Perioperative management in chronically anticoagulated children undergoing tonsillectomy.

BACKGROUND: When undergoing tonsillectomy, patients at high risk of thrombosis who require chronic anticoagulation therapy pose a special challenge as bleeding may occur up to 2 weeks after surgery. Because of a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our study was to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy. METHODS: The study group were a retrospective series of patients on chronic anticoagulation therapy at high risk of a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued because of a low risk of thromboembolic events were excluded. RESULTS: Four patients met the inclusion criteria (age range, 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH), drip-titrated to a therapeutic dose until 4-6 h prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. Unfractionated heparin was readministered according to the hospital protocol on the night of surgery and titrated to a therapeutic dose. Warfarin was restarted within 2 days postsurgery for all patients. High-risk patients were kept in hospital until postoperative day 6-8 because of concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention; none of the patients developed early or delayed hematemesis. CONCLUSIONS: Our data show that bridging therapy with UFH has been successful in chronically anticoagulated patients undergoing tonsillectomy. These patients require multidisciplinary care for the management of their pre- and postoperative course.

Algorithm for Airway Management in Patients With Pierre Robin Sequence.

PURPOSE: Airway management in neonates with Pierre Robin sequence (PRS) can be challenging. The goal was to describe the algorithm developed by the authors over the past 8 years. METHODS: A retrospective case series analyzing airway management in neonates with PRS admitted to the neonatal intensive care unit at a tertiary care pediatric hospital was performed. The utility of the proposed algorithm for airway management incorporating more consistent use of polysomnography (PSG), and airway assessment was assessed. RESULTS: A total of 31 neonates with PRS (12 men, 19 women) with a mean gestational age of 38.2 weeks were analyzed. Thirteen (41.9%) patients had a named syndrome, chromosomal abnormality, or global delay. Twenty (64.5%) patients had pre-intervention PSG, and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) ≥ 10 events/hour was identified in 19 (95.0%). Mandibular distraction osteogenesis was performed in 18 (58.1%) patients, and improved the AHI on post-operative PSGs. Direct assessment of the upper and lower airways was performed in 19 patients, and 13 (68.4%) were found to have secondary airway pathology. Presence of a concomitant syndrome was significantly associated with need for tracheostomy. CONCLUSION: The algorithm differs from previous ones in that it relies on rigorous pre- and post-intervention PSG (including with a nasopharyngeal airway), as well as that it allows flexibility between treatment options given the whole-patient clinical scenario and endoscopic findings. Results from these studies may be integrated to stratify patients into those who are most likely to benefit from conservative interventions or surgical procedures.

The Effect of Systemic Magnesium on Postsurgical Pain in Children Undergoing Tonsillectomies: A Double-Blinded, Randomized, Placebo-Controlled Trial.

BACKGROUND: Tonsillectomy is a frequently performed surgical procedure in children; however, few multimodal analgesic strategies have been shown to improve postsurgical pain in this patient population. Systemic magnesium infusions have been shown to reliably improve postoperative pain in adults, but their effects in pediatric surgical patients remain to be determined. In the current investigation, our main objective was to evaluate the use of systemic magnesium to improve postoperative pain in pediatric patients undergoing tonsillectomy. We hypothesized that children who received systemic magnesium infusions would have less post-tonsillectomy pain than the children who received saline infusions. METHODS: The study was a prospective, randomized, double-blinded, clinical trial. Subjects were randomly assigned using a computer-generated table of random numbers to 1 of the 2 intervention groups: systemic magnesium infusion (initial loading dose 30 mg/kg given over 15 minutes followed by a continuous magnesium infusion 10 mg/kg/h) and the same volume of saline. The primary outcome was pain scores in the postanesthesia care unit (PACU) measured by FLACC (Face, Legs, Activity, Cry, Consolability) pain scores. Pain reduction was measured by the decrement in the area under the pain scale versus 90-minute postoperative time curve using the trapezoidal method. Secondary outcomes included opioid consumption in the PACU, emergence delirium scores (measured by the pediatric anesthesia emergence delirium scale), and parent satisfaction. RESULTS: Sixty subjects were randomly assigned and 60 completed the study. The area under pain scores (up to 90 minutes) was not different between the study groups, median (interquartile range [IQR]) of 30 (0-120) score × min and 45 (0-135) score × min for the magnesium and control groups, respectively (P = 0.74). Similarly, there was no clinically significant difference in the morphine consumption in the PACU between the magnesium group, median (IQR) of 2.0 (0-4.44) mg IV morphine, compared with the control, median (IQR) of 2.5 (0-4.99) mg IV morphine (P = 0.25). The serum level of magnesium was significantly lower in the control group than in the treatment group at the end of the surgery (P < 0.001). CONCLUSIONS: Despite a large number of studies demonstrating the efficacy of systemic magnesium for preventing postsurgical pain in adults, we could not find evidence for a significant clinical benefit of systemic magnesium infusion in children undergoing tonsillectomies. Our findings reiterate the importance of validating multimodal analgesic strategies in children that have been demonstrated to be effective in the adult population.

