The Airway Pocket: Novel Advancement in Endoscopic Submucosal Placement of Posterior Cartilage Graft.

Endoscopic technology has increased our options for treatment of airway stenosis in a minimally invasive manner. This novel technique advances endoscopic posterior graft placement by creation of an airway pocket, potentially reducing risk of graft migration and improving outcomes. Laryngoscope, 2024.

Type 3 Laryngeal Clefts Presenting with Upper Airway Obstruction without Aspiration.

Traditionally, otolaryngologists are taught that the defining clinical feature of a laryngeal cleft is aspiration. However, in a small subset of patients-even those with extensive clefts-the sole presenting feature may be airway obstruction. Here, we report two cases of type III laryngeal clefts that presented with upper airway obstruction without aspiration. The first patient was a 6-month-old male with history of tracheoesophageal fistula (TEF) who presented with noisy breathing, initially thought to be related to tracheomalacia. Polysomnogram (PSG) demonstrated moderate OSA and modified barium swallow (MBS) was negative for aspiration. In-office laryngoscopy was notable for a mismatch of tissue in the interarytenoid region. A type III laryngeal cleft was identified on bronchoscopy, and airway symptoms resolved after endoscopic repair. The second patient was a 4-year-old male with a diagnosis of asthma who presented with progressive exercise-induced stridor and airway obstruction. In-office flexible laryngoscopy revealed redundant tissue in the posterior glottis and MBS was negative for aspiration. He was found to have a type III laryngeal cleft on bronchoscopy and his stridor and upper airway obstruction resolved after endoscopic repair. While aspiration is the most common presenting symptom of a laryngeal cleft, it is important to consider that patients can have a cleft in the absence of dysphagia. Laryngeal cleft should be included in the differential diagnosis for patients with obstructive symptoms not explained by other etiologies and in those with suspicious features on flexible laryngoscopy. Laryngeal cleft repair is recommended to restore normal anatomy and relieve obstructive symptoms. Laryngoscope, 134:977-980, 2024.

Assessing National Trends and Perceived Safety of Off-Label Ciprofloxacin-Dexamethasone Use by Pediatric Otolaryngologists.

OBJECTIVES: Off-label use of Ciprodex® (ciprofloxacin-dexamethasone: CPD), an antibiotic-steroid combination solution, in the airway has been reported by pediatric otolaryngologists with anecdotal success. We examined national trends regarding off-label CPD use including prevalence, common indications, prescriber patterns, adverse events, and accessibility. METHODS: 15-item cross-sectional survey was distributed to American Society of Pediatric Otolaryngology members from January-April 2022. Univariate analyses were performed to compare responses for users of off-label CPD versus non-users. Ease of access was compared across geographies and practice types using multivariate logistic regressions. RESULTS: Of the 163 complete responses (26.6% response rate), 156 (95.7%) reported using off-label CPD. Most common indications for off-label CPD were tracheal granulation (87.8%, n = 137) and choanal atresia (82.1%, n = 128). Ease of access was significantly increased in the Midwest (OR:18.79, 95%CI:3.63-1.24, p = 0.001) and West (OR:29.92, 95%CI:3.55-682.00, p = 0.006). Ease of access was significantly lower at tertiary referral centers (OR:0.11, 95%CI:0.01-0.64, p = 0.041) and private practices (OR:0.04, 95%CI:0.002-0.33, p = 0.009) compared to academic free-standing children's hospitals. Two-thirds of respondents reported feeling "Very Comfortable" with the safety profile of off-label CPD; 99.4% (n = 156) felt that the benefits outweighed the risks of off-label use. Seven respondents (4.5%) reported adverse events (e.g., local allergic reaction, cushingoid symptoms) from off-label use. CONCLUSIONS: Our findings (26.6% response rate) suggest that off-label CPD is commonly used by pediatric otolaryngologists, many of whom reported feeling that the benefits of off-label CPD outweigh the risks. Our results establish a baseline for future efforts to assess the efficacy and safety of off-label CPD and to improve its accessibility. LEVEL OF EVIDENCE: V Laryngoscope, 134:2922-2930, 2024.

