Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

Bridging the gap: Using 3D printed polycaprolactone implants to reconstruct circumferential tracheal defects in rabbits.

OBJECTIVE: 1) To assess the feasibility of reconstructing 2-cm-long circumferential tracheal defects with a 3D printed polycaprolactone (PCL) implant in rabbits. 2) To evaluate endoscopic, histologic, and functional characteristics of a PCL tracheal implant over time. METHODS: Ten New Zealand rabbits were included in this study. A 2-cm-long 3D printed PCL tracheal implant was created. All rabbits underwent surgical excision of a 2-cm-long cm segment of cervical trachea, which was reconstructed with the implant. Rabbits were sacrificed at the following time points: 0, 4, 5, 6, and 7 weeks postoperatively. At these time points, a rigid bronchoscopy was performed, and blinded evaluators calculated the percentage of airway stenosis. The tracheas were then harvested and prepared for histologic analysis. RESULTS: All rabbits survived to their date of sacrifice except for one. Rabbits were euthanized between 0 to 54 days postoperatively with a median of 30 days. All rabbits developed significant granulation tissue with an average percentage stenosis of 92.3% ± 6.1%. On histology, granulation was present with extensive neovascularization and mixed inflammatory cells. There was re-epithelialization present on the luminal surface of the PCL implant near the anastomoses but absent at the center of the implant. CONCLUSION: This study demonstrates that our 2-cm-long 3D printed PCL tracheal implant can be used to reconstruct a tracheal defect of equivalent size in a New Zealand rabbit model in the short term. However, significant granulation tissue formation limits long-term survival. Further research is warranted to limit the granulation tissue overgrowth. LEVEL OF EVIDENCE: NA Laryngoscope, 2019.

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric tracheotomy. STUDY DESIGN: Blinded, modified, Delphi consensus process. METHODS: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items. RESULTS: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus. CONCLUSIONS: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:2700-2707, 2020.

Rhinologic manifestations of Burkitt Lymphoma in a pediatric population: Case series and systematic review.

INTRODUCTION: Burkitt lymphoma (BL), an aggressive form of B-cell non-Hodgkin's lymphoma, arising from the nose and paranasal sinuses is relatively rare. It can present with various symptoms leading to potential misdiagnosis and delayed treatment. BL is fatal if left untreated, while early identification and treatment can improve prognosis. OBJECTIVES: 1) To review clinical presentations and sites of involvement of six cases of pediatric BL with rhinologic manifestations and compare these with the current literature. 2) To raise awareness on the variety of presentations of BL in this particular anatomic location. METHODS: A series of six cases of pediatric (0-18 years) BL with rhinologic manifestations is presented. Age, sex, ethnicity, symptoms, imaging, staging, treatment and outcome were recorded. A systematic review of literature was also conducted using PRISMA guidelines. The search strategy used keywords related to rhinologic manifestations of BL (nasal cavity, nasopharynx, paranasal sinus etc.; Burkitt etc.) and included studies published in English and French describing patients 0-18 years of age. RESULTS: 42 patients were included (six from case series and 36 from current literature). Most common presenting symptoms were: nasal obstruction (29%), facial swelling (24%), headache (21%) and proptosis (19%). Most frequent sites of presentation were: nasopharynx (40%), maxilla (40%) and sphenoid (33%). More than half (60%) had systemic involvement, of which the most common locations were: kidney (19%), pancreas (17%) and liver (17%). Mortality from BL in children from this study population was correlated with a longer duration of symptoms prior to presentation, as well as a misdiagnosis preceding the final diagnosis of BL. CONCLUSIONS: This study brings understanding to the numerous presentations of the same aggressive disease, promotes high clinical suspicion when evaluating common otolaryngologic symptoms and can guide healthcare providers in diagnosing pediatric BL with rhinologic manifestations.

Concha bullosa mucocele: A case series and review of the literature.

BACKGROUND: Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinges on surrounding structures and can easily be mistaken for a neoplasm. OBJECTIVE: The objective of this study was to shed light on this rare entity and report its diagnostic features and treatment outcomes. METHODS: A case series conducted in a tertiary health care center. Demographic data, clinical presentation, imaging, cultures, and treatments were recorded. Operative video illustration and key images were obtained. A review of the literature was also performed. RESULTS: A total of five cases were reviewed, four of which were concha bullosa mucoceles and one was a mucopyocele. Three of the patients had some form of previous nasal trauma. Headache and nasal obstruction were the most common symptoms with a nasal mass finding on physical examination. Computed tomography was used in all the patients, and magnetic resonance imaging was used in four of the five patients. Four patients had coexistent chronic rhinosinusitis, and three had positive bacterial cultures. All these patients were treated endoscopically either with middle turbinate marsupialization or subtotal resection. No recurrence has been noted thus far. CONCLUSION: Concha bullosa mucocele is a rare diagnosis. Imaging characteristics are helpful in considering the diagnosis, although surgical intervention is often necessary to confirm the diagnosis and treat concha bullosa mucocele.