Integrative Approach to Managing Obstructive Sleep Apnea.

Conventional therapies for obstructive sleep apnea (OSA), including CPAP and oral appliances, offer the best opportunity for symptomatic improvement and reduction in OSA overall health impact. Integrative medicine brings conventional and complementary approaches together in a coordinated way. With rising obesity rates, weight loss and lifestyle programs seem to be the most favorable integrative methods to combine with conventional OSA therapies. Complementary and integrative approaches to OSA management are varied and, in conjunction with conventional methods, may offer some reduction in the apnea-hypopnea index.

Outcomes of pediatric tracheostomy after surgery for congenital heart disease: A 20-year experience.

Objective: Children with congenital heart defects (CHD) requiring cardiovascular surgery (CVS) rarely require tracheostomy placement; however the mortality rate remains high. The study aimed to analyze the incidence of tracheostomy in children with CHD, and to determine factors contributing to postoperative outcomes, decannulation rates, and mortality. Methods: Retrospective case series of children ≤18 years old with CHD status post-CVS who underwent tracheostomy placement between January 1, 2001 and December 31, 2020. Variables analyzed included demographic information, presence of comorbidities including prematurity, respiratory diseases, presence of genetic syndromes, decannulation status, type of repair (univentricular vs. biventricular), and need for cardiopulmonary bypass. Adverse events analyzed included all-cause mortality, development of mediastinitis, fatal decannulation, and persistence of tracheocutaneous fistula. Results: Fifty-one patients were analyzed. The incidence of tracheostomy was 0.8%. Median age at tracheostomy was 5.3 months. The 5-year survival estimate was 56.3% (95% confidence interval 43.6%, 72.6%). Age ≤6 months at the time of tracheostomy placement (p = .03), and the presence of tracheomalacia (p = .04) were factors significantly associated with 5-year survival. Two patients (3.9%) experienced fatal decannulation, and one patient (2.0%) developed postoperative mediastinitis. The 10-year decannulation rate estimate was 47.8% (30.5%, 63.2%). Seven patients (13.7%) had a persistent tracheocutaneous fistula. Conclusions: This study corroborates high mortality rates in this population. Factors associated with improved survival were younger age at the time of tracheostomy and presence of tracheomalacia. Decannulation rates were low, but estimates improved over 10 years. Further studies are needed to determine optimal indications and timing for tracheostomy placement in this patient population. Level of Evidence: 4.

Tonsillectomy Outcomes in Children After Solid-Organ Transplantation: A 15-Year Single-Center Experience.

OBJECTIVE: Solid-organ transplantation (SOT) has become the standard of care for children with terminal organ failure. Long-term immunosuppression has improved survival substantially but is associated with secondary malignancies and impaired wound healing. Our goal was to review the incidence, outcomes, complications, and rate of posttransplant lymphoproliferative disorder on pathologic examination following tonsillectomy/adenotonsillectomy (T/AT) in children after SOT. STUDY DESIGN: A retrospective cohort study. SETTING: Tertiary care children's hospital. METHODS: Data were extracted from charts of children with a history of kidney, heart, or liver transplantation, who underwent T/AT between 2006 and 2021. RESULTS: A total of 110 patients met the inclusion criteria, including 46 hearts, 41 kidneys, 19 livers, and 4 liver-and-kidney transplants. The mean age at transplantation was 4.2 years, and the mean transplantation-to-T/AT time interval was 28.8 months. The posttransplant lymphoproliferative disorder was diagnosed in 52 (47.3%) patients, and 25% of these had no tonsillar hypertrophy. There was no difference in age at transplantation, organ received, transplantation-to-T/AT time interval, immunosuppressive medications, tonsil size, or tonsillar asymmetry between patients diagnosed with the posttransplant lymphoproliferative disorder and patients with benign tonsillar/adenotonsillar hypertrophy. Posttonsillectomy complications were similar between the groups. CONCLUSION: The incidence of posttransplant lymphoproliferative disorder undergoing tonsillectomy for any indication was 47.3%. There was no association between preoperative signs and symptoms and the histopathological diagnosis of posttransplant lymphoproliferative disorder. Stratification by organ received and immunosuppressive medications did not identify differences among the groups relative to the incidence of posttransplant lymphoproliferative disorder and other postoperative complications.

