Quality tracheotomy care can be maintained for non-COVID patients during the COVID-19 pandemic.

Objectives: To analyze changes in tracheotomy practices at the onset of the COVID-19 pandemic, and determine if quality patient care was maintained. Methods: This was a single institution retrospective study that included patients undergoing tracheotomy from May 2019 to January 2021. Patients were divided into two groups, pre-COVID and post-COVID. Only three patients tested positive for COVID-19, and they were excluded from the study. Data were collected from the electronic medical record. Statistical analyses were performed using 2-tailed independent t tests, Wilcoxon Rank Sum tests, Chi-Square tests, and Kaplan-Meier curves. Results: There were 118 patients in the pre-COVID group and 91 patients in the post-COVID group. The main indication for tracheotomy in both groups was prolonged intubation. There were no significant differences in overall length of stay, time to tracheotomy, duration of tracheotomy procedure, or time to initial tracheotomy change between the two groups. Due to protocols implemented at our institution to limit viral transmission, there were significant increases in the percent of tracheotomies performed in the OR (p = .02), and those performed via open technique (p = .04). Additionally, the median time to decannulation significantly decreased in the post-COVID group (p = .02). Conclusion: Several variables regarding the timing of patient care showed no significant differences between groups which demonstrates that quality patient care was maintained. It is important to note that this data was collected early in the Pandemic, and additional trends may become apparent over time. Level of evidence: 4.

Can a flexible surgical robot be used in the pediatric population: A feasibility study.

OBJECTIVES: Transoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population. METHODS: This was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale. RESULTS: A total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects. CONCLUSIONS: This study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.

Otolaryngology in the face of A pandemic.

Although infrequent, pandemics are serious public health concerns with unpredictable courses. The COVID-19 pandemic began over 2 years ago and is far from over. This pandemic has spread rapidly throughout the world and led to several million deaths, making it commonly compared to the deadly Spanish influenza pandemic. Policy and safety measures are constantly being adapted to reduce transmission rates. The pandemic places stress on all healthcare workers, but especially otolaryngology providers due to their direct contact with airway connected cavities. This puts them at high risk for infection and has impacted inpatient and outpatient otolaryngology care, as well as education, research, and mental health.

Iatrogenic Tracheal Injuries: Case Series and Review of the Literature.

Iatrogenic tracheal injuries are an uncommon but serious complication of endotracheal tube intubation. We present two cases that illustrate iatrogenic tracheal injuries presenting hours after the time of their injury. This report addresses the critical diagnostic evaluation and management of iatrogenic tracheal injuries resulting from endotracheal intubation.

In RRP, serologic response to HPV is frequently absent and slow to develop.

BACKGROUND: Recurrent respiratory papillomatosis (RRP) is characterized by repeated formation of papillomas in the respiratory tract and is caused by human papillomavirus (HPV) types 6 and 11. Women with genital HPV infection are slow to develop weak humoral immunity, but respond robustly to the HPV vaccine. We wondered if people with RRP had a similar immune response. METHODS: A convenience cross-sectional sample of patients with RRP were recruited into one of four groups: 1) adults and adolescents with active RRP, 2) children with active RRP, 3) RRP patients who had undergone HPV vaccination prior to enrollment and, 4) people with RRP who were in remission. Anti-HPV6 and HPV11 serology was determined by cLIA on a single blood draw. RESULTS: Of the 70 subjects enrolled, 36, 16, 8, and 10, were in groups 1, 2, 3, and 4, respectively. 47% of participants aged >11 years and 81% aged ≤11 years possessed no antibodies against HPV6 or HPV11 (ie. double seronegative). 61% of patients in remission were double seronegative. All participants who had received HPV vaccine previously were seropositive to at least one of these low risk HPV types (ie none of them were double seronegative). Among patients who had active RRP and never had HPV vaccination (n = 52) there was an association between duration of symptoms and seropositivity. Of those who were seropositive, the geometric mean duration of symptoms was 11 years compared to 4.7 years for those who were seronegative (p = 0.001). CONCLUSION: People with RRP are capable of developing a humoral response to HPV6 and HPV11. That response appears to be robust when initiated by the HPV vaccine, but either nonexistent or slow to develop in response to infection. Most in remission do not have demonstrable antibody levels against HPV6 or HPV11.