Role of toll-like receptor 4 in protection by bacterial lipopolysaccharide in the nasal mucosa of atopic children but not adults.

BACKGROUND: Exposure to bacterial products in early life could protect against development of atopy. We examined the effect of bacterial lipopolysaccharide on allergic inflammation and expression of cytokines and lipopolysaccharide receptor (toll-like receptor 4 TLR4) in nasal mucosa of 15 atopic children and ten atopic adults. METHODS: Explanted mucosa was cultured with allergen with or without lipopolysaccharide (0.1 mg/L) for 24 h. Immunocytochemistry and in-situ hybridisation were used to phenotype the cells and cytokines. FINDINGS: In explants from atopic children, lipopolysaccharide prevented allergen-induced T-helper type 2 (Th2) inflammation and upregulated Th1 cytokine reactivity and expression. These effects were blocked by antibody to interleukin 10. In children but not in adults, lipopolysaccharide caused increases of three times in T-cell reactivity, five times in T-cell proliferation, and four times in expression of interleukin 10 compared with mucosa stimulated with allergen alone. This difference in response was mirrored by lipopolysaccharide-induced increases in TLR4 reactivity in children but not adults. TLR4 receptor was expressed by CD3-positive T cells, and TLR4-positive cells contained interleukin 10. Lipopolysaccharide increased expression of cells positive for both CD3 and TLR4; both TLR4 and interleukin 10; and both CD4 and CD25. INTERPRETATION: Lipopolysaccharide inhibits allergic inflammation in nasal mucosa of atopic children by skewing local immune responses from Th2 to Th1 and upregulating production of interleukin 10. These effects are mediated by TLR4. Our results emphasise an important difference between adults and children in their ability to respond to bacterial products. These differences could have a role in normal maturation of the immune system.

Congenital intra-oral adhesions: a surgical approach to cleft palate lateral synechia syndrome.

An array of genetic syndromes has been associated with intra-oral adhesions in neonates. The primary medical issues arise from airway obstruction, feeding difficulties and poor oral development, specifically with cleft palate lateral synechia syndrome (CPLSS). Despite this, a paucity of data exists for the clinical management of intra-oral adhesions in this population. We report the cases of a father and daughter diagnosed with CPLSS who presented with respiratory and feeding difficulties at birth undergoing surgical correction. Early surgical ligation of intra-oral bands allows for a stabilization of the airway, improved feeding and oral development with a good long-term outcome.

Lund-Mackay and modified Lund-Mackay score for sinus surgery in children with cystic fibrosis.

OBJECTIVE: Patients with cystic fibrosis (CF) frequently present with severe sinonasal disease often requiring radiologic imaging and surgical intervention. Few studies have focused on the relationship between radiologic scoring systems and the need for sinus surgery in this population. The objective of this study is to evaluate the Lund-Mackay (LM) and modified Lund-Mackay (m-LM) scoring systems in predicting the need for sinus surgery or revision surgery in patients with CF. METHODS: We performed a retrospective chart review of CF patients undergoing computed tomography (CT) sinus imaging at a tertiary care pediatric hospital from 1995 to 2008. Patient scans were scored using both the LM and m-LM systems and compared to the rate of sinus surgery or revision surgery. Receiver-operator characteristics curves (ROC) were used to analyze the radiological scoring systems. RESULTS: A total of 41 children with CF were included in the study. The mean LM score for patients undergoing surgery was 17.3 (±3.1) compared to 11.5 (±6.2) for those treated medically (p<0.01). For the m-LM, the mean score of patients undergoing surgery was 20.3 (±3.5) and 13.5 (±7.3) for those medically treated (p<0.01). Using a ROC curve with a threshold score of 13 for the LM, the sensitivity was 89.3% (95% CI of 72-98) and specificity of 69.2% (95% CI of 39-91). At an optimal score of 19, the m-LM system produced a sensitivity of 67.7% (95% CI of 48-84) and specificity of 84.6% (95% CI of 55-98). CONCLUSION: The modified Lund-Mackay score provides a high specificity while the Lund-Mackay score a high sensitivity for CF patients who required sinus surgery. The combination of both radiologic scoring systems can potentially predict the need for surgery in this population.