Integrative Approach to Managing Obstructive Sleep Apnea.

Conventional therapies for obstructive sleep apnea (OSA), including CPAP and oral appliances, offer the best opportunity for symptomatic improvement and reduction in OSA overall health impact. Integrative medicine brings conventional and complementary approaches together in a coordinated way. With rising obesity rates, weight loss and lifestyle programs seem to be the most favorable integrative methods to combine with conventional OSA therapies. Complementary and integrative approaches to OSA management are varied and, in conjunction with conventional methods, may offer some reduction in the apnea-hypopnea index.

Salivary gland surgery and nonviral respiratory-related hospitalizations in children with neurodevelopmental impairment.

OBJECTIVES: Neurodevelopmentally impaired (NI) children with chronic sialorrhea are at elevated risk for aspiration and respiratory tract infections. Direct resection or ligation ("DROOL") of the submandibular glands (SMG) with parotid duct ligation are surgical interventions intended to decrease salivary output. The objective of this study is to determine the impact of DROOL surgery on the incidence of nonviral respiratory-related (NVR) post-procedure hospital encounters including emergency department visits and admissions. METHODS: Retrospective case series of NVR related outcomes after DROOL surgery in children performed at a single institution, tertiary referral center. RESULTS: A total of 35 gastrostomy tube-dependent patients (60% male, average age 8.2 [SD 6.0] years) with NI underwent DROOL surgery (86% SMG excision). Pre- and post-surgical follow-up time was 3.6 and 3.2 years, respectively. Presurgical and postsurgical NVR hospital encounters occurred in 28 (80%) and 14 (40%) patients, respectively (p < 0.01). Mean (SD) postoperative NVR hospital encounters occurred less frequently when compared to presurgical period (0.4 [0.6] vs. 1.0 [1.2] per year, p < 0.01) with average change of -0.7 encounters per year (SD 1.4, 95% CI -1.0 to -0.2). Patients with encounters within a year preceding DROOL (OR 4.9, p = 0.04, 95% CI 1.1-22.8), or those with at least 3 preoperative encounters (OR 8.0, p = 0.01, 95% CI 1.6-40.3) were significantly associated with a postsurgical NVR event. Fewer patients used anti-sialorrhea medication postoperatively compared to preoperatively (60% vs. 17%, p < 0.01). No patient developed surgical site complications requiring operative interventions. CONCLUSIONS: DROOL surgery for chronic sialorrhea in patients with NI was associated with decreased hospitalization and ED visits for NVR respiratory events post-procedurally. Sialorrhea may be an actionable source of recurrent respiratory illnesses requiring hospitalizations.

Outcomes of a postoperative day one call to families after adenotonsillectomy in children.

Objective: To examine the outcomes of a postoperative day one (POD 1) phone call to families of ambulatory surgical patients, as a means of guiding clinical interventions and quality initiatives, with a focus on children undergoing adenotonsillectomy (T&A). Methods: Retrospective analysis of outcomes of a POD 1 questionnaire completed in children <18 years of age undergoing T&A at a tertiary care children's hospital over a 3-year period (August 14, 2018-August 31, 2021). Results: Responses to the questionnaire were obtained for a total of 1428/3464 (41.2%) children undergoing T&A during the study period. There was no difference in gender, age at surgery, race, ethnicity, insurance product, or preoperative diagnosis for those whose caregiver responded to the questionnaire versus those who did not. Parent responses included 84 (5.9%) who reported problems or concerns postdischarge. These included 18 (1.3%) patients unable to take their pain medication, 9 (0.6%) refusing oral intake, 28 (2.0%) with postoperative emesis, 27 (1.9%) with fevers, and 6 (0.4%) with a change in breathing. A total of 75/122 (61.5%) who reported pain were taking their pain medication as directed. Nineteen (1.3%) patients were noted to have bleeding after surgery, including 4 (21.5%) with nosebleeds, and 12 (63.2%) with oral cavity bleeding requiring no interventions. Conclusions: The POD 1 questionnaire identified patients with common concerns and complications after T&A. Although most of these concerns were infrequent, it afforded the clinical team the opportunity to provide additional education and instructions on care and management to caregivers after their child's surgical procedure.

