Fetoscopic Balloon Dilation and Stent Placement of Congenital High Airway Obstruction Syndrome Leading to Successful Cesarean Delivery.

INTRODUCTION: Without fetal or perinatal intervention, congenital high airway obstruction syndrome (CHAOS) is a fatal anomaly. The ex utero intrapartum treatment (EXIT) procedure has been used to secure the fetal airway and minimize neonatal hypoxia but is associated with increased maternal morbidity. CASE PRESENTATION: A 16-year-old woman (gravida 1, para 0) was referred to our hospital at 31 weeks gestation with fetal anomalies, including echogenic lungs, tracheobronchial dilation, and flattened diaphragms. At 32 weeks, fetoscopic evaluation identified laryngeal stenosis, which was subsequently treated with balloon dilation and stent placement. The patient developed symptomatic and regular preterm contractions at postoperative day 7 with persistent sonographic signs of CHAOS, which prompted a repeat fetoscopy with confirmation of a patent fetal airway followed by Cesarean delivery under neuraxial anesthesia. Attempts to intubate through the tracheal stent were limited and resulted in removal of the stent. A neonatal airway was successfully established with rigid bronchoscopy. Direct laryngoscopy and bronchoscopy confirmed laryngeal stenosis with a small tracheoesophageal fistula immediately inferior to the laryngeal stenosis and significant tracheomalacia. A tracheostomy was then immediately performed for anticipated long-term airway and pulmonary management. The procedures were well tolerated by both mom and baby. The baby demonstrated spontaneous healing of the tracheoesophageal fistula by day of life 7 with discharge home with ventilator support at 3 months of life. CONCLUSION: Use of repeated fetoscopy in order to relieve fetal upper airway obstruction offers the potential to minimize neonatal hypoxia, while concurrently decreasing maternal morbidity by avoiding an EXIT procedure. Use of the tracheal stent in CHAOS requires further investigation. The long-term reconstruction and respiratory support of children with CHAOS remain challenging.

Surgical Techniques for Tonsillectomy and Perioperative Respiratory Complications in Children.

OBJECTIVES: The aim of this study was to determine the incidence of perioperative respiratory complications in children following tonsillectomy with cold and hot dissection surgical techniques. STUDY DESIGN: The study was a retrospective cohort study. SETTING: Retrospective chart review was performed for all children presenting for a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. METHODS: Pre- and intraoperative patient factors, including surgical technique with cold or hot dissection (electrocautery or radiofrequency ablation), and perioperative anesthetic factors were collected to determine the incidence of perioperative respiratory complications. RESULTS: A total of 2437 patients underwent a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. The incidence of perioperative respiratory complications was 20.0% (n = 487). Sickle cell disease, cardiac disease, reactive airway disease, pulmonary disease, age >2 and <3 years, and obesity, defined as a body mass index >95th percentile for age, were significant for overall perioperative respiratory complications. There was no difference in the incidence of perioperative respiratory complications in children undergoing tonsillectomy by cold or hot dissection. CONCLUSION: Perioperative respiratory complications following tonsillectomy are more affected by patient factors than surgical technique.

Perinatal characteristics and early childhood follow up after ex-utero intrapartum treatment for head and neck teratomas by prenatal diagnosis.

BACKGROUND: Ex utero intrapartum treatment (EXIT) is utilized for safe delivery when a baby has a compromised airway. The purpose of this retrospective study was to examine the indications and outcomes of 11 children presenting with airway occluding oropharyngeal and cervical teratomas. METHODS: Study of all children with an airway occluding teratoma delivered via EXIT (2001-2018) in our unit. Primary outcomes included survival and tracheostomy at discharge. Data are reported using descriptive statistics as median (range) and rate (%). RESULTS: We performed 45 EXIT procedure performed between January 2001 and April 2018. Of these, eleven were for cervical and/or upper airway teratoma. Ten (91%) cases had associated polyhydramnios, two (18%) developed nonimmune hydrops, and eight (72%) delivered preterm. Six (45.5%) were performed as an emergency. Estimated blood loss was 1000 ml (500, 1000). The neonatal mortality rate was 18% (2/11) and 33% (3/9) of the survivors were discharged with a tracheostomy. CONCLUSION: EXIT is a reasonable option for delivery of babies with an occlusive upper airway mass. Neonatal survival depends on individualized factors but may be as high as 82% in those with teratoma.

EXIT (ex utero Intrapartum Treatment) to Airway Procedure for Twin Fetuses With Oropharyngeal Teratomas: Lessons Learned.