Transnasal endoscopic medial maxillectomy for inverting papilloma.

OBJECTIVE: To describe the new technique of transnasal endoscopic medial maxillectomy. STUDY DESIGN: Study design included application of the new technique in the management of five patients with inverting papilloma; retrospective review of five patients who had lateral rhinotomy with medial maxillectomy for inverting papilloma; comparison of transnasal endoscopic medial maxillectomy to open medial maxillectomy for scope of resection, margin control, operative time, and surgical access; and detailed description of transnasal endoscopic medial maxillectomy. METHODS: Charts were reviewed and tabulated for operative time, duration of follow-up, and recurrence. Pathology reports were reviewed for number and orientation of the specimens and for margin control. RESULTS: Operative time was shorter for patients managed with transnasal endoscopic medial maxillectomy. All patients with transnasal endoscopic medial maxillectomy had one large, well-oriented specimen with margin control. There was no recurrence in either group. CONCLUSIONS: Transnasal endoscopic medial maxillectomy providing full access to the maxillary and ethmoid sinuses is described in detail. Transnasal endoscopic medial maxillectomy is an effective, reproducible technique with less operative time and morbidity and, possibly, better pathological tumor mapping than open medial maxillectomy for selected patients. Maxillary sinus involvement with inverting papilloma is not a contraindication for this technique. Strong illumination, superior resolution, and angled visualization, coupled with exact osteotomies, make transnasal endoscopic medial maxillectomy an efficacious technique for inverting papilloma with extension limited to the maxillary and ethmoid sinuses.

Adenoidectomy: selection criteria for surgical cases of otitis media.

OBJECTIVE: Nasopharyngeal adenoids may serve as a mechanical obstruction to the eustachian tube and contribute to the pathophysiology of otitis media (OM). The purpose of this study was to determine whether abutment of adenoids laterally against the torus tubaris affects the outcome of patients requiring pressure equalization tubes (PET) for OM. STUDY DESIGN: Randomized, controlled, prospective clinical trial. METHOD: Patients requiring PET for recurrent acute OM or OM with persistent effusion were randomized into two groups: 1) PET placement and 2) PET placement and adenoidectomy, regardless of whether the adenoids were abutting or not abutting the torus tubaris. Patients were followed for a minimum of 1 year to determine rate of treatment failure, defined as recurrence of acute OM (>3 times/year), OM with effusion, or reinsertion of PET. RESULTS: Of the 34 patients in the abutting group, 16 patients underwent only PET insertion, of whom 8 (50%) failed, whereas 18 patients had combined PET placement and adenoidectomy, of whom 3 (17%) failed. There was a statistical difference between these two groups (P < 05). Of the 29 patients in the nonabutting group, 24 patients underwent only PET insertion, of whom 9 (37.5%) failed, whereas 5 patients underwent combined PET placement and adenoidectomy, of whom 2 (40%) failed. There was no statistical difference between these two groups (P =.92). CONCLUSION: This study demonstrates that the position of hypertrophied adenoids may alter the final otologic outcome of patients requiring PET insertion for OM. Patients with adenoids abutting the torus tubaris may benefit most from an adjuvant adenoidectomy.

Inflammation and remodeling of the sinus mucosa in children and adults with chronic sinusitis.

OBJECTIVES/HYPOTHESIS: The sinus mucosal inflammatory response in adult patients with chronic sinusitis is well documented in the literature. In contrast, little is known about the pathogenesis of this condition in children. The objective of the study was to compare the inflammatory cell profile and the extent of tissue remodeling in the sinus mucosa of children and adults with chronic sinusitis. STUDY DESIGN: Prospective design. METHODS: Children (n = 7) and adult patients (n = 7) with chronic sinusitis undergoing functional endoscopic sinus surgery were recruited for the study. Patients with no evidence of sinus disease (n = 6) were used as control subjects. Using immunohistochemical analysis, sinus mucosal specimens were assessed for the presence of T lymphocytes, eosinophils, basophils, mast cells, and neutrophils. The extent of submucosal collagen deposition was evaluated in histological sections using van Gieson stain. RESULTS: The number of T lymphocytes, eosinophils, and basophils and the amount of subepithelial collagen deposition are significantly higher in the mucosa of both adults and children with chronic sinusitis compared with normal control subjects (P <.01). The number of mast cells is significantly higher in the mucosa of children with chronic sinusitis compared with normal control subjects (P <.01). The number of eosinophils and neutrophils and the amount of subepithelial collagen deposition are significantly greater in adults compared with children with chronic sinusitis (P <.01). CONCLUSIONS: The sinus mucosal inflammatory profile is similar in adults and children with chronic sinusitis. However, the degree of tissue eosinophilia and remodeling is significantly greater in adult sinus specimens when compared with those of children with chronic sinusitis.