The Generalizability of the Clinical Assessment Score-15 for Pediatric Sleep-Disordered Breathing.

OBJECTIVE: The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion. METHODS: Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15. RESULTS: Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P < .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1. CONCLUSION: This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing. LEVEL OF EVIDENCE: 2B Laryngoscope, 130:2256-2262, 2020.

Age at diagnosis, but not HPV type, is strongly associated with clinical course in recurrent respiratory papillomatosis.

BACKGROUND: Recurrent Respiratory Papillomatosis (RRP) is a rare disease characterized by the growth of papillomas in the airway and especially the larynx. The clinical course is highly variable among individuals and there is poor understanding of the factors that drive an aggressive vs an indolent course. METHODS: A convenience cohort of 339 affected subjects with papillomas positive for only HPV6 or HPV11 and clinical course data available for 1 year or more, from a large multicenter international study were included. Exploratory data analysis was conducted followed by inferential analyses with frequentist and Bayesian statistics. RESULTS: We examined 339 subjects: 82% were diagnosed prior to the age of 18 years, 65% were infected with HPV6, and 69% had an aggressive clinical course. When comparing age at diagnosis with clinical course, the probability of aggressiveness is high for children under five years of age then drops rapidly. For patients diagnosed after the age of 10 years, an indolent course is more common. After accounting for confounding between HPV11 and young age, HPV type was minimally associated with aggressiveness. Fast and Frugal Trees (FFTs) were utilized to determine which algorithms yield the highest accuracy to classify patients as having an indolent or aggressive clinical course and consistently created a branch for diagnostic age at ~5 years old. There was no reliable strong association between clinical course and socioeconomic or parental factors. CONCLUSION: In the largest cohort of its type, we have identified a critical age at diagnosis which demarcates a more aggressive from less aggressive clinical course.

Effectiveness of Powered Intracapsular Tonsillectomy in Children With Severe Obstructive Sleep Apnea.

IMPORTANCE: Powered intracapsular tonsillectomy and adenoidectomy (PITA) is an increasingly common pediatric procedure. Few studies have examined its effectiveness in children with severe obstructive sleep apnea (OSA). OBJECTIVE: To assess the effectiveness of PITA in patients with severe OSA as evidenced by change in polysomnographic parameters. DESIGN, SETTING, AND PARTICIPANTS: We performed a case series study with medical record review of 70 children with severe OSA who underwent PITA at a tertiary care pediatric hospital from January 1, 2010, through December 31, 2014. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative polysomnographic parameters. RESULTS: Of the 70 children with severe OSA who underwent PITA, 39 (56%) were boys, and the median age at surgery was 3.7 years. There were significant mean (SD) decreases in the postoperative apnea-hypopnea index (32.4 [28.4] vs 5.8 [9.7], P < .001), obstructive apnea index (20.4 [17.97] vs 2.55 [5.9]), obstructive apnea-hypopnea index (25.5 [22.4] vs 3.9 [7.3], P < .001), arousal index (53.7 [33.9] vs 27.4 [22.6], P < .001), percentage of total sleep time spent snoring (28.6 [30.5] vs 13.6 [20.8], P = .001), and oxygen desaturation index of 4% or more (22.9 [26.4] vs 4.5 [9.9], P < .001). Mean (SD) oxygen saturation (96.8 [2.0] vs 98.2 [1.3], P < .001) and oxygen saturation nadir (75.5 [13.1] vs 88.4 [8.1], P < .001) increased significantly. A significant decrease in time was observed with an end-tidal carbon dioxide greater than 55 mm Hg (49.67 [97.5] vs 19.1 [73.9] minutes, P = .01). CONCLUSIONS AND RELEVANCE: Powered intracapsular tonsillectomy and adenoidectomy improved OSA in this series of pediatric patients by reducing obstructive apneas and hypopneas, oxygen desaturation, arousal index, carbon dioxide level, and snoring, as well as increasing oxygen saturation nadir. Results are comparable to those described for traditional electrocautery tonsillectomy and support the use of PITA for the treatment of severe OSA in children with adenotonsillar hypertrophy.