Ex utero intrapartum treatment (EXIT) to airway has been described as a safe method to secure challenging fetal airways while on placental support. Herein, we present a unique case of a monochorionic-diamniotic twin pregnancy where both fetuses presented with oropharyngeal tumors requiring airway securement on placental bypass. A multidisciplinary tabletop simulation was convened to allow for personnel coordination between multiple services, OR equipment allocation, and preparation for a range of possible clinical scenarios. A tabletop simulation was chosen for planning since this is a simulation methodology commonly used for preparation in acute, high intensity multidisciplinary situations such as disaster preparation, and allows for exploration of multiple potential scenarios when outcomes are uncertain. The twins were urgently delivered for decreased fetal movement and decelerations in Twin B at 28 weeks 6 days. Twin A was delivered via EXIT to airway while Twin B had debulking of the tumor on placental support, with subsequent airway securement through a tracheostomy. In conclusion, for complex fetal procedures, detailed pre-operative planning with tabletop simulation may be a useful tool in achieving successful patient outcomes.

Mandibular Distraction in Robin Sequence With Multi-Level Airway Disease: Always Contraindicated?

In patients with Pierre Robin sequence (PRS), understanding the mechanism of airway obstruction and the potential for concurrent airway lesions is important for determining appropriate intervention. When concomitant airway anomalies are present with PRS, mandibular distraction osteogenesis alone is often contraindicated and unsuccessful at alleviating the obstruction, mandating the need for tracheostomy. Herein, the authors present the second-reported case of PRS with concomitant complete tracheal rings and highlight the importance collaborative surgical efforts to avoid tracheostomy. Our patient was born with signs and symptoms of PRS and concomitant complete tracheal rings. At birth, he developed respiratory compromise that was resistant to invasive and noninvasive intervention and was transferred to our care. The severity of his airway compromise necessitated operative intervention. Due to the patient's complex medical condition, avoiding the long-term sequelae of a tracheostomy and performing mandibular distraction was favorable. However, due to his multi-level airway disease, a 2-staged approach was planned: sliding tracheoplasty to release the tracheal rings, followed by mandibular distraction to correct the micrognathia. The patient tolerated both procedures and was successfully distracted and eventually weaned into room air. When managing patients with PRS in the setting of severe respiratory distress, securing the airway and carefully evaluating for concomitant airway anomalies is crucial. Even in the setting of multi-level airway disease where mandibular distraction is typically contraindicated, by directly addressing each anatomic level of airway obstruction, the airway can be safely secured and the resultant consequences of tracheostomy can be avoided. Careful planning with a multidisciplinary team is essential.

Parental assessment of pain control following pediatric adenotonsillectomy: Do opioids make a difference?

INTRODUCTION: Postoperative prescribing of opioids following pediatric adenotonsillectomy can have negative consequences including unnecessary opioid exposure and potential for respiratory depression. While guidelines from The American Academy of Otolaryngology/Head & Neck Surgery recommend treatment of post adenotonsillectomy pain using acetaminophen and ibuprofen, many providers continue to prescribe opioids and may do so, in part with concern for parental dissatisfaction with post-operative analgesia. Our aim was to determine whether a post-operative prescription for opioids affects parental assessment of pain control following pediatric adenotonsillectomy. METHODS: This post-operative survey assessed the parental assessment of pain control in 324 patients, ages 1-17 years undergoing adenotonsillectomy. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 1, 2018 through March 31, 2019. Post-operative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for post-operative analgesia based on the attending surgeons prescribing preferences. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric adenotonsillectomy as poor or inadequate based on the post-operative analgesic regimen including opioids. RESULTS: Of the 798 surveys sent, the response rate was 42% (324/775) of those who received the survey email, and 69% (324/470) for those who opened the email. Between the opioid and non-opioid groups, there was no difference in gender (male; 48% vs. 51.3%; p = 0.58), race/ethnicity (white; 53% vs. 46%; p = 0.35) or insurance status (insured; 62% vs. 50.9%; p = 0.06). The proportion of parents who rated their child's pain as poor or inadequately controlled following adenotonsillectomy was relatively rare: 9% and 5% in the non-opioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following adenotonsillectomy were 58% and 50% in the non-opioids and opioid groups respectively. CONCLUSION: The results of this study indicate that non-opioid analgesic regimens following pediatric adenotonsillectomy were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric adenotonsillectomy is feasible and does not result in worse parental satisfaction with the analgesic plan.

Pediatric Drug Induced Sleep Endoscopy: A Simple Sedation Recipe.