Increased expression of interleukin-9, interleukin-9 receptor, and the calcium-activated chloride channel hCLCA1 in the upper airways of patients with cystic fibrosis.

OBJECTIVES/HYPOTHESIS: Mucus overproduction is commonly found in airway disease in patients with cystic fibrosis. Interleukin-9 (IL-9) has been shown to mediate airway hyper-responsiveness and mucus overproduction. Recently, the calcium-activated chloride channel hCLCA1 has been described to be upregulated by IL-9 and has been thought to regulate the expression of soluble gel-forming mucins. We sought to examine the expression of IL-9, interleukin-9 receptor (IL-9R), and hCLCA1 in the upper airway of patients with cystic fibrosis in comparison to healthy control subjects and to demonstrate the relationship of IL-9, IL-9R, and hCLCA1 expression with mucus production. STUDY DESIGN: Prospective design. METHODS: Biopsy samples from nasal polyps of four patients with cystic fibrosis, nasal mucosa of six patients with cystic fibrosis, sinus mucosa of eight patients with cystic fibrosis, and nasal mucosa of six healthy control subjects were stained with periodic acid-Schiff (PAS) to identify mucus glycoconjugates. IL-9, IL-9R, and hCLCA1 expression was determined by immunocytochemical study. RESULTS: We demonstrated significant increases in IL-9, IL-9R, and hCLCA1 immunoreactivity in the mucosa of patients with cystic fibrosis compared with that found in control subjects (P <.05). There were no significant differences between the different locations (nasal polyps, nasal mucosa, and sinus mucosa) in the patient group (P >.05). We also observed a significant increase in the number of mucus-producing cells in biopsy specimens from patients with cystic fibrosis in comparison to control subjects. A positive correlation was found between hCLCA1-positive cells and IL-9-positive cells (correlation coefficient [r] = 0.79, P <.05) or IL-9R-positive cells (r = 0.92, P <.05). Moreover, a positive correlation was also present between PAS-positive (mucus-producing) cells and hCLCA1-positive cells (r = 0.64, P <.05) or IL-9R-positive cells (r = 0.64, P <.05). CONCLUSIONS: Increased expression of IL-9 and IL-9R, as well as upregulation of hCLCA1, in mucus-overproducing epithelium of patients with cystic fibrosis supports the hypothesis that IL-9 contributes to mucus overproduction in cystic fibrosis. Expression of hCLCA1 may also be responsible, in part, for the overproduction of mucus. These preliminary findings suggest that hCLCA1 might be an interesting new therapeutic target to control mucus overproduction in airway disease in patients with cystic fibrosis.

Computer-assisted voice analysis: establishing a pediatric database.

OBJECTIVES: To establish and characterize the first pediatric normative database for the Multi-Dimensional Voice Program, a computerized voice analysis system, and to compare the normative data with the vocal profiles of patients with vocal fold nodules. DESIGN: A cross-sectional, observational design was used to establish the normative database. The comparative study was completed using a case-control design. SETTING: University-based outpatient pediatric otolaryngology clinic. PARTICIPANTS: One hundred control subjects (50 boys and 50 girls) aged 4 to 18 years contributed to the normative database. The voices of 26 patients (19 boys and 7 girls) with bilateral vocal fold nodules were also analyzed. MAIN OUTCOME MEASURES: Demographic data, including sex, age, height, weight, body mass index, and cigarette smoke exposure, were obtained. The Multi-Dimensional Voice Program extracted up to 33 acoustic variables from each voice analysis. RESULTS: The mean (SEM) values of each of the acoustic variables are presented. At age 12 years, boys experience a dramatic decrease in fundamental frequency measurements. The voices of patients with vocal fold nodules had significantly elevated frequency perturbation measurements compared with control subjects (P<.001). CONCLUSIONS: The vocal profile of children is uniform across all girls and prepubescent boys. Patients with vocal fold nodules demonstrated a consistent acoustic profile characterized by an elevation in frequency perturbation measurements. Normal acoustic reference ranges may be used to detect various vocal fold pathologic abnormalities and to monitor the effects of voice therapy.

