COVID-19 vaccination, risk-compensatory behaviours, and contacts in the UK.

The physiological effects of vaccination against SARS-CoV-2 (COVID-19) are well documented, yet the behavioural effects not well known. Risk compensation suggests that gains in personal safety, as a result of vaccination, are offset by increases in risky behaviour, such as socialising, commuting and working outside the home. This is potentially important because transmission of SARS-CoV-2 is driven by contacts, which could be amplified by vaccine-related risk compensation. Here, we show that behaviours were overall unrelated to personal vaccination, but-adjusting for variation in mitigation policies-were responsive to the level of vaccination in the wider population: individuals in the UK were risk compensating when rates of vaccination were rising. This effect was observed across four nations of the UK, each of which varied policies autonomously.

Implication of American Society of Anesthesiologists Physical Status (ASA-PS) on tonsillectomy with or without adenoidectomy outcomes.

BACKGROUND: The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T ± A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T ± A. STUDY DESIGN: A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T ± A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups. RESULTS: On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p ≤ 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay >1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T ± A. CONCLUSION: Higher ASA-PS classification is an independent predictor of complications following T ± A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T ± A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

Examining the pediatric subglottic airway by ultrasound: A systematic review.

OBJECTIVE: The purpose of this review was to determine the ability of ultrasound (US) to assess the subglottic airway in pediatric patients to estimate the appropriate size of endotracheal tube (ETT). DATA SOURCES: Pubmed, Scopus, and Embase databases. METHODS: A search of the literature was performed for studies that utilized ultrasonography to examine the minimal transverse diameter of the subglottic airway (MTDSA) in the pediatric (age < 18) population to estimate endotracheal tube (ETT) size. Articles were excluded if they involved adults or non-humans, had no comparison method, or were case reports. The primary outcome was the successful use of ultrasound compared to the reference standard defined by the study. RESULTS: Sixteen studies were included, for a total of 1,633 pediatric subjects in whom transcervical laryngeal ultrasound was used prospectively to examine the MTDSA to estimate ETT size prior to intubation. Ultrasound reliably predicted the clinically best fit endotracheal tube by air leak test in 48-100% of subjects, while age-based formulas were accurate 24-95% of the time. Ultrasound was highly predictive of proper size, with R2 ranging between 0.684 to 0.980. Of those reintubated (n = 104), 86 (83%) required larger-sized tubes, while 18 (17%) required smaller-sized tubes. Both methods tended to underestimate ETT size, but the age-based formulas accounted for most of these differences. CONCLUSION: Transcervical laryngeal ultrasound appears to be a reliable predictor of endotracheal tube size in children undergoing elective surgery, which has implications for preventing intubation-related trauma and ensuring adequate ventilation for those who may require prolonged intubation.

Telehealth Adoption and Perspectives Among Pediatric Otolaryngologists Following the COVID-19 Pandemic.

OBJECTIVES: To assess use of and physician experiences with pediatric otolaryngology telehealth visits as impacted by the COVID-19 pandemic. STUDY DESIGN/SETTING: Cross sectional survey. METHODS: A 15-question survey was electronically distributed to 656 members of the American Society of Pediatric Otolaryngology in August 2021, addressing member demographics, experiential practice elements, and use pre-pandemic, during the initial shutdown period of March-May 2020, and current use at the time of survey inquiry. RESULTS: There were 124 respondents (response rate = 18.9%). Incident use pre-pandemic and during the shutdown were 21.0% (n = 26), and 92.7% (n = 115), respectively. Current use was 83.9% (n = 104) and the percentage of new current users (79.5%, n = 78) was significant (P < .0001,95% CI = 70.6%-86.4%). Estimated median telehealth visit rates pre-pandemic, during shutdown, and currently were 0 to 1, 4 to 5, and 2 to 3 per week, respectively (P < .0001). A difference in post-covid adoption rates was noted only for location (P = .008), with no differences for years out of training or practice type. Compared to in-person visits, physician satisfaction with telehealth visits was rated equivalent (49.0%) or worse/much worse (48.1%). The most common telehealth uses were follow-up visits (83.7%), pre-operative counseling (76.9%), and post-operative evaluation (69.2%). The need for a detailed exam (89.4%) and initial visits (32.7%) were reasons a telehealth visit was not offered. CONCLUSIONS: The COVID-19 pandemic appears to have precipitated a rapid increase in telehealth adoption among surveyed pediatric otolaryngologists, regardless of age or practice type. The most significant limitations remain the need for a detailed exam, perceived low patient technological literacy, and limitations to interpretive services. Technology-based optimization of these barriers could lead to increased use and physician satisfaction.

