patients with a nodule on US before definitive therapy, FNA should be performed to appropriately select thyroidectomy versus RAI ablation. © 2015 S. Karger AG, Basel.