Cytokine profile of chronic sinusitis in patients with cystic fibrosis.

BACKGROUND: The inflammatory-cell and cytokine profiles of chronic sinusitis (CS) are well documented in the literature. In contrast, little is known about the pathogenesis of this condition in patients with cystic fibrosis (CF). OBJECTIVE: To determine whether patients with CF have inflammatory-cell and cytokine profiles that differ from other patients with CS. METHODS: Patients with CF (n = 7) and adults with CS (n = 7) undergoing functional endoscopic sinus surgery were recruited for the study. Patients with no allergies or sinus disease (n = 6) were used as controls. Using immunohistochemical analysis, we assessed sinus mucosal specimens for the presence of T lymphocytes, eosinophils, macrophages, and neutrophils. Using in situ hybridization, we assessed the expression of interleukin (IL) 4, IL-5, IL-8, IL-10, and interferon gamma. RESULTS: There was a higher number of neutrophils, macrophages, and cells expressing messenger RNA for interferon gamma and IL-8 in patients with CF than in patients with CS or in controls (P<.01). The number of eosinophils and cells expressing messenger RNA for IL-4, IL-5, and IL-10 was higher in patients with CS than in those with CF and controls (P<.01). CONCLUSIONS: Sinus disease in patients with CF presents different inflammatory-cell and cytokine profiles than that seen in other patients with CS. These results may explain the difference in response to treatment in the CF group.

Intraoral drainage: recommended as the initial approach for the treatment of parapharyngeal abscesses.

OBJECTIVE: We sought to compare the efficacy, safety, and cost of intraoral drainage (IOD) of parapharyngeal abscesses (PPAs) in the pediatric population with those of the more commonly used external neck drainage (END). PATIENTS AND STUDY DESIGN AND SETTING: An 11-year retrospective review was conducted of all patients admitted to a tertiary-care, university-affiliated, pediatric hospital with a diagnosis of PPA. Patients were divided into 2 groups according to the treatment received (IOD or END) and were followed to 1 month postoperatively. All children referred to our institution with a final diagnosis of PPA were included in the study. OUTCOME: Outcome measures were duration of anesthesia, duration of postoperative intravenous antibiotics (DPOIA), length of postoperative hospital stay (LPOHS), and occurrence of complications. RESULTS: Fifteen patients underwent IOD, and 10 patients, END. IOD shortened anesthesia time by 31.7 minutes compared with END (P = 0.0003). IOD was associated with a decrease in DPOIA and LPOHS by 1.1 days (P = 0.1931) and 1.6 days (P = 0.0649), respectively. The cost of treatment was thereby reduced. No complications were encountered in either group. CONCLUSIONS: IOD is a safe and effective treatment for PPA in the pediatric population. It leads to decreased morbidity, shortened anesthesia time, and reduced economic burden.

Extensive tongue hemangiopericytoma in a child: modified combined modality of treatment to preserve well functioning tongue.

Hemangiopericytoma is a rare vascular tumor, usually occurring in adults. The tumor is believed to originate from pericytes, the contractile cells surrounding capillaries. It has predilection for the musculoskeletal system. Clinically, the tumor occurs at any age, with highest incidence between the third and sixth decades and without any sex predilection. Head and neck hemangiopericytoma incidence in all age groups ranges from 9.4 to 28%. In children, head and neck hemangiopericytoma is as frequent as 35%, with the highest frequency (46%) found in infants. We report a case of hemangiopericytoma of the tongue in a 6-year-old child resembling to the infantile/congenital type, which was treated by a combination of surgery, chemotherapy, and brachytherapy. This approach has resulted in a normal functioning tongue for the past 5 years.

Granular cell tumor of the trachea in a child.

Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly the tongue. They have, however, been described in all areas of the body. Their presentation in the trachea is exceedingly rare, with their presence in the pediatric trachea being an even rarer occurrence. We describe a case of a granular cell tumor of the trachea in a 10-year-old boy with a dramatic, almost lethal, presentation. This is followed by a review of the literature, including pathology and treatment options.

Incomplete tracheal duplication associated with severe unilateral lung hypoplasia.

A rare case of incomplete tracheal duplication with severe unilateral lung hypoplasia is presented. Photo-documentation of the gross post-mortem specimens is presented so that the anatomical aspects of this unusual anomaly can be recognized and appreciated. Clinical information is presented in the hope that successful premorbid identification of potential complications of this anomaly could be made by future physicians. To our knowledge, this is the first reported case of pathologically-confirmed duplication of the trachea.

