Predictive Value of Laryngeal Penetration to Aspiration in a Cohort of Pediatric Patients.

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6 month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions.

Compensatory laryngeal function and airway protection in children following airway reconstruction.

OBJECTIVES: Laryngotracheal reconstruction (LTR) procedures for repair of complex congenital or acquired airway stenosis of the larynx and/or trachea in pediatric patients have advanced over recent decades. The aim of the present project was to investigate the relationships among diagnoses, type of surgical intervention, and laryngeal findings in a post-LTR patient cohort to identify factors associated with adequate airway protection and swallowing outcomes. METHODS: A retrospective review of 30 airway patients undergoing simultaneous or close interval functional laryngeal and swallowing examinations was completed. Analyses of the data were performed to examine factors associated with postoperative airway protection and swallowing function. The patient cohort was separated into 2 groups according to the adequacy of their airway protection (aspiration and no aspiration) as judged by clinicians via instrumental examination. RESULTS: Data analyses revealed statistically significant differences between the 2 groups for 3 key parameters: laryngeal closure, laryngeal closure timeliness (relative to bolus flow), and overall swallowing coordination. CONCLUSIONS: These findings contribute to the knowledge of laryngeal closure patterns present in patients undergoing airway reconstruction and the effect on the essential laryngeal function of airway protection during swallowing. Implications of the data for swallowing function in this population are discussed.

Evaluating the biomechanical characteristics of cuffed-tracheostomy tubes using finite element analysis.

The objective of this study was to perform finite element analysis (FEA) of cuff inflation within an anatomically accurate model of an adult trachea in four different cuffed-tracheostomy tube designs. The leakage quantified by the distance between the cuff and trachea was largest for the Tracoe cuff and smallest for the Portex cuff. The smooth muscle stresses were greatest for the Portex and least for the Distal cuff, respectively. The proposed FEA model offers a promising approach to virtually evaluate the sealing efficacy of cuffed-tracheostomy tubes and the tracheal wall stresses induced by cuff inflation, prior to application.

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.

Real-time assessment of perioperative behaviors in children and parents: development and validation of the perioperative adult child behavioral interaction scale.

BACKGROUND: Behavior in response to distressful events during outpatient pediatric surgery can contribute to postoperative maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, and attention seeking. Currently available perioperative behavioral assessment tools have limited utility in guiding interventions to ameliorate maladaptive behaviors because they cannot be used in real time, are only intended to be used during 1 phase of the experience (e.g., perioperative), or provide only a static assessment of the child (e.g., level of anxiety). A simple, reliable, real-time tool is needed to appropriately identify children and parents whose behaviors in response to distressful events at any point in the perioperative continuum could benefit from timely behavioral intervention. Our specific aims were to (1) refine the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to improve its reliability in identifying perioperative behaviors and (2) validate the refined PACBIS against several established instruments. METHODS: The PACBIS was used to assess the perioperative behaviors of 89 children aged 3 to 12 years presenting for adenotonsillectomy and their parents. Assessments using the PACBIS were made during perioperative events likely to prove distressing to children and/or parents (perioperative measurement of blood pressure, induction of anesthesia, and removal of the IV catheter before discharge). Static measurements of perioperative anxiety and behavioral compliance during anesthetic induction were made using the modified Yale Preoperative Anxiety Scale and the Induction Compliance Checklist (ICC). Each event was videotaped for later scoring using the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) and Observational Scale of Behavioral Distress (OSBD). Interrater reliability using linear weighted kappa (kappa(w)) and multiple validations using Spearman correlation coefficients were analyzed. RESULTS: The PACBIS demonstrated good to excellent interrater reliability, with kappa(w) ranging from 0.62 to 0.94. The Child Coping and Child Distress subscores of the PACBIS demonstrated strong concurrent correlations with the modified Yale Preoperative Anxiety Scale, ICC, CAMPIS-SF, and OSBD. The Parent Positive subscore of the PACBIS correlated strongly with the CAMPIS-SF and OSBD, whereas the Parent Negative subscore showed significant correlation with the ICC. The PACBIS has strong construct and predictive validities. CONCLUSIONS: The PACBIS is a simple, easy to use, real-time instrument to evaluate perioperative behaviors of both children and parents. It has good to excellent interrater reliability and strong concurrent validity against currently accepted scales. The PACBIS offers a means to identify maladaptive child or parental behaviors in real time, making it possible to intervene to modify such behaviors in a timely fashion.

The use of videos in preparation for pediatric otolaryngology cases-a national survey.