Outcomes of Mastoidectomy With Antibiotic Catheter Irrigation for Patients With Draining Ventilation Tubes.

OBJECTIVES: To evaluate the effectiveness of mastoidectomy with antibiotic catheter irrigation in patients with chronic tympanostomy tube otorrhea. METHODS: A chart review of adult and pediatric patients with persistent tympanostomy tube otorrhea who had failed outpatient medical management and underwent mastoidectomy with placement of a temporary indwelling catheter for antibiotic instillation was performed. Patients were retrospectively followed for recurrent drainage after 2 months and outcomes were categorized as resolution (0-1 episodes of otorrhea or otitis media with effusion during follow-up), improvement (2-3 episodes), or continued episodic (>3 episodes). RESULTS: There were 22 patients and 23 operated ears. Median age was 46 years (interquartile range, IQR = 29-65). The median duration of otorrhea from referral was 5.5 months (IQR = 2.8-12). Following surgery, 14 ears had resolution of drainage, 6 had improvement, and 3 had episodic. The observed percentage of resolved/improved ears (87%) was significant (P = .0005, 95% CI = 67.9%-95.5%). Median follow-up time was 25 months (IQR = 12-59). Pre and postoperative pure tone averages improved (difference of medians = -3.3 dB, P = .02) with no significant difference in word recognition scores (P = .68). Methicillin-resistant Staphylococcus aureus was the most common isolated microbe while no growth was most frequently noted on intraoperative cultures. CONCLUSIONS: Mastoidectomy with antibiotic catheter irrigation may be an effective surgical strategy, and single stage alternative to intravenous antibiotics, for select patients with persistent tube otorrhea who have failed topical and oral antibiotics.

Monitoring populations at increased risk for SARS-CoV-2 infection in the community using population-level demographic and behavioural surveillance.

BACKGROUND: The COVID-19 pandemic is rapidly evolving, with emerging variants and fluctuating control policies. Real-time population screening and identification of groups in whom positivity is highest could help monitor spread and inform public health messaging and strategy. METHODS: To develop a real-time screening process, we included results from nose and throat swabs and questionnaires taken 19 July 2020-17 July 2021 in the UK's national COVID-19 Infection Survey. Fortnightly, associations between SARS-CoV-2 positivity and 60 demographic and behavioural characteristics were estimated using logistic regression models adjusted for potential confounders, considering multiple testing, collinearity, and reverse causality. FINDINGS: Of 4,091,537 RT-PCR results from 482,677 individuals, 29,903 (0·73%) were positive. As positivity rose September-November 2020, rates were independently higher in younger ages, and those living in Northern England, major urban conurbations, more deprived areas, and larger households. Rates were also higher in those returning from abroad, and working in healthcare or outside of home. When positivity peaked December 2020-January 2021 (Alpha), high positivity shifted to southern geographical regions. With national vaccine roll-out from December 2020, positivity reduced in vaccinated individuals. Associations attenuated as rates decreased between February-May 2021. Rising positivity rates in June-July 2021 (Delta) were independently higher in younger, male, and unvaccinated groups. Few factors were consistently associated with positivity. 25/45 (56%) confirmed associations would have been detected later using 28-day rather than 14-day periods. INTERPRETATION: Population-level demographic and behavioural surveillance can be a valuable tool in identifying the varying characteristics driving current SARS-CoV-2 positivity, allowing monitoring to inform public health policy. FUNDING: Department of Health and Social Care (UK), Welsh Government, Department of Health (on behalf of the Northern Ireland Government), Scottish Government, National Institute for Health Research.

Comparison of Pediatric Otolaryngology clinical and operative case volume among surgical specialties in the COVID-19 pandemic.