Synchronous airway lesions in children: an analysis of characteristics and comorbidities.

OBJECTIVES: To analyze the characteristics and the associated medical co-morbidities in children with synchronous airway lesions (SALs) found during rigid bronchoscopy. METHODS: Retrospective case series and chart review of patients who were found to have more than one airway lesion after undergoing airway evaluation via rigid endoscopy at a tertiary care pediatric hospital between 2001 and 2011. Patient demographics, presence of associated non-airway pathologies, and the number and types of airway lesions were collected. For analysis, airway lesions were classified based on the anatomical subsites involved (supraglottic, glottic, subglottic, tracheal and bronchial). RESULTS: Out of 592 rigid bronchoscopies performed, there were 73 cases with SALs (12.3%). Of these, only 20% of patients were term infants without associated congenital anomalies. Over 70% of patients with SALs have combinations of lesions involving the trachea, subglottis and supraglottis. Neurological anomalies and GERD were both independently associated with a three-time increase in the odds of having synchronous involvement of these three anatomical subsites (OR 3.15, 95% CI 1.06-9.41; OR 3.0, 95% CI 1.05-8.50, respectively). Glottic lesions were present in 28.7% of patients. Prematurity and cardiac anomalies were both associated with tendency of doubling the odds of glottic lesions (OR 2.34, 95% CI 0.84-6.52; OR 2.0, 95% CI 0.76-5.60, respectively). Overall, almost 10% of newly diagnosed lesions in context of SALs required an additional intervention. CONCLUSIONS: The majority of patients with SALs are either born prematurely or have associated congenital anomalies. In SAL patients with associated neurological anomalies or GERD, the lesions are more likely to be localized to the supraglottis, subglottis and trachea whereas prematurity and cardiac anomalies could both be increasing the odds of a glottic lesion. High suspicious index should be kept in mind when rigid bronchoscopy is performed to not miss an associated lesion.

Testing for pediatric obstructive sleep apnea when health care resources are rationed.

IMPORTANCE: Evaluation of pediatric obstructive sleep apnea in resource-limited health care systems necessitates testing modalities that are accurate and more cost-effective than polysomnography. OBJECTIVE: To trace the clinical pathway of children referred to our sleep laboratory for possible obstructive sleep apnea who were evaluated using nocturnal pulse oximetry and the McGill Oximetry Score. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of children 2 to 17 years old with suspected obstructive sleep apnea due to adenotonsillar hypertrophy, conducted at a Canadian pediatric tertiary care center. INTERVENTIONS: Nocturnal pulse oximetry studies scored using the McGill Oximetry Score. MAIN OUTCOMES AND MEASURES: For children who underwent adenotonsillectomy we determined the length of time from oximetry to surgery, postoperative length of stay, postoperative readmissions, and emergency department visits in the month following surgery and major surgical complications. We analyzed these outcomes by oximetry result. We compared the cost savings of our diagnostic approach with those of other diagnostic models. RESULTS: Among 362 children, the median age was 4.8 years (interquartile range, 3.3-6.7), and 61% were male. Two-hundred-sixty-six (73%) and 96 (27%), respectively, had inconclusive and abnormal oximetry results. Eighty of 96 of children with abnormal oximetry results (83%) and 81 of 266 children with inconclusive oximetry results (30%) underwent adenotonsillectomy. Thirty-three of 266 children (12%) underwent further evaluation with polysomnography; of 14 diagnosed as having OSA, 12 underwent adenotonsillectomy. Children with abnormal oximetry results were operated on soonest after testing and triaged based on oximetry results. No child with an inconclusive oximetry result required hospitalization for more than 1 night postoperatively; 14% of children (11 of 80) with an abnormal oximetry result required hospitalization for 2 or 3 nights (χ2 = 12.0; P = .001). Rates of readmissions and emergency department visits were low, irrespective of oximetry results (whether inconclusive or abnormal). We show that our oximetry-based diagnostic approach results in considerable cost savings compared with a polysomnography-for-all approach. CONCLUSIONS AND RELEVANCE: Oximetry studies evaluated with the McGill Oximetry Score expedite diagnosis and treatment of children with adenotonsillar hypertrophy referred for suspected sleep-disordered breathing. When resources for testing for sleep-disordered breathing are rationed or severely limited, our proposed diagnostic approach can help maximize cost-savings and allows sleep laboratories to focus resources on medically complex children requiring polysomnographic evaluation of suspected sleep disorders.