OBJECTIVE: To describe a minimalist approach to sedating children for DISE procedures. METHODS: We searched existing literature and derived and tested our algorithm on patients using evidence-based studies. RESULTS: We were able to successfully sedate, without airway intervention, 15 highly complex children with a variety of comorbidities for DISE procedures. CONCLUSION: We describe a minimalistic sedation approach for DISE procedures in highly complex children. Further studies are required to compare this regimen to natural sleep states.

Cervical lymphatic malformations: Prenatal characteristics and ex utero intrapartum treatment.

BACKGROUND: The ex utero intrapartum treatment (EXIT) is utilized to transition fetuses with prenatally diagnosed airway obstruction to postnatal life. We describe the unique clinical course, diagnosis, treatment, and outcomes of patients with cervical lymphatic malformation (CLM) managed with EXIT. METHODS: Review of fetuses with diagnosed CLM was delivered by EXIT (2001-2018) in a tertiary referral fetal center. Outcomes included survival, tracheostomy at discharge, neonatal course after delivery, and pulmonary hypoplasia. Data are reported as median [range] and rate (%). RESULTS: Out of 45 patients delivered by EXIT, 10 were delivered for CLM: seven had polyhydramnios, one had nonimmune hydrops, five delivered preterm, and three were emergency EXITs. The EXIT time and estimated blood loss were 125 minutes (95, 158) and 900 mL (500, 1500), respectively. Airway was secured in all. There was one neonatal death (day 8) with prematurity, sepsis, and pulmonary hypoplasia. Three out of nine were discharged with a tracheostomy. CONCLUSION: In CLM, close monitoring for structural neck involvement and development of polyhydramnios are important and may be an indication for EXIT as the optimal delivery mode. An experienced multidisciplinary team is a key factor for an effective approach to the obstructed airway in CLM.

Outcome measures for pediatric laryngotracheal reconstruction: International consensus statement.

OBJECTIVES: Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies. METHODS: Standard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site-specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria. RESULTS: Thirty-three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative-/intraoperative-/procedure-related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site-specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable. CONCLUSION: This consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta-analyses, quality improvement, transfer of information, and surgeon self-assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient. LEVEL OF EVIDENCE: 5 Laryngoscope, 129:244-255, 2019.

Structured care to improve outcomes in primary single stage laryngotracheal reconstruction.

PURPOSE: To examine single stage laryngotracheal reconstruction (SSLTR) care to reduce complication and failure rate. METHODS: Forty-five patients that underwent primary SSLTR were examined retrospectively. All had pre-operative direct laryngoscopy and bronchoscopy, esophagoscopy with biopsy and MRSA screening. Pre-operative subglottic stenosis (SGS) grade and associated comorbidities were recorded. Intraoperative graft location and type was documented. Hospital course and results were evaluated and compared to cited literature. RESULTS: The median age at reconstruction was 2 years (0-15 years). 42.2% were male. 66.7% had gastroesophageal disease and 24.4% a MRSA history. Grade 2 SGS was noted pre-operatively in 37.8% and grade 3 or 4 in 57.7% of patients. Post-surgical hospital course was examined. 77.8% of patients were extubated on planned date. 95.6% of patients had operation specific successful decannulation. Graft type and variations of graft placement as well as MRSA and GERD status didn't affect procedure success rate. Active GERD was related to failure of extubation on planned day (p = 0.02). An abnormal pre-operative swallowing examination was associated with higher complication rates (p = 0.03). CONCLUSION: Utilizing a more structured approach to SSLTR work-up and addressing potential SSLTR pitfalls may result in higher operation specific decannulation rates. Pre-operative GERD and swallowing dysfunction were associated with higher rates of adverse events.

Perinatal diagnosis and management of oropharyngeal fetus in fetu: A case report.

Fetus in fetu is an extremely rare congenital anomaly. We describe the perinatal diagnosis and management of a fetus with oropharyngeal and cervical fetus in fetu. High-resolution ultrasonography with 3-dimensional rendering can identify increased risks of airway obstruction in utero. Early identification allows a multidisciplinary team to be assembled for a scheduled ex utero intrapartum treatment procedure.

Preferred parental method of post-operative tonsillectomy and adenoidectomy follow-up (phone call vs. clinic visit).