Comparing nationally reported adverse events associated with coblation vs. PlasmaBlade for tonsillectomy.

OBJECTIVE(S): Coblation, or radiofrequency ablation, and pulsed-electron avalanche knife (PEAK) plasmablade are newer approaches for tonsillectomy that reduce exposure to thermal heat. This study aims to describe and compare adverse events related to these devices for tonsillectomy. STUDY DESIGN: Retrospective cross-sectional study. SETTING: The US Food and Drug Administration's Manufacture and User Facility Device Experience (MAUDE) database. METHODS: The MAUDE database was queried for reports involving coblation devices and the PEAK plasmablade from 2011 to 2021. Data were extracted from reports pertaining to tonsillectomy with and without adenoidectomy. RESULTS: There were 331 reported adverse events for coblation and 207 for the plasmablade. For coblation, 53 (16.0 %) of these involved patients and 278 (84.0 %) were device malfunctions. Similarly for the plasmablade, 22 (10.6 %) involved patients and 185 (89.4 %) were device malfunctions. The most frequent patient-related adverse event was burn injury, which was significantly more common with the plasmablade compared to coblation (77.3 % vs. 50.9 %, respectively, p = 0.042). For both the coblator and plasmablade, the most common device malfunction was intraoperative tip or wire damage (16.9 % vs. 27.0 %, respectively, p = 0.010). The Plasmablade tip caught fire in five reports (2.7 %) with one causing burn injury. CONCLUSIONS: While coblation devices and the plasmablade have demonstrated utility in tonsillectomy with or without adenoidectomy, they are associated with adverse events. Plasmablade use may require greater caution for intraoperative fires and patient burn injuries compared to coblation use. Interventions to improve physician comfort with these devices may help reduce adverse events and inform preoperative discussions with patients.

A Quantitative Analysis of Smartphone-Based Endoscopy and Video Tower Endoscopy.

OBJECTIVES: Examine the differences between traditional tower-based endoscopy (TBE) and smartphone-based endoscopy (SBE) using objective measures of cost, setup time, and image quality. METHODS: Cost analysis study and randomized single-blinded prospective trial was performed at a tertiary academic health center. Twenty-three healthcare providers, 2 PA-C, 9 residents, 2 fellows, 10 attendings varying in practice from 1 to 27 years were a part of the study. Actual cost analysis was used for purchase of the Karl Storz video tower system and the Save My Scope smartphone-based endoscopy system for cost analysis. For setup time, providers entered a room and were randomized to set up either an SBE or TBE system and timed from room entry to a visible on-screen image. A crossover was then performed so all providers performed both setups. For image discernment, standardized photos of a modified Snellen's test were sent via text message to providers who were blinded as to which photo represented which system. Practitioners were randomized as to which photo to receive first. RESULTS: Cost savings was 95.8% ($39,917 USD) per system. Setup time for the smartphone system was 46.7 seconds less than video tower system on average (61.5 vs 23.5 seconds; P < .001, 95% CI: 30.3-63.1 seconds). Level of visual discernment was slightly better for SBE over TBE, with reviewers able to identify Snellen test letters at a size of 4.2 mm with SBE versus 5.9 mm with TBE (P < .001). CONCLUSIONS: Smartphone-based endoscopy was found to be cheaper, quicker to set up, and to have marginally better image quality when transmitted via messaging than tower-based endoscopy, although the clinical significance of these visual differences are unknown. If appropriate for their needs, clinicians should consider smartphone-based endoscopy as a viable option for viewing and collaborating on endoscopic images from a fiberoptic endoscope.

Pediatric laryngeal cleft repair with coblation: Functional comparison of a novel technique with traditional methods.

