Update on the diagnosis and management of pediatric laryngotracheal stenosis.

INTRODUCTION: Laryngotracheal stenosis comprises a broad spectrum of congenital and acquired conditions that commonly cause pediatric airway obstruction. With the introduction and popularization of operative procedures such as laryngotracheoplasty, cricotracheal resection, and slide tracheoplasty more patients are presenting with airway issues at multiple anatomic levels. A combination of endoscopic and open techniques continues to be utilized for these complex issues. Additionally, there are specific long-term considerations for the post reconstruction patient. AREAS COVERED: This review highlights important aspects of the diagnosis, work up, and surgical treatment of pediatric laryngotracheal stenosis with updates for revision airway surgery and the post reconstruction patient. Important research articles and techniques within pediatric airway reconstruction are summarized and included in the review, in addition to recent articles from the last five years on pediatric laryngotracheal stenosis which were identified through a search of the PubMed database. EXPERT OPINION: The multidisciplinary concept of evaluation and treatment of laryngotracheal stenosis continues to be essential. Revision airway surgery presents unique challenges to improve the quality of life of patients as they age after reconstruction. Tracheal transplantation remains an important research area in the treatment of laryngotracheal stenosis.

Laryngotracheal separation through the cricoid ring for management of tracheobronchomegaly.

Tracheobronchomegaly is a rare condition characterized by diffuse dilation of the trachea and main bronchi. In ventilator-dependent neonates with tracheobronchomegaly, a tracheostomy may be hazardous due to the lack of an appropriate tracheostomy tube size that can fit the enlarged trachea. Here, we describe a modification of the laryngotracheal separation procedure to permit ventilation in a child with tracheobronchomegaly and severe bronchopulmonary dysplasia.

Effect of Graft Size on Air-bone Gap Closure in Cartilage Button Tympanoplasty.

OBJECTIVE: To study the effect of graft size on postoperative air-bone gap in children undergoing butterfly inlay cartilage tympanoplasty using circular punch grafts. STUDY DESIGN: Retrospective case review. SETTING: Tertiary, academic children's hospital. PATIENTS: Children less than 16 years old undergoing circular butterfly inlay tympanoplasty using 4, 5, or 6 mm round grafts. INTERVENTION: Butterfly inlay tympanoplasty using circular punch graft harvest technique. MAIN OUTCOME MEASURES: Postoperative pure-tone average and air-bone gap. RESULTS: Fifty-two children were included in the analysis: 18 in the 4 mm group, 28 in the 5 mm group, and 6 in the 6 mm group. There was no significant difference in either postoperative pure-tone average or air-bone gap among the three groups. Closure rates for the 4, 5, and 6 mm graft groups were 94, 96, and 67%, respectively, for an overall rate of 92%. CONCLUSIONS: Cartilage button butterfly inlay tympanoplasty with punch graft is an effective method for tympanic membrane repair with similar hearing results among various graft diameters but may have diminished success with perforations requiring grafts larger than 5 mm. Larger case series are necessary to determine if larger defects are best managed with other repair techniques.

Pediatric orbital floor fractures and the oculocardiac reflex: Experience from a level I trauma center.

PURPOSE: The purpose of this study is to determine whether bradycardia associated with the oculocardiac reflex is a significant source of morbidity in the post injury period following orbital floor fractures in children. MATERIALS/METHODS: A retrospective review of all pediatric patients who presented to our emergency department with an orbital floor fracture from May 1, 2016 to June 1, 2018 were included. Basic demographic data was collected as well as mechanism of injury, presence of bradycardia, and time to operating room. Morbidity was based on the need for medications to treat bradycardia. RESULTS: Thirty-five pediatric patients with orbital floor fractures were reviewed. 6 (17.1%) patients had post injury bradycardia, with one patient requiring medication to stabilize their heart rate. There was no statistically significant difference in sex, race/ethnicity, or age in patients with or without bradycardia (p > 0.05) however there was a significant relationship between bradycardia and need for operative repair (X2 = 7.88, df = 1, p = 0.005). The most common mechanism of injury was motor vehicle collision (45.7%). The average time to the operating room was 145 h (6.04 days). CONCLUSIONS: While activation of the oculocardiac reflex is a legitimate concern in the post injury period, there is unlikely to be significant morbidity due to bradycardia, and the greater concern should be for the ischemic muscle injury incurred from the fracture.

Characteristics and considerations for children with ankyloglossia undergoing frenulectomy for dysphagia and aspiration.

OBJECTIVE: The purpose of this study is to analyze the basic demographics of patients who underwent frenulectomy at our institution as well as additional considerations regarding age, location of procedure, and possible effects on aspiration. METHODS: A retrospective chart review was performed based on CPT codes for frenulectomy and basic demographic data was collected. Other information such as presenting symptoms, type of ankyloglossia, location of the procedure, and modified barium swallow study (MBSS) information were also obtained. RESULTS: A total of 226 (66.4% male) patients underwent frenulectomy in the study time frame. Younger patients underwent frenulectomy for feeding symptoms (average age 6.5 months) and older children typically presented with speech related symptoms (average age 3.8 years). Of patients who had MBSS before and after the procedure, 5/11 (43%) had improvement of their aspiration after frenulectomy. CONCLUSIONS: Symptomatic ankyloglossia is more common in boys. Two age groups typically present for frenulectomy, infants for feeding difficulties and toddlers/preschoolers for speech related difficulties. Children with aspiration may benefit from frenulectomy, though aspiration is unlikely to resolve if other comorbidities are present. Proper evaluation and documentation of anatomy and functional tongue movement is important for future studies and decision-making regarding frenulectomy.