Single Visit Evaluation and Tympanostomy Tube Placement for the Treatment of Acute Otitis Media in Children.

OBJECTIVE: To review our experiences with development of a single visit surgery (SVS) program for children with recurrent acute otitis media (AOM) undergoing tympanostomy tube (TT) placement the same day as their otolaryngology surgical consultation. STUDY DESIGN: Retrospective cohort analysis. METHODS: Retrospective series of patients participating in SVS from inception March 1, 2014 to April 30, 2020 were analyzed, with attention to factors associated with increasing interest and participation in SVS and parent experiences/satisfaction. RESULTS: A total of 224 children had TT placed through SVS for AOM management. The average age of patients was 18.1 months (standard deviation 7.8 months), and 130 (58.0%) were male. The median interval between initial contact to schedule SVS, and the SVS date was 15 days (interquartile range 9-23 days). When analyzing year-over-year volumes from inception of SVS, notable increases were seen in 2016 and 2017 after a radio advertisement was played locally. A marked increase in volume was noted after implementation of a Decision Tree Scheduling (DTS) algorithm for children with recurrent AOM. Sixty-six (28.8%) procedures were performed after institution of DTS. A parent survey demonstrated high levels of satisfaction with the SVS experience. Estimations of savings to families in terms of time away from work demonstrated potential for indirect healthcare benefits. CONCLUSIONS: SVS for TT placement was a successful, alternative model of care for management of children with AOM. Marketing strategies regarding SVS, and the inclusion of SVS pathway in DTS platforms increased rates of interest and choice of this option. Parents of children undergoing TT through SVS were satisfied with the overall experience. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2823-2829, 2021.

Outcomes of a Postoperative Data-Extraction Questionnaire After Adenotonsillectomy in Children.

OBJECTIVES/HYPOTHESIS: To evaluate outcomes of a postoperative telephone questionnaire for children who underwent adenotonsillectomy (T&A). To determine whether episodes of postoperative hemorrhage were not captured until the call, and whether this impacted knowledge of physician rates of hemorrhage. STUDY DESIGN: Retrospective database analysis. METHODS: Retrospective analysis of outcomes of an 11-question data extraction tool utilized at a tertiary care children's hospital for follow-up in T&A patients <18 years of age over a 2-year period. Sub-analysis of positive responses to the question asking about incidence of postoperative hemorrhage. RESULTS: During the study period, 1,068/3,142 (34.0%) parents responded to the phone call. Median age was 6.0 years (interquartile range [IQR] 4.0-8.2), and 566 (53.0%) were male. Ninety (8.4%) noted that the child was still snoring, but only 9 (0.84%) reported signs of obstructed breathing. A total of 402 (37.6%) reported a voice change after surgery. Most children (n = 885, 82.9%) did not receive opioid analgesics, and 252 (23.6%) received acetaminophen/ibuprofen 7 days postoperatively. Return visits to the emergency department were reported in 149 patients; primarily for hemorrhage in 46 (30.8%). In 7 (15.2%) patients, the hemorrhage event was not recorded until the call. The majority-of respondents (n = 1,031, 96.5%) were satisfied with the outcome of the procedure. CONCLUSIONS: The postoperative T&A tool provided a means of gathering information on success and satisfaction with surgical outcomes. Children were able to be managed primarily with acetaminophen and ibuprofen. Most complications were captured in the electronic record, although some episodes of hemorrhage were not noted until the call, emphasizing the importance of follow-up. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2821-E2826, 2021.

Back to the Future: Principles on Resuming Outpatient Services in the COVID-19 Era.

The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to outpatient care.

Return to Normalcy? Principles on Resuming Surgical Services in the COVID-19 Era.

The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits and surgical volumes. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. Our institution has had the unique opportunity to already return operations back to full capacity. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to patient care.

Polysomnography variables associated with postoperative respiratory issues in children <3 Years of age undergoing adenotonsillectomy for obstructive sleep apnea.