OBJECTIVE: 1) Review surgical preparation methods for pediatric otolaryngology fellows and fellowship directors, focusing on surgical video usage. STUDY DESIGN: Cross sectional survey. METHODS: Structured survey querying preparation methods for surgical cases was distributed to current pediatric otolaryngology fellows and fellowship program directors (FD's). RESULTS: 84 surveys were distributed (47 fellows, 37 FD). Overall response rate was 44% (37/84); fellow response rate was 55% (26/47) and FD response rate was 30% (11/37). Most respondents used videos (84%) and textbooks (95%) to prepare for surgery; fellows were more likely than FD's to use videos (96% vs. 55%, p < 0.01). 89% of respondents used YouTube to prepare; C-videos was the next most common platform used (27%). Fellows were more likely to have used YouTube than FD's (100% vs 63%, p < 0.01). 45% of FD's did not know or did not think their fellows use videos to prepare for cases. Mean helpfulness of surgical videos on a 5 point scale was 3.41 (95% CI 3.0-3.8). Videos were considered most helpful for illustrating technical portions of cases (51%), visualizing the case (27%) and reviewing anatomy (24%). Survey respondents mentioned poor quality (59%) and irrelevance to a particular institutions approach (19%) as weaknesses of available surgical videos. CONCLUSIONS: Surgical videos are commonly used by pediatric otolaryngology fellows to prepare for cases, and can assist in building anatomic knowledge and illustrating technical details of complex cases. YouTube is the most commonly utilized platform accessed by fellows, but poor quality and limited generalizability may restrict the usefulness of current video resources. LEVEL OF EVIDENCE: 4.

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.

How design characteristics of tracheostomy tubes affect the cannula and tracheal flows.

OBJECTIVES: The aim of this study was to perform computational simulations of airflow within an anatomically accurate model of an adult trachea in different tracheostomy tube designs. We hypothesized that tracheal airflow in patients is significantly influenced by the geometry and size of these devices. METHODS: The three-dimensional (3D) geometry of the trachea was reconstructed using computed tomography scans for an adult with no history of lung disease. 3D models of four cuffed tube designs, namely Tracoe, Portex, and Shiley Proximal and Distal tracheostomy tubes were generated using geometric modeling software. Transient simulations of airflow in the tube-airway assembly were performed for each tube using computational fluid dynamics (CFD). RESULTS: Airflow velocity was higher for the Shiley tubes compared with Portex and Tracoe tubes. For all designs, the largest magnitude of inspiratory airflow turbulence was obtained midway in the trachea. The work of breathing, quantified by the resistance of the tracheostomy tube, was lowest for Tracoe. Maximum airway wall shear stress (WSS), defined as flow-induced frictional forces, occurred at the same spatial location in all cases. Low inspiratory WSS at the carina and high expiratory airway WSS at the cuff-airway interface were observed for the Tracoe and Portex tubes. CONCLUSION: Our CFD model offers a promising approach not only for choosing a tracheostomy tube for a patient but for improving existing tracheostomy tube designs. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1791-1799, 2019.

Suction cautery and electrosurgical risks in otolaryngology.

BACKGROUND: Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device's thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature. METHODS: FLIR Systems Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries. RESULTS: Temperatures exceeding 60 degrees C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40 Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices. CONCLUSIONS: Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed.

Cervical thymic remnants in children.

OBJECTIVE: Define the clinical presentation, diagnostic value of preoperative imaging, surgical management, and outcomes of treatment of congenital cervical thymic remnants in children. DESIGN: Retrospective cohort. SETTING: Single tertiary care institution. PATIENTS: 20 children who underwent excision of cervical thymic remnant, 1975-2006. MAIN OUTCOMES MEASURED: Utility of preoperative imaging to diagnose cervical thymic anomalies; success of surgical treatment of cervical thymic remnants. RESULTS: A total of 20 children were identified, with an average age of 6.98+/-5.63 years. All ectopic thymus tissue was found in the embryonic distribution area associated with the third branchial pouch. Fourteen patients underwent excision of a cystic ectopic thymus. Four of these patients exhibited lesions isolated to the cervical region, and 10 patients displayed lesions involving cervicomediastinal areas. Six patients underwent excision of solid ectopic cervical thymus, and each of these was an unanticipated mass encountered during surgical dissection for other procedures. 83% of patients with solid ectopic cervical thymus presented at age 3 or younger. Physical exam and preoperative imaging correctly diagnosed thymic remnants in 15% patients. Resection of thymic remnants was successful in all patients, and there were no recurrences. CONCLUSIONS: Though rare, thymic remnants should be considered in the differential diagnosis of masses presenting in locations associated with derivatives of the third branchial pouch. Though preoperative imaging is helpful in identifying the extent of these lesions, congenital thymic remnants prove difficult to diagnosis radiologically. Surgical excision is the diagnostic and therapeutic treatment of choice in the management of cervical thymic remnants.

A Systematic Review of Patient- or Proxy-Reported Validated Instruments Assessing Pediatric Dysphagia.