OBJECTIVES: To report changes in clinical and surgical volume impacting a Pediatric Otolaryngology division one year prior to and following the onset of the COVID-19 pandemic in comparison to five other pediatric surgical subspecialties. METHODS: The number of clinical visits and surgical cases per month for six pediatric surgical specialties (Otolaryngology, Orthopedic Surgery, Urology, Neurosurgery, Plastic Surgery, and General Surgery) for 12 months prior to the pandemic and 12 months following the onset of the pandemic was collected. Poisson regression analysis was performed for the number of visits and cases per season adjusting for specialty, season, staffing changes, and the pandemic to determine adjusted rate ratios (aRR) post-pandemic for the surgical fields compared to Otolaryngology. RESULTS: A percentage decrease in median visits per paired month (-15.63%, IQR = -23.01, -1.66) and operative cases (-19.86%, IQR = -29.39, -10.17) was seen for Pediatric Otolaryngology. Regression analysis showed a significant negative effect on the number of visits (aRR = 0.74, 95% CI = 0.70-0.77) and cases (aRR = 0.65, 95% CI = 0.60-0.71) due to the pandemic. While many of the other specialties had predicted reductions in volume (notably Orthopedics), they all experienced significant predicted increases in productivity following the pandemic compared to Otolaryngology. CONCLUSIONS: These findings suggest that Pediatric Otolaryngology is particularly vulnerable to this change in clinical pattern, which could be due to a decline in community infections from mask wearing and social distancing, and may result in a longer-term volume deficit when compared to other pediatric surgical subspecialties.

Impact of vaccination on new SARS-CoV-2 infections in the United Kingdom.

The effectiveness of COVID-19 vaccination in preventing new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in the general community is still unclear. Here, we used the Office for National Statistics COVID-19 Infection Survey-a large community-based survey of individuals living in randomly selected private households across the United Kingdom-to assess the effectiveness of the BNT162b2 (Pfizer-BioNTech) and ChAdOx1 nCoV-19 (Oxford-AstraZeneca; ChAdOx1) vaccines against any new SARS-CoV-2 PCR-positive tests, split according to self-reported symptoms, cycle threshold value (<30 versus ≥30; as a surrogate for viral load) and gene positivity pattern (compatible with B.1.1.7 or not). Using 1,945,071 real-time PCR results from nose and throat swabs taken from 383,812 participants between 1 December 2020 and 8 May 2021, we found that vaccination with the ChAdOx1 or BNT162b2 vaccines already reduced SARS-CoV-2 infections ≥21 d after the first dose (61% (95% confidence interval (CI) = 54-68%) versus 66% (95% CI = 60-71%), respectively), with greater reductions observed after a second dose (79% (95% CI = 65-88%) versus 80% (95% CI = 73-85%), respectively). The largest reductions were observed for symptomatic infections and/or infections with a higher viral burden. Overall, COVID-19 vaccination reduced the number of new SARS-CoV-2 infections, with the largest benefit received after two vaccinations and against symptomatic and high viral burden infections, and with no evidence of a difference between the BNT162b2 and ChAdOx1 vaccines.

Resident Education in Laryngeal Stroboscopy: Part II-Evaluation of a Multimedia Training Module.

OBJECTIVE: To evaluate the efficacy of a web-based training module for teaching interpretation of laryngeal stroboscopy in a cohort of otolaryngology residents. STUDY DESIGN: Randomized controlled trial. SETTING: Academic tertiary center. SUBJECTS AND METHODS: Residents from three training programs were invited to complete an assessment consisting of a survey and five stroboscopic exams. Subsequently, participants were randomized to receive teaching materials in the form of (1) a handout (HO) or (2) a multimedia module (MM) and asked to complete a post-training assessment. Responses were compared to responses provided by three fellowship-trained laryngologists. RESULTS: Thirty-five of 47 invited residents (74.4%) completed both assessments. Overall mean postassessment scores were 64.3% ± 7.0, with the MM group (67.0% ± 7.6, n = 17) scoring higher (P = 0.03) than the HO (61.6% ± 5.4, n = 18) cohort. Postassessment scores did not differ by postgraduate year (P = 0.75) or institution (P = 0.17). Paired analysis demonstrated an overall mean improvement of 7.4% in the handout (HO) cohort (P = 0.03) and 10.3% in the MM cohort (P = 0.0006). Subset analysis demonstrated higher scores for the MM cohort for perceptual voice evaluation (HO = 68.8% ± 11.0; MM = 77.3% ± 10.6, P = 0.03) and stroboscopy-specific items (HO = 55.5% ± 8.2; MM = 61.9% ± 10.8, P = 0.06). On a five-point Likert scale, residents reported improved confidence in stroboscopy interpretation (P < 0.0001), irrespective of cohort (P = 0.62). Residents rated the MM (median = 5) more favorably as a teaching tool compared to the HO (median = 4, P = 0.001). CONCLUSION: Use of both the written HO and MM module improved scores and confidence in interpreting laryngeal stroboscopy. The MM was more effective in perceptual voice evaluation and stroboscopy-specific items. The MM was also rated more favorably by residents and may be an ideal adjunct modality for teaching stroboscopy.

