Jaw Thrust: A Simple Predictor of Success in Mandibular Distraction Osteogenesis.

BACKGROUND: The hypoplastic mandible in the congenital condition Pierre Robin sequence (PRS) displaces the base of the tongue posteriorly, which results in upper airway obstruction (UAO) that can potentially be corrected with mandibular distraction osteogenesis (MDO). Jaw thrust (JT) is routinely performed during evaluation of the airway; similar to MDO, it projects the mandible and tongue anteriorly to open the airway. The authors demonstrate that JT can be used as a criterion to predict successful MDO outcomes in infants with PRS. METHODS: The study was a single-center, retrospective chart review of infants diagnosed with PRS between 2016 and 2023. Data regarding their demographics, comorbid diagnoses, JT success, airway anomalies, laryngeal grade of view, apnea-hypopnea index, and perioperative course were statistically analyzed. RESULTS: Of the 16 patients included in the study, 11 had successful relief of their airway obstruction with JT and proceeded with MDO. The unsuccessful JT group had significantly greater proportions of females, birth prematurity, gastrostomies, tracheostomies, and longer hospital stays. In the successful JT group, both the mean laryngeal grade of view ( P =0.029) and mean apnea-hypopnea index ( P =0.025) improved significantly post-MDO. Post-MDO tracheostomy was also avoided in all but 1 patient who was not previously tracheostomized. CONCLUSIONS: There is no widely accepted algorithm to guide craniofacial surgeons on the optimal intervention for relieving UAO in infants with PRS. In our institutional experience, patients whose preoperative JT relieved UAO also successfully relieved UAO with MDO. In patients with PRS, JT may be a useful criterion for selecting appropriate candidates for MDO.

Tracheostomy, the Not So Definitive Airway?: Tracheostomy Morbidity in Pediatric Craniofacial Patients.

BACKGROUND: Tracheostomy is the definitive treatment for airway management in severe cases of craniofacial-associated upper airway obstruction, like the Pierre-Robin sequence, but is associated with significant morbidity. The purpose of this study was to examine tracheostomy-associated morbidities and mortalities in craniofacial patients to identify opportunities to improve clinical care and patient prognosis. METHODS: The study was a retrospective review of pediatric craniofacial patients who were tracheostomized between 2016 and 2022. Data regarding their demographics, craniofacial diagnoses, endoscopic airway anomalies, intubation grade of view classification, tracheostomy-related complications, and causes of mortality were analyzed. RESULTS: Sixteen of the 17 tracheostomized pediatric patients had the Pierre-Robin sequence, with 5 of those patients having an additional syndromic craniofacial diagnosis. Additional airway anomalies were found in 82.4% of the patients. The mean length of hospital stay after tracheostomy was 4.08 months. Infection was the most common complication, observed in 94.1% of patients, followed by stomal granulation in 76.5% of patients. Two mortalities were observed: one following the compassionate removal of ventilator support and the other following the accidental dislodgment of the tracheostomy tube. CONCLUSIONS: Tracheostomy-related complications were observed in all craniofacial patients in this group. Compared with the general pediatric population, tracheostomized craniofacial patients may endure longer hospital stays and greater stomal granulation rates. Mandibular distraction osteogenesis may allow for tracheostomy avoidance in these patients, and future research should focus on comparing the long-term complication rates and outcomes between tracheostomy mandibular distraction osteogenesis in this challenging patient population.

Medical School Characteristics Associated with Matched Otolaryngology Residency Applicants.

OBJECTIVE: Identify which medical schools produce the most otolaryngology residents, and associated characteristics which may contribute to this productivity. DESIGN: The medical school and residency program of each otolaryngology-matched student was identified. Various characteristics for each medical school and residency were compared in univariate and multivariate analysis after adjusting for class size. Percentage of matched students relative to class size was identified and compared for each geographic region. SETTING: Cross-sectional study of publicly available match data from otomatch.com and otolaryngology residency program websites from 2020-2023. PARTICIPANTS: 1411 students from 174 medical schools matched into 126 otolaryngology residencies were identified. RESULTS: Private medical schools (ß = 0.50, p = 0.03), larger otolaryngology departments (ß = 0.01, p = 0.04), and higher U.S. News and World Report (USNWR) ranking (ß = -0.01, p = 0.02) was associated with a greater percentage of otolaryngology-matched students while schools in the Mountain region were associated with a lower percentage of matched students (ß = -1.08, p = 0.02). A difference in percentage of matched students was observed when comparing across all regions (p < 0.01) but no significant differences were observed between any individual regions. The East North Central Region and the Middle Atlantic regions were more likely to match students from their respective regions compared to the Mountain region (OR: 4.98, 95% CI: 1.18, 21.01; OR: 8.20, 95% CI: 1.92, 34.99, respectively). Additionally, the Mountain region was less likely to match students from their own region compared to the Pacific (OR: 0.21, 95% CI: 0.05, 0.90), South Atlantic (OR: 0.20, 95% CI: 0.05, 0.85), and West South Central (OR: 0.15, 95% CI: 0.03, 0.67) regions. CONCLUSIONS: Medical school characteristics such as private vs public status, size of otolaryngology department, higher USNWR ranking, and geographic region impact the number of otolaryngology-matched students. Applicants should consider the impact of their geographic region when allocating signals during the residency application process.