OBJECTIVE: Pediatric dysphagia occurs in 500,000 children each year; however, there is not a common tool to assess these children. Our aim was to identify validated patient- or parent-reported outcome assessment tools evaluating pediatric dysphagia. DATA SOURCES: Scopus, EMBASE, PubMed, Cochrane Library, and CINAHL electronic databases (all indexed years through August 2014). REVIEW METHODS: Inclusion criteria included English-language articles containing instruments evaluated in children. Two investigators independently reviewed all articles, and the review was performed according to PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). RESULTS: The initial search yielded 1697 abstracts; 158 studies were assessed further. Four symptom questionnaires, validated in adults, were used to report pediatric dysphagia outcomes. Four outcomes tools assessing dysphagia were validated in pediatrics in selected populations. The Dysphagia in Multiple Sclerosis questionnaire and the Dysphagia Symptom Questionnaire for eosinophilic esophagitis were validated in adolescents and adults. The Symptom Questionnaire for Eosinophilic Esophagitis was validated in children with eosinophilic esophagitis. The Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module, validated in children with gastrointestinal disorders, includes 2 domains that assess swallowing function. CONCLUSION: We did not identify any validated patient- or parent-reported outcome assessment tools examining dysphagia symptoms in a general pediatric population. However, we identified 4 questionnaires that have been validated in specific pediatric disease cohorts. Having a standardized assessment instrument validated in all children would allow clinicians to systematically report symptoms and compare results of pediatric clinical trials. With this in mind, we recommend establishing a standard questionnaire for the broader pediatric population.

Swallowing dynamics status post caustic ingestion in a pediatric patient: A multidisciplinary case report.

A case report of a 10 year old male illustrates the effect of damage to the tongue base, hypopharynx, cricopharyngeus, and esophagus on the sensory and motor components of the swallowing mechanism. The characteristics of the dysphagia were manifested clinically, radiographically, and endoscopically. A myectomy was required to restore functional swallowing as scar tissue formation in the cricopharyngeus severely interfered with the dynamic components of swallowing. A collaborative approach facilitated communication and effective treatment planning; the multidisciplinary components in the management of this case are discussed.

Internet use by parents of children undergoing outpatient otolaryngology procedures.

OBJECTIVES: (1) To determine the prevalence of Internet medical information searches by parents prior to their child's surgical procedure, and (2) to evaluate whether Internet-based health information influences parents' medical decisions on behalf of their children. DESIGN: A questionnaire designed to gather information regarding preoperative use of the Internet by parents of children who were scheduled to undergo outpatient otolaryngology procedures. Parents were asked to respond to questions regarding Internet searches for information specific to their child's diagnosis and anticipated surgical procedure. SETTING: Tertiary care pediatric hospital. RESULTS: Internet access was available to 83% of respondents. Of those parents with Internet access, 48% searched the Internet for information regarding their child's diagnosis and surgical procedure. Of those who searched the Internet, 93% said they found information that was both understandable and helpful. More important, 84% of parents using the Internet said the information influenced or somewhat influenced the medical decisions they made on behalf of their child. Only 43% of parents discussed the information they found on the Internet with their child's surgeon. CONCLUSIONS: Approximately 50% of the parents in our study with Internet access used it to find medical information prior to their child's surgery. Parents who used the Internet found the information helpful and influential, although physicians remain the most important source of information that guides a parent or patient in their medical decision making. Ideally, surgeons would direct parents or patients to a few trusted Internet sites and be prepared to discuss this information.

Airway reconstruction in pediatric burn patients.

OBJECTIVE: Reconstruction of the laryngotracheal airway in pediatric burn victims has been described anecdotally as less successful than reconstruction performed in other populations. To evaluate this clinical impression, outcomes of laryngotracheal reconstruction (LTR) in pediatric burn victims were compared with a randomly selected, matched control population of children receiving LTR. DESIGN: Retrospective case control study. SUBJECTS: The records of 34 pediatric burn victims undergoing LTR were reviewed. A control group of 48 children undergoing LTR for acquired stenosis was randomly selected from a population matched for age and grade of stenosis. RESULTS: Decannulation rate after 1st procedure, number of open airway procedures required, and length of time after 1st procedure until decannulation were not significantly different between the 2 groups. Two deaths (both tracheostomy tube related) occurred in the burn group; 1 occurred in the control group. Two patients in the burn group and 3 patients in the control group remain tracheostomy tube dependent at least 1 year after the initial reconstructive attempt. CONCLUSIONS: Long-term outcomes of LTR in burn patients are not significantly different from outcomes of LTR in the pediatric acquired airway stenosis population.

Altered laryngeal sensation: a potential cause of apnea of infancy.