OBJECTIVES: The traditional endoscopic techniques for surgical management of laryngeal clefts are carbon dioxide (CO2) laser or microlaryngeal instruments (cold steel). This study compares the functional efficacy and safety of coblation, or "cold" radiofrequency ablation, to traditional approaches for endoscopic laryngeal cleft repair. METHODS: Patients who underwent endoscopic laryngeal cleft repair with CO2 laser, cold steel, or coblator at two tertiary academic centers from 2015 to 2021 were retrospectively identified. The primary outcome studied was swallowing function: pre- and postoperative swallow studies were scored according to the International Dysphagia Diet Standardization Initiative with higher scores indicating worse swallow function. Secondary outcomes included surgical complications and rates of dehiscence. RESULTS: Of the 53 patients included, 14 underwent repair with CO2 laser, 23 with cold steel, and 16 with the coblator. Mean age at surgery was 2.2 ± 1.1 years for the laser group, 4.3 ± 4.0 years for cold steel, and 1.9 ± 1.4 years for the coblator group. In the laser group, 100% of clefts were type I; for the cold steel group, 82.6% of clefts were type I and 17.4% were type II; for the coblator group, 93.8% of clefts were type I and 6.3% were type II. Pre- and postoperative swallow study scores were 6.3 ± 2.8 and 4.3 ± 3.2, respectively, (p = 0.001) for the laser group, 6.9 ± 2.8 and 5.3 ± 3.1 (p = 0.071) for the cold steel group, and 7.5 ± 1.5 and 4.0 ± 2.9 (p < 0.001) for the coblator group. Mean change in swallow study scores were similar across the three groups (p = 0.212). No patients experienced postoperative dehiscence at the surgical site or complications; no revisions were required. CONCLUSIONS: Cleft repair with the novel coblation technique showed significant improvements in swallow study scores without any occurrences of postoperative dehiscence or revisions. Coblation is a safe and efficacious approach for laryngeal cleft repair.

Assessing outcomes after partial and total tonsillectomy for sleep-disordered breathing in children using Clinical Assessment Score-15.

INTRODUCTION: The Clinical Assessment Score-15 (CAS-15) is an office-based tool for assessing the risk of sleep disordered breathing (SDB), a relatively common condition in the pediatric population. Change in CAS-15 following total tonsillectomy (TT) has been shown to have a large effect size, but it is unclear how it varies following partial intracapsular tonsillectomy (PIT). Thus, the objective of the present study is to evaluate the utility of the CAS-15 score in assessing the effectiveness of PIT and how this compares to change after TT. MATERIAL METHODS: Children ages 2-18 undergoing PIT (N = 16) or TT (N = 8) with or without adenoidectomy for SDB completed the CAS-15 before surgery and at their post-operative follow-up visit. Changes in CAS-15 score were assessed by paired t-test. The mean difference in CAS-15 change between PIT and TT was evaluated by unpaired t-test for unequal variances. Differences in participant characteristics were determined via unpaired t-test for unequal variances. RESULTS: Participants undergoing PIT did not differ significantly than those undergoing TT with regard to age, sex, BMI percentile, pre-op CAS-15 score or tonsil size, or admission rates following surgery (p > 0.05). The median follow-up after surgery was 5.2 (PIT) and 4.4 (TT) weeks. CAS-15 score improved significantly following PIT (42.8 ± 12.3 vs. 9.4 ± 5.6, p < 0.0001) and TT (45.5 ± 13.3 vs. 7.9 ± 5.8, p < 0.0002). The decrease in CAS-15 for PIT did not differ from TT (33.3 ± 11.8 vs. 37.6 ± 15.0, p > 0.49). DISCUSSION: CAS-15 decreases drastically following PIT and TT, indicating significant improvement of SDB symptoms. Because the change in CAS-15 after PIT was similar to TT, PIT may be preferred due to the decreased morbidity of the procedure. Given the cost, time required, inconvenience, and other limitations of overnight polysomnography (PSG), which is the gold standard method of diagnosing SDB, CAS-15 may be a suitable replacement or adjunct for the assessment of SDB following PIT in addition to TT.

Pediatric sleep outcomes after endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy.