OBJECTIVES: To determine the polysomnogram (PSG) variables associated with increased incidence of postoperative respiratory complications in children <3 years of age undergoing adenotonsillectomy (T&A) for the management of obstructive sleep apnea (OSA). METHODS: Retrospective case series of children <3 years of age who underwent T&A for the management of OSA at a tertiary care children's hospital from 1/1/08-6/1/2018. Postoperative hospital courses were analyzed to determine if certain clinical or PSG variables might have predicted an increased rate of respiratory complications. RESULTS: A total of 195 children <3 years of age with OSA on preoperative PSGs underwent T&A. The mean age of patients was 25.8 months (range 9-35 months). Seventeen patients (16.2%) had mild OSA, 35 (17.9%) had moderate, and 141 (72.3%) had severe OSA. Most patients (n = 155, 79.5%) required no respiratory intervention postoperatively. Those with severe OSA were more likely to require oxygen support (n = 25, 17.7%) when compared to those with mild-moderate OSA (n = 3, 5.6%). Patients admitted directly to the pediatric intensive care unit (PICU) from the sleep lab (n = 7) had a mean apnea-hypopnea index (AHI) of 63.6 events/hour (range 23-146/hr.), and a mean SpO2 nadir of 56.3% (range 46-68%). Four of these patients required CPAP after T&A. Of the 7 patients (3.6%) who required intubation after their procedure, only 1 did not have severe OSA, and 2 were intubated to manage post-obstructive pulmonary edema (POPE). Only 4 patients (4.2%) had unplanned PICU admissions. An AHI >12.7 events/hour, >18.5 obstructive apneas, and SpO2 nadir <72.5% were associated with a greater likelihood of requiring postoperative respiratory interventions. CONCLUSIONS: Most children <3 years of age, even with severe OSA, had no respiratory issues postoperatively. Those with severe OSA and hypoxemia admitted directly from the sleep lab were more likely to require CPAP postoperatively. All but one patient who developed POPE or who required intubation had severe OSA with associated hypoxemia on their preoperative PSGs.

Evolving Management of COVID-19: A Multi-institutional Otolaryngology Perspective.

OBJECTIVE: To provide evolving information on active protocols regarding inpatient, outpatient, procedural, and surgical case management taking place in otolaryngology practices in response to COVID-19. STUDY TYPE: Cross-sectional multi-institutional survey. METHODS: An online survey of 55 otolaryngology departments across North America. RESULTS: As of March 25, 2020, almost all (n = 53 of 55, 96.3%) otolaryngology departments had canceled elective cases and were performing only urgent consults. Most residents continued to participate in operative cases (n = 45 of 49, 91.8%) and take call (n = 48 of 50, 96.0%). Of the respondents, 27 of 29 (93.1%) stated that they were deferring nonemergent tracheostomy procedures for the time being. The use of personal protective equipment followed a general trend of an increasing level of protection with an increased risk of the procedure; most (n = 49 of 54, 90.7%) incorporated N95 mask usage for bedside/clinic examinations with flexible laryngoscopy. Powered air-purifying respirators and N95 masks were used mainly for procedures involving the mucosal surfaces. DISCUSSION: Due to the high viral density in the nasal cavity and nasopharynx of patients with COVID-19, basic examinations and common otolaryngology procedures place practitioners at high risk of exposure. Although there is variability in practice among otolaryngologists across North America in managing the COVID-19 outbreak, most are primarily seeing urgent ambulatory and inpatient consultations. Most are also incorporating personal protective equipment appropriate to the level of transmission across mucous membranes. IMPLICATIONS FOR PRACTICE: In these rapidly evolving times, it is helpful to find solidarity and assurance among health care providers. Current data aimed to provide (1) perceived methods regarding the safe care of otolaryngology patients and (2) updated practice patterns at a national level.

Patient factors associated with NPO violations in a tertiary care pediatric otolaryngology practice.