Impact of Diabetes Mellitus Following Tonsillectomy in Adults: A National Surgical Quality Improvement Program Analysis.

OBJECTIVES: To identify 30-day complication rates specific to patients with diabetes mellitus following tonsillectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing tonsillectomy between 2005 and 2018. Patients were stratified into 3 cohorts: insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM), and non-diabetes mellitus (NODM). Coarsened-exact-matching was utilized to account for baseline differences between cohorts. Outcomes studied included post-operate complications, prolonged hospitalization, and unplanned readmissions. RESULTS: A total of 986 DM and 26 774 NODM patients were included, and the mean age of patients undergoing tonsillectomy was 29.5 ± 11.6 and 28.7 ± 11.0 years, respectively. The majority of patients were female (70.5% for both DM and NODM cohorts) and White/Caucasian (89.2% vs 89.3%). Among patients undergoing tonsillectomy, a greater proportion of DM patients experienced an operative time greater than or equal to the 75th percentile (35 minutes; 25.9% vs 22.8%, P = .024), overall morbidity (12.6% vs 5.4%, P < .001), pneumonia (0.6% vs 0.2%, P = .036), and reoperation (10.2% vs 3.5% P < .001) in comparison to NODM patients. In an analysis between IDDM (n = 379) and NIDDM (n = 211) patients, IDDM patients were at an increased risk for prolonged hospitalization (1.4% vs 0.0%, P = .045), pneumonia (5.2% vs 0.5%, P < .001), urinary tract infections (3.3% vs 0.3% P = .004), major complications (15.6% vs 7.7%, P = .002), minor complications (19.9% vs 8.2%, P < .001), and overall complications (10.0% vs 1.3%, P < .001). CONCLUSION: DM patients are at a heightened risk for complications following tonsillectomy. Standardized protocols, careful pre-operative planning, and stringent glycemic management may help optimize patient outcomes.

The Postcricoid Cushion: An Unusual and Surgically Treatable Cause of Infant Aspiration.

OBJECTIVES: To highlight the importance of recognizing the postcricoid cushion as a surgically treatable cause of newborn aspiration in select cases unresponsive to conservative measures. METHODS: A retrospective review was performed on a single case of neonatal aspiration at a tertiary care pediatric hospital. RESULTS: Resolution of aspiration was achieved in an otherwise healthy six-week old term infant following ablation of a postcricoid cushion using microlaryngeal instrumentation and coblation. Prior airway and swallowing evaluations, along with a trial of reflux therapy and pacing of feeds, preceded the surgical excision, successfully avoiding gastrostomy tube placement. CONCLUSIONS: Otolaryngology consults for neonatal dysphagia and aspiration are challenging. The postcricoid cushion is considered an anatomic variant that can engorge with crying. When large, it can prevent feeds from entering the esophagus and lead to pooling and aspiration. The postcricoid cushion is evident on flexible fiberoptic laryngoscopy, but without a vigilant eye may be easily overlooked. This single case report suggests that surgical ablation may be effective management in select cases after ruling out concomitant aerodigestive pathology and neurodevelopmental causes of aspiration and only after conservative therapy has failed. A video demonstrating the surgical ablation is included.

Novel use of lip balm under tracheostomy ties to prevent skin irritation in the pediatric patient.