BACKGROUND: The purpose of this study was to evaluate the efficacy of sleep endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy in patients with sleep disordered breathing (SDB), including polysomnography (PSG) and swallowing outcomes. METHODS: A retrospective review was performed of all patients undergoing simultaneous lingual tonsillectomy and epiglottopexy over the study period. PSG objective measures were recorded pre- and postoperatively, along with demographic data, comorbidities, and descriptive data of swallowing dysfunction in the postoperative setting. RESULTS: A total of 24 patients met inclusion criteria for consideration, with 13 having valid pre- and postoperative PSG data. Successful surgery was achieved in 84.6% of patients, with no difference based on presence of medical comorbidities including Trisomy 21. Median reduction in obstructive apnea-hypopnea index (oAHI) with the procedure was 69.9%. Four patients (16.7%) had postoperative concern for dysphagia, but all objective swallowing evaluations were normal and no dietary modifications were necessary. CONCLUSION: Combination lingual tonsillectomy and epiglottopexy in indicated patients has a high rate of success in this single-institutional study without new dysphagia in this population. These procedures are amenable to a combination surgery in appropriately selected patients determined by sleep state endoscopy in the setting of SDB evaluated with drug-induced sleep endoscopy.

Differential Integrin Adhesome Expression Defines Human NK Cell Residency and Developmental Stage.

NK cells are innate immune cells that reside within tissue and circulate in peripheral blood. They interact with a variety of microenvironments, yet how NK cells engage with these varied microenvironments is not well documented. The adhesome represents a molecular network of defined and predicted integrin-mediated signaling interactions. In this study, we define the integrin adhesome expression profile of NK cells from human tonsil, peripheral blood, and those derived from human hematopoietic precursors through stromal cell coculture systems. We report that the site of cell isolation and NK cell developmental stage dictate differences in expression of adhesome associated genes and proteins. Furthermore, we define differences in cortical actin content associated with differential expression of actin regulating proteins, suggesting that differences in adhesome expression are associated with differences in cortical actin homeostasis. These data provide understanding of the diversity of human NK cell populations and how they engage with their microenvironment.

Educational Value of Endoscopic Versus Microscopic Ear Surgery.

OBJECTIVE: To compare the educational value of endoscopic ear surgery versus microscopic ear surgery among medical students. METHODS: Medical students anonymously completed a cross-sectional survey immediately after observing endoscopic or microscopic ear surgery. A Likert scale (1 = worst, 5 = best) was used to analyze variables across 3 domains including: (1) area of interest visibility, (2) optical quality, (3) education and understanding. The Mann-Whitney U-test and multivariable linear regression were used to compare mean scores of individual items and domain means between endoscopic and microscopic groups. RESULTS: Forty-four surveys were analyzed (20 endoscopic and 24 microscopic ear surgeries). Across domains, the endoscope was superior to the microscope (adjusted P < .05) for visibility of the area of interest (mean ± SD: 4.74 ± 0.26 vs 4.28 ± 0.50), optical quality (4.78 ± 0.38 vs 4.28 ± 0.64), and education and understanding (4.70 ± 0.47 vs 4.13 ± 0.61). In multivariable linear regression, the mean domain score for visibility of the area of interest was 1.23 (95% CI = 0.56, 1.90; adjusted P < .01) points higher for the endoscopic group, compared to the microscopic group, adjusting for surgeon, procedure, and student type. The mean domain score for education and understanding was 1.19 (95% CI = 0.49. 1.90; adjusted P < 0.01) points higher for the endoscopic group, compared to the microscopic group, adjusting for the same confounders. CONCLUSIONS: Among medical students, endoscopic ear surgery was superior to microscopic ear surgery for several visual quality indicators and perceived educational benefit. These findings have implications for medical student education and surgical training.

Use of a Rigid Bronchoscope as the Sole Prebypass Airway During Pediatric Tracheal Tumor Resection: A Case Report.