Delayed maturation of respiratory control of breathing and the laryngeal adductor reflex (LAR) are commonly implicated in infant apnea. A swallow response occurs to remove the stimulus from the pharynx to prevent aspiration once the glottis reopens. Induction of apnea by poorly cleared endogenous upper airway secretions has been postulated to be a potential cause of infant apnea. Our purpose was to determine whether alteration in the LAR, an indicator of laryngeal sensation, and the presence of secretions influenced the responsiveness of the LAR in infants with apnea. The LAR was induced in 20 infants with apnea (median gestational age, 36.5 weeks) by application of air pulses of controlled duration (50 ms) and intensity (2.5 to 10 mm Hg) to the aryepiglottic fold. Twenty infants evaluated for upper respiratory tract anomalies were used as a comparison group (median gestational age, 39 weeks). The infants with apnea required higher-intensity stimuli (p < .001) to induce the LAR (6.2 +/- 1.6 mm Hg) than did the comparison group (4.3 +/- 1.0 mm Hg) and demonstrated poorer clearance of secretions (p < .001). These findings were significant even when we adjusted for postconceptional age at the time of the test (p = .007). The findings of this study suggest that decreased laryngeal sensitivity results in poor endogenous secretion clearance and that it may induce a prolonged glottic closure event to prevent aspiration. This closure may play a role in infant apnea.

Lingual cyst lined by squamous epithelium.

Lingual choristomas or foregut duplication cysts are infrequently reported congenital anomalies that typically present in the perinatal period, and can cause respiratory or feeding problems. These cysts are lined by epithelial cells characteristic of the upper aerodigestive tract. We describe two children who presented shortly after birth with lingual cysts lined with squamous epithelium and foci of respiratory epithelium. Unlike previously reported lingual choristomas, these cysts did not contain gastrointestinal epithelium. In both these cases, the lingual cysts were successfully excised via a transoral approach. This article will discuss the histological findings in these two cases, the differential diagnosis and attempt to classify these lesions in the context of existing terminology.

Persistent velopharyngeal insufficiency.

This chapter outlines the management of patients who have failed initial surgical correction of velopharyngeal insufficiency. Clinical judgment is required to determine the most appropriate revision option for each patient.

Obstructive sleep apnea.

This chapter outlines the surgical management of children who experience symptoms of airway obstruction after undergoing pharyngeal flap surgery or sphincter pharyngoplasty for the correction of velopharyngeal insufficiency. It also describes the management of children with hyponasality following these corrective surgical interventions.

Harmonic scalpel for tonsillectomy.

OBJECTIVE: To describe the Harmonic scalpel and review recent studies comparing its use in tonsillectomy with standard dissection and electrocautery. STUDY DESIGN: Review. METHODS: The Harmonic scalpel uses ultrasonic technology to cut and coagulate tissues at lower temperatures than those associated with electrocautery and lasers. Studies of the use of this device have assessed its performance with respect to intraoperative blood loss, postoperative hemorrhage, and postoperative pain. RESULTS: Intraoperative blood loss and episodes of postoperative hemorrhages have been found to be minimal in patients in whom the Harmonic scalpel was used for tonsillectomy. The device also appears to be associated with a reduction in postoperative pain. CONCLUSION: Use of the Harmonic scalpel for tonsillectomy may have several advantages over standard methods.

Nonoperative management of complete tracheal rings.

BACKGROUND: Children with complete tracheal rings are often challenging to manage. Most children will present early with a severely compromised airway and will require tracheal reconstruction. OBJECTIVE: To show that a small number of minimally symptomatic patients with complete tracheal rings experience airway growth over time and do not require tracheoplasty. DESIGN: A retrospective medical chart review over a 10-year period. SETTING: A tertiary care pediatric hospital. PATIENTS: Children (N = 10) with a diagnosis of complete tracheal rings, confirmed on bronchoscopy, who were observed for a minimum of 1 year prior to determining the need for tracheoplasty. MAIN OUTCOME MEASURES: Patient symptoms, bronchoscopic findings, airway size, and the progression of these over time. Other congenital anomalies, the reason for initial diagnosis, and the need for tracheoplasty were documented. RESULTS: The 10 patients in our series fell into the following 3 categories: 5 patients were minimally symptomatic or asymptomatic, showed bronchoscopic evidence of progressive airway growth, and did not require tracheoplasty; 2 patients had worsening symptoms of exercise intolerance, showed minimal airway growth, and ultimately required tracheoplasty; and 3 patients are still being clinically observed and may eventually require tracheoplasty. Periods of observation have varied from 1 year to over 12 years. CONCLUSIONS: Not all patients with complete tracheal rings require tracheoplasty. Some have satisfactory airway growth and do not require airway reconstruction. A period of observation to monitor airway growth and clinical symptoms is safe and may spare some patients from undergoing unwarranted airway reconstruction.