OBJECTIVES: To study the effectiveness of lip balm in reducing skin irritation and preventing pressure induced injury in tracheostomy dependent children. METHODS: The skin of tracheostomy patients presenting to a pediatric otolaryngology clinic over a 12 month period from 2018 to 2019 was assessed and categorized as hyperemic blanchable (abnormal pre-pressure injury), hyperemic non-blanchable, partial thickness skin loss, or full thickness skin loss. Caregivers were instructed to apply lip balm to the skin under soft ties three times per day and with tracheostomy tie changes. Patients were followed prospectively by a tracheostomy care nurse. RESULTS: 24 patients enrolled and reported daily adherence with lip balm use. Median age was 7.3 years (interquartile range, IQR, = 1.3-12.4) with 10 females and 14 males. The majority of patients (n = 20) were identified as having hyperemic blanchable skin. 96% (23/24) of caregivers reported a subjective benefit. 79.2% (95% CI: 57.8%-92.9%) of patients with hyperemic skin (n = 24) demonstrated complete resolution with continued application, and was found to be significant: all patients had skin hyperemia before application, while 20.8% (5/24) continued to have hyperemia after application (P < .001). Infants and ventilation dependent patients demonstrated recovery rates of 88.9% and 75% respectively. Median duration of follow-up was 6.3 months (IQR = 3.4-11.3). There were no documented allergic reactions, accidental decannulations, or skin deterioration in the cohort. CONCLUSIONS: Lip balm appears to be a low cost, hydrophobic, and friction-reducing agent that is potentially useful in preventing at risk pressure injuries in tracheostomy dependent pediatric patients.

The Role of Mastoidectomy in Draining Ventilation Tubes.

OBJECTIVES: To discuss the indication for performing a mastoidectomy with catheter placement in patients with chronic tympanostomy tube otorrhea. METHODS: The Medical Literature Analysis and Retrieval System Online was searched via PubMed for relevant articles using serous mastoiditis, mastoidectomy, chronic otorrhea, tube otorrhea, tympanostomy tubes, and biofilm as keywords. RESULTS: Further understanding of the pathophysiology of otorrhea and the development of ototopical fluoroquinolones have made a draining tympanostomy tube more manageable. Nevertheless, chronic otorrhea refractory to an otolaryngologist's traditional treatment algorithm still occurs and may benefit from a mastoidectomy with antibiotic irrigation using a catheter in certain cases. We theorize that resolution of otorrhea results from this technique by decreasing the burden of diseased mucosa and providing a larger concentration or dose of antibiotic to the middle ear cleft through the antrum. High-resolution images of the technique and catheter placement are included in this review. CONCLUSIONS: Despite being an uncommon management strategy, the literature suggests an indication for performing a mastoidectomy in a small percentage of patients with a chronically draining tympanostomy tube.

Resident Education in Laryngeal Stroboscopy and Perceptual Voice Evaluation: An Assessment.

OBJECTIVES: To evaluate otolaryngology residents' level of confidence and understanding in interpreting laryngeal stroboscopy. METHODS: Otolaryngology residents from three residency programs with fellowship-trained laryngologists on faculty were invited to participate. An assessment consisting of a survey and five stroboscopic exams was administered. Each exam consisted of questions on perceptual voice evaluation, laryngoscopic findings, and stroboscopic findings. Scores were compared to answers provided by three fellowship-trained laryngologists. RESULTS: Thirty-eight of 47 invited residents (80.8%) enrolled in the study. On a five-point likert scale, residents reported low confidence (median = 2, range = 1-4) in interpreting stroboscopy, regardless of training program (P = 0.81). Mean assessment scores were 56.5% ± 11.9, with scores in perceptual voice evaluation = 68.5% ± 10.6; laryngoscopy = 70.2% ± 12.8; and stroboscopy = 45.3% ± 17.8. Residents performed worse on stroboscopy questions compared to laryngoscopy questions (P < 0.0001). There was a significant difference in scores by postgraduate year (P = 0.03), but not by institution (P = 0.34). A moderately positive correlation between reported level of confidence and overall scores (ρ = .47, P = 0.003) was demonstrated. CONCLUSIONS: Despite didactic and clinical exposure, residents report low confidence in interpreting stroboscopy and scored lower on stroboscopy-specific questions compared to other assessment items. Additional resources and learning opportunities are needed to improve resident confidence and comprehension of stroboscopy.

Endobronchial Non-Tuberculosis Mycobacterium Infection Presenting in a Healthy Child.

OBJECTIVES: To describe a safe and effective treatment for endobronchial Mycobacterium avium complex. METHODS: Case report and literature review. RESULTS: We present a case of endobronchial M. avium complex in a healthy child treated with serial carbon-dioxide laser excisions and antibiotic triple therapy using azithromycin, rifampin, and ethambutol. No current guideline for the treatment of these lesions in the pediatric population exists. CONCLUSIONS: In patients with airway impingement, serial endoscopic surgical resection combined with antibiotics can provide safe and effective management.