Standardization of reporting post-tonsillectomy bleeding.

OBJECTIVES: Postoperative bleeding is a well-recognized complication after tonsillectomy. We believe significant variation exists in how bleeding following tonsillectomy is reported and that a standardized system is needed. Our goal was to develop such a system. METHODS: Relevant literature was found on Ovid Medline. Studies published from 1996 to 2009 involving post-tonsillectomy bleeding were analyzed, and data were collected on the basis of strict criteria. A standardized system for reporting post-tonsillectomy bleeding was then developed. RESULTS: A review of the literature found variation in the reporting of post-tonsillectomy bleeding and found that categorization systems for reporting bleeding are often not used. The following standardization system is proposed. Type I is bleeding, historical or observed, that does not require any intervention or control of the bleeding (except for oral rinses or intravenous administration of fluids). Type II is bleeding that requires control with local measures under topical or local anesthesia. Type III is bleeding that requires control with local measures, suture ligation, and/or aggressive cauterization in the operating room. Type IV is bleeding that requires control that includes external carotid artery ligation or embolization. Type V is bleeding that leads to the patient's death. The postoperative day on which the bleeding occurs is also reported. CONCLUSIONS: The literature on tonsillectomy varies greatly in describing and reporting post-tonsillectomy bleeding. We propose a system to standardize the reporting of post-tonsillectomy bleeding.

Histopathologic differences between adult and pediatric patients with chronic rhinosinusitis.

BACKGROUND: Adult and pediatric patients with chronic rhinosinusitis (CRS) may have differing philosophies in therapeutic management. Few studies have examined sinonasal tissue-level comparisons of these groups. This study examines histopathologic differences between children and adults with CRS, with the goal of understanding disease pathogenesis and optimizing medical management for both populations. METHODS: In a retrospective cohort of CRS patients who underwent functional endoscopic sinus surgery (FESS), demographic factors, pertinent comorbidities, and a structured histopathologic report of 13 variables were compared across pediatric and adult CRS patients with and without nasal polyps (pCRSwNP, pCRSsNP, aCRSwNP, aCRSsNP, respectively). RESULTS: A total of 378 adult (181 aCRSsNP, 197 aCRSwNP) and 50 pediatric (28 pCRSsNP, 22 pCRSwNP) patients were analyzed. Significantly more children compared with adults had a comorbid asthma diagnosis (64.5% vs. 37.2%, p = 0.003). Adults with CRS exhibited significantly more tissue neutrophilia (28.9% vs. 12.0%, p = 0.006), basement membrane thickening (70.3% vs. 44.0%, p < 0.001), subepithelial edema (61% vs. 30.0%, p < 0.001), squamous metaplasia (22.0% vs. 4.0%, p < 0.001), and eosinophil aggregates (22.8% vs. 4.0%, p < 0.001) than children with CRS. The majority (66.5%) of adult CRS patients exhibited a lymphoplasmacytic-predominant inflammatory background, whereas the majority (57.8%) of children with CRS exhibited a lymphocyte-predominant inflammatory background. CONCLUSIONS: Sinonasal tissue of adult and pediatric CRS patients demonstrates clear histopathologic differences. Our findings provide insight into differing pathophysiology, which may enable optimization of targeted therapies for patients in each of these unique clinical groups.

Coblation of suprastomal granulomas in tracheostomy-dependent children.

OBJECTIVE: Suprastomal granulomas pose a persistent challenge for tracheostomy-dependent children. They can limit phonation, cause difficulty with tracheostomy tube changes and prevent decannulation. We describe the use of the coblator for radiofrequency plasma ablation of suprastomal granulomas in five consecutive children from September 2012 to January 2016. METHOD: Retrospective case series at a tertiary medical center. RESULTS: The suprastomal granuloma could be removed with the coblator in all 5 cases. Three were removed entirely endoscopically and 2 required additional external approach through the tracheal stoma for complete removal. There were no intraoperative or postoperative complications. One patient was subsequently decannulated and 2 patients have improved tolerance of their speaking valves. Two patients remain ventilator dependent, but their bleeding and difficulty with tracheostomy tube changes resolved. Three of the patients have had subsequent re-evaluation with bronchoscopy, demonstrating resolution or markedly decreased size of the granuloma. This technique is time efficient, simple and minimizes risks associated with other techniques. The relatively low temperature and use of continuous saline irrigation with the coblator device minimizes the risk of airway fires. Additionally, the risk of hypoxia from keeping a low fractional inspiratory oxygen level (FIO2) to prevent fire is avoided. The concurrent suction in the device decreases blood and tissue displacement into the distal airway. CONCLUSION: Coblation can be used safely and effectively with an endoscopic or external approach to remove suprastomal granulomas in tracheostomy-dependent children. More studies that are larger and have longer follow-up are needed to evaluate the use of this technique.