OBJECTIVES: To determine demographic and patient variables associated with nothing by mouth (NPO) violations prior to surgery in a tertiary care pediatric hospital. METHODS: A retrospective study of patients <18 years of age undergoing elective surgery at a tertiary care children's hospital from 1/1/16 to 4/30/19 who violated their NPO guidelines was performed. Variables associated with a higher rate of NPO violations were analyzed among the different surgical sub-specialties. Additional analyses were performed comparing those with NPO violations to the total group of patients undergoing surgery in the study period. RESULTS: Of the 42 495 children who underwent elective surgical procedures in the study period, 625 (1.5%) committed NPO violations. The median age for those committing a violation was 3 years, and the majority (n = 421, 67.4%) were between 0 and 6 years of age. Otolaryngology patients committing NPO violations had a longer time between scheduling surgery and operative date than other surgical services (P < .0001), but a similar time as the urology service. Otolaryngology patients had the highest number of NPO violations (n = 245, 39.2%) compared to the other surgical services, despite doing 32.4% of the total surgical cases (P < .001). Children from Spanish-speaking homes accounted for 137 (21.9%) NPO violations, despite accounting for only 11.2% of total surgeries performed. Patients with Medicaid insurance (n = 438, 63.0%) had a higher rate of NPO violations, despite making up 43.6% of total patients. CONCLUSIONS: NPO violations occurred in 1.5% of patients during the study period, particularly among the youngest age range of the children analyzed, and they were most prevalent in the otolaryngology patients. Spanish speaking families, and those with Medicaid insurance had higher rates of NPO violations despite making up a smaller percentage of those being operated on overall. This highlighted the need for improvement in communication of fasting guidelines to caregivers. LEVEL OF EVIDENCE: 3.

Telemedicine During the COVID-19 Pandemic: A Pediatric Otolaryngology Perspective.

The COVID-19 pandemic has created a situation unparalleled in our lifetime. As the medical community has attempted to navigate a sea of ever-changing information and policies, this uncertainty has instead bred creativity, community, and evolution. Necessity is the mother of invention, and one of the by-products of our rapidly changing environment is the increased reliance on telemedicine. Here, we discuss our experience with incorporating telemedicine into an urban academic pediatric otolaryngology practice, the challenges that we have encountered, and the principles unique to this population.

Polysomnography Outcomes after Supraglottoplasty in Children with Obstructive Sleep Apnea.

OBJECTIVE: Laryngomalacia has been reported to contribute to the severity of obstructive sleep apnea (OSA) in children. It is unclear if surgical treatment of laryngomalacia improves polysomnography (PSG) outcomes in these patients. The objective of this study is to report the impact of supraglottoplasty on PSG parameters in children with laryngomalacia-related OSA. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: Historical cohort study of consecutive children with laryngomalacia who underwent supraglottoplasty and who had undergone overnight PSG before and after surgery. RESULTS: Forty-one patients were included in the final analysis: 22 (53.6%) were male, and 19 (46.3%) were female. The mean ± SEM age of patients at preoperative PSG was 1.3 ± 0.89 years (range, 0.003-2.9). In entire cohort, the mean obstructive apnea-hypopnea index score was reduced from 26.6 events/h before supraglottoplasty to 7.3 events/h after surgery (P = .003). Respiratory disturbance index was reduced from 27.3 events/h before supraglottoplasty to 7.8 events/h after surgery (P = .003). The percentage of REM sleep decreased from 30.1% ± 2.4 to 24.8% ± 1.3 (P = .04). Sleep efficiency was improved (P = .05). CONCLUSION: Overall, supraglottoplasty significantly improved several PSG outcomes in children with laryngomalacia. However, mild to moderate OSA was still present postoperatively in most children. This suggested a multifactorial cause for OSA in this population.

Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients.

OBJECTIVE: Identify demographic variables related to emergency department (ED) returns, and analgesic administration in the ED for postoperative pain after adenotonsillectomy (T&A). STUDY DESIGN: Pediatric Health Information System (PHIS) database analysis. METHODS: Forty-seven children's hospitals included in the PHIS database were queried for all ED visits within 30 days of surgery with a diagnosis of acute postoperative pain (n = 2459) from 2014 to 2015. The subset of postoperative T&A patients (n = 861) was further analyzed for variables associated with return, and for pain management strategies, specifically opioids, employed by the ED. RESULTS: Of the 2459 pediatric patients returning to the ED for acute postoperative pain, the largest subset included T&A patients (n = 861, 35%). Patients were seen an average of 4 days (SD 2.4) after their surgery. ED administration of opioids was not associated with gender, race, surgical diagnosis, or ethnicity. The rate of opioid administration by the ED increased with advancing age of the children analyzed (P = .01). The incidence was also higher for those with commercial versus Medicaid insurance carriers. A total of 204 (23.7%) patients received opioids while in the ED, 439 (51%) received both opioids and non-opioids, and only 51 (5.9%) received no pain medication. CONCLUSION: T&A patients make up the largest subset of patients returning to the ED for postoperative pain. A total of 74.7% of patients receive opioids, either alone or in combination with non-opioids, on return to the ED. ED opioid administration was associated with older age of the child and payer, but not with gender, race, surgical diagnosis, or ethnicity. LEVEL OF EVIDENCE: 4.