We describe the anesthetic and operative techniques utilized for a tracheal tumor resection in a pediatric patient with 95% tracheal occlusion. In prior tracheal tumor cases that dictated complete resection, our team had been able to comfortably bypass a tumor with an endotracheal tube. In this case, we could not intubate past the tumor. A rigid bronchoscope was able to be placed past the tumor, so we continued with sternotomy and dissection before cardiopulmonary bypass while ventilating through that bronchoscope as our definitive airway.

Combination Surgical Procedure for Fourth Branchial Anomalies: Operative Technique and Outcomes.

OBJECTIVE: Branchial apparatus anomalies of the fourth cleft are the rarest subtype of anomaly and occasionally present with suppurative thyroiditis or thyroid abscess due to their relationship with the thyroid gland. Surgical approaches vary and some surgeons favor cauterization of associated pyriform sinus tracts alone versus complete surgical excision. Currently, the literature is scarce and there is limited data on surgical outcomes and procedural steps. Here we describe a combination surgical technique for fourth branchial anomalies including: (1) surgical excision of the cyst and any external pit, (2) hemithyroidectomy, and (3) direct laryngoscopy with cauterization of pyriform apex tract, if present. METHODS: A retrospective review was performed on all patients who underwent surgical excision of fourth branchial apparatus lesions (including fistulae, cysts, and sinus tracts) at an urban pediatric university hospital from 2000 to 2019. Data regarding demographics, medical history, surgical methods, complications, and surgical cure rates were collected. RESULTS: A total of 16 patients (9 female, 7 male) underwent a combination surgical procedure for fourth branchial apparatus lesions. Success rate after primary surgery was 94%. One patient had residual disease requiring re-operation. Two patients had post-operative complications: 1 transient vocal fold paresis and 1 seroma, both managed conservatively. A consensus surgical algorithm was created based on operative steps present in the majority of cases. CONCLUSION: A combination approach to fourth branchial apparatus lesions-including endoscopic cauterization, external excision, and hemithyroidectomy-is safe and provides a high rate of primary cure. Although less invasive options exist, remnants of the branchial lesion, especially in the thyroid, may remain and cause recurrent issues. Therefore, we advocate for complete surgical excision of this rare developmental anomaly, especially when obvious thyroid involvement exists.

A Guiding Principles Checklist for Otolaryngologic Surgery in the COVID-19 Era.

The COVID-19 pandemic has had a dramatic impact on surgical workflows. There is an abundance of ever-changing information, and protocols are reflexively modified on a daily basis. As many otolaryngologic procedures are shown to have higher risk of viral transmission-so-called aerosol-generating procedures-it is imperative that multidisciplinary care teams be provided updated, timely, and consistent information. A single-page Guiding Principles surgical checklist was developed to discuss 7 key factors: patient information, staff wellness, risk minimization, prioritization, resource utilization, key society criteria, and communication. This was completed for every patient requiring otolaryngologic surgery and was distributed to the care teams involved. It provided the most information for those on the frontline and allowed for cogent pre-, intra-, and postoperative planning.

A Second Pandemic? Perspective on Information Overload in the COVID-19 Era.

The outbreak of COVID-19 has affected the globe in previously unimaginable ways, with far-reaching economic and social implications. It has also led to an outpouring of daily, ever-changing information. To assess the amount of data that were emerging, a PubMed search related to COVID-19 was performed. Nearly 8000 articles have been published since the virus was defined 4 months ago. This number has grown exponentially every month, potentially hindering our ability to discern what is scientifically important. Unlike previous global pandemics, we exist in a world of instantaneous access. Information, accurate or otherwise, is flowing from one side of the world to the other via word of mouth, social media, news, and medical journals. Changes in practice guidelines should be based on high-quality, well-powered research. Our job as health care providers is to mitigate misinformation and provide reassurance to prevent a second pandemic of misinformation.

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.

Early experience with feasibility of balloon sinus dilation in complicated pediatric acute frontal rhinosinusitis.