Steroid Versus Antibiotic Drops in the Prevention of Postoperative Myringotomy Tube Complications.

OBJECTIVES: To determine the incidence of early postoperative tympanostomy tube insertion otorrhea and obstruction in pediatric patients receiving antibiotic ear drops with or without steroid perioperatively. METHODS: A retrospective chart review was performed on patients who underwent outpatient myringotomy and tube placement. Patients from June 2013 to February 2014 received ciprofloxacin/dexamethasone perioperatively while patients from May 2014 to April 2015 received ofloxacin. Statistical analysis was performed to compare outcomes between the cohorts. RESULTS: One hundred thirty-four patients received topical ciprofloxacin/dexamethasone, and 116 patients received topical ofloxacin. The rate of postoperative otorrhea was 5.2% for the ciprofloxacin/dexamethasone group and 8.2% for the ofloxacin group. Tube obstruction was seen in 6.0% of the ciprofloxacin/dexamethasone group and 5.2% in the ofloxacin group. Neither outcome had a statistically significant difference ( P = .21 and .85, respectively). There was no difference in the rate of effusion at the time of tube placement between the 2 cohorts ( P = .16), and this included subgroup analysis based on effusion type (mucoid, purulent, serous). Patients with a mucoid effusion at the time of surgery were more likely to experience otorrhea/obstruction than patients with dry ears (odds ratio = 2.23, P = .02). CONCLUSION: No significant difference in the incidence of immediate postoperative tympanostomy tube otorrhea or obstruction was seen between the antibiotic-steroid and antibiotic alone cohorts, regardless of effusion type. Overall, patients with mucoid effusions are more likely to develop tube otorrhea or obstruction at follow-up. Cost-effective drops should be used when prescribing topical therapy to prevent complications after ear tubes.

Airway Anomalies in Patients With 22q11.2 Deletion Syndrome: A 5-Year Review.

OBJECTIVES: To characterize the frequency of airway anomalies in patients with 22q11.2 deletion syndrome (22q11DS). METHODS: Retrospective review of patients with 22q11DS who had undergone microlaryngoscopy/bronchoscopy (MLB) for aerodigestive symptoms at a tertiary care children's hospital from 2011 to 2016. RESULTS: Thirty patients underwent an MLB due to the following indications: aspiration (11), stridor (10), chronic respiratory failure due to ventilator dependence (8), and difficult intubation (1). Median age at MLB was 6.5 months (range, 0.25-32 months). Forty airway anomalies were identified in 20 (66%) patients. Laryngomalacia (10), tracheomalacia (8), and bronchomalcia (8) were the most common intraoperative findings, followed by laryngeal cleft (5), anterior glottic web (5), subglottic stenosis (3), and subglottic cysts (1). Synchronous airway anomalies were common and identified in 11 (55%) of the patients who had identified anomalies on MLB. Nineteen of the 20 patients required operative intervention due to the anomalies identified. CONCLUSIONS: Structural airway abnormalities are common in children with 22q11DS undergoing MLB, and synchronous anomalies can frequently exist. Providers caring for children with 22q11DS should be vigilant about airway evaluation when aerodigestive symptoms are present.

Differential Gene Expression and Pathway Analysis in Juvenile Nasopharyngeal Angiofibroma Using RNA Sequencing.

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascularized and locally aggressive tumor that typically presents in adolescent males. The molecular biology of this tumor remains understudied. We sought to identify differentially expressed genes in the JNA transcriptome through messenger RNA sequencing of primary fibroblasts from 2 tumor explants and tonsil tissue from tumor-free subjects. In total, 1088 significant, differentially expressed genes were identified with 749 upregulated and 339 downregulated. Pathway analysis identified a number of activated signaling pathways, most notably, the vascular endothelial growth factor (VEGF) pathway (adjusted overlap P = .03). VEGF-A showed a 4.4-fold upregulation in JNA samples. In addition, the angiogenic receptor, fibroblast growth factor receptor 2 (FGFR2), was not present in tumor-free samples but increased in JNA. We validate these findings with immunohistochemistry, demonstrating upregulation of VEGF and FGFR2 in patient sections. Inhibition of the VEGF or FGFR signaling axes may have therapeutic potential in the treatment of JNA.