BACKGROUND/OBJECTIVE: Complicated acute rhinosinusitis in the pediatric population is an uncommon problem that may affect the orbit or brain and is life-threatening. This condition requires surgical intervention with endoscopic sinus surgery for source control, and prior studies have demonstrated the safety of balloon sinuplasty in chronic frontal sinusitis. METHODS/RESULTS: We present our approach with a balloon sinus dilation hybrid procedure to resolve four distinct types of complicated acute frontal sinusitis in pediatric patients, including intracranial manifestations, intraorbital complications, and recurrent disease. All four patients were able to be managed operatively with frontal balloon sinuplasty. CONCLUSIONS: Prior efficacy has been demonstrated for chronic frontal sinusitis in the pediatric population. We demonstrate that frontal balloon sinuplasty is also feasible in the proper clinical setting for acute frontal sinusitis, even in the presence of regional complications or recurrent disease. LEVEL OF EVIDENCE: 4.

Pediatric flexible laryngoscopy: Trends in diagnostic abilities throughout training.

OBJECTIVES: Our objectives were to evaluate the ability of residents to diagnose pathology of the pediatric larynx on laryngoscopy, to trend this ability throughout training, to compare their skills to pediatric otolaryngologists, and to determine whether reviewing digitally captured videos in slow motion, as opposed to a live exam, enhanced diagnostic abilities. In addition, we identified pathologies and anatomical sub-sites that posed diagnostic challenges. METHODS: Qualtrics was used to design and distribute an online test, which included 15 pediatric laryngoscopy videos. Participants selected a diagnosis for each video after (1) watching it once at full speed and (2) watching the video multiple times in slow motion. Anonymous responses were exported into excel for statistical analysis, including T-test, ANOVA, and descriptive statistics. RESULTS: There were 21 total participants. Median scores for full speed versus slow motion video review were 47% and 60% respectively. When analyzed by training level, there was no significant difference in scores for full speed videos, but there was a significant difference across groups for slow motion review (p = 0.04). Post Graduate Year (PGY) 4 residents and pediatric otolaryngologists performed best with an average of 69% and 77% respectively. Base of tongue, subglottic, and laryngeal cleft lesions were the most difficult to diagnose. Motor, laryngeal, and vallecular pathologies were more accurately identified. CONCLUSIONS: The ability to diagnose pathology on pediatric laryngoscopy tends to improve throughout residency training. Slow motion review enhances diagnostic skills. Laryngeal and vallecular pathologies are more easily diagnosed than base of tongue and subglottic lesions.

Smartphone capture of flexible laryngoscopy: Optics, subsite visualization, and patient satisfaction.

OBJECTIVE: To determine whether a smartphone adaptor can record laryngoscopic videos of adequate quality for clinical diagnosis and communication among otolaryngologists and assess the impact of recorded exams on patient satisfaction. METHODS: Twenty adult inpatients undergoing flexible laryngoscopy in a tertiary care medical center were prospectively enrolled. Each subject's larynx was visualized with the standard laryngoscope eyepiece and with an attached mobile phone adaptor with video recording capabilities. A 5-point Likert scale was used by the resident performing the scope to grade the adaptor and eyepiece exams. The same scale was used by an offsite otolaryngology attending to grade the adaptor video. Patients were shown the video, and a satisfaction survey was administered. RESULTS: In all patients, the adaptor was easy to use and required minimal setup. Ninety percent of patients reported an increase in satisfaction after watching the video of their exam. The eyepiece was superior to the adaptor in resolution, focus, color fidelity, brightness, and optical fluidity (P < 0.05). The video recording was deemed sufficient for clinical assessment in 90% of cases. The offsite reviewer determined that there would be "little" (15%) or "no value" (65%) in repeating the scope exam in the majority of patients. The laryngeal subsites were equally visible with the eyepiece and the adaptor ("full view," 85%-100%). CONCLUSION: Laryngoscopy videos recorded by a portable smartphone adaptor are sufficient for clinical evaluation in the majority of cases. This technology may improve patient satisfaction and communication among clinicians. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2147-2152, 2019.