INTRODUCTION: Tonsillectomy is the second most common procedure performed in the United States. Over 530,000 tonsillectomies are performed on children under 15 years of age in the United States, accounting for 16% of surgeries in this age group, resulting in missed school for patients of school-age and also resulting in missed work for caregivers. This study compared parent preferences for in-clinic follow-up (CFU) to telephone interview follow-up (TFU) after tonsillectomy. MATERIALS AND METHODS: One hundred twenty-one parents of children who underwent a tonsillectomy and/or adenoidectomy were recruited to complete a survey about their child's post-operative visit. RESULTS: Statistical analyses were performed using t-test, Wilcoxon rank-sum, and Fischer's exact tests where appropriate. 60.3% of the surveys were completed as a TFU and the remainder were completed as a CFU. There were no statistical differences in the children's age, the time to follow-up, satisfaction with their follow-up, or the frequency of unresolved symptoms. Of parents receiving TFU, 91.8% disagreed they would have preferred a CFU, with 86.3% strongly disagreeing, and only 5.5% expressing that they would have preferred a CFU. Of the parents with CFU, 47.9% expressed a preference for a TFU. For CFU, 43.9% of parents missed work and 58.1% of their school-age children missed school. CONCLUSION: Our study results indicate that parents receiving phone follow-up strongly preferred this method to an in-clinic follow-up, and that nearly half of all parents receiving in-clinic follow-up would have preferred a telephone follow-up. In select patients, telephone follow-up after tonsillectomy may increase patient satisfaction and decrease days of missed work and school.

Outcomes and predictors of surgical management in type 1 laryngeal cleft swallowing dysfunction.

OBJECTIVES/HYPOTHESIS: To examine the effect of and predict the success of type 1 laryngeal cleft (LC-1) augmentation through swallowing evaluations. STUDY DESIGN: Retrospective chart analysis. METHODS: Sixty-eight patients with LC-1s underwent interarytenoid injection laryngoplasty (IL) and were examined. The median age at IL was 9 months. Swallowing evaluations were performed pre- and postoperatively using fiberoptic endoscopic examination of swallowing or modified barium swallow. The presence of aspiration or penetrations at various consistencies was recorded. McNemar's tests were used to detect changes in swallowing pre- and postoperatively. Logistic regression was used to assess factors affecting the odds of postoperative success. RESULTS: Preoperatively, 89.7% of patients demonstrated penetration or aspiration. Post-IL, 69.1% were safe for thins, and 75% showed improvement in swallowing. Postoperatively, there was a significant reduction in patients experiencing problems with thin liquids (P < 0.001) and in those with frank or silent aspiration (P < 0.001). Patients with penetrations on thin liquids had higher likelihood of a successful IL (odds ratio [OR] = 3.68, P = 0.021). The probability of success with silent aspiration at any consistency was significantly decreased (OR = 0.26, P = 0.015). Fifteen patients underwent formal endoscopic surgical repair, and 90.0% were safe with thin consistencies postoperatively. CONCLUSION: A large proportion of patients with LC-1 and associated swallowing dysfunctions respond favorably to IL and formal repair. Children who demonstrated penetration with thin liquids had a higher rate of swallowing dysfunction resolution post-IL; whereas patients demonstrating silent aspiration had poorer responses to IL. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2838-2843, 2016.

Diagnosis of Pediatric Foreign Body Ingestion: Clinical Presentation, Physical Examination, and Radiologic Findings.

OBJECTIVES: (1) To describe clinical and radiologic findings in patients with esophageal foreign bodies. (2) To examine the sensitivity and specificity of history, physical examination, and radiologic studies in children with suspected foreign body ingestion. METHODS: A retrospective cohort study was performed evaluating all children who underwent esophagoscopy for suspected foreign body ingestion at our institution from 2006 to 2013. RESULTS: Five hundred forty-three patients were included (54% male). Average age was 4.7 years (SD = 4.1 years). Foreign bodies were identified on esophagoscopy in 497 cases (92%). Ingestion was witnessed in 23% of cases. Most common presenting symptoms were choking/gagging (49%), vomiting (47%), and dysphagia/odynophagia (42%). Most patients with foreign bodies had a normal exam (76%). Most foreign bodies were radiopaque (83%). In 59% of patients with normal chest radiographs, a foreign body was present. Sensitivity and specificity of 1 or more findings on history, physical examination, and imaging were 99% and 0%, 21% and 76%, and 83% and 100%, respectively. CONCLUSIONS: Most patients with esophageal foreign bodies are symptomatic. Although many patients will have a normal physical examination, an abnormal exam should increase suspicion for a foreign body. Most esophageal foreign bodies are radiopaque, but a normal chest radiograph cannot rule out a foreign body.

Clinical relevance of quality of life in laryngomalacia.

OBJECTIVES/HYPOTHESIS: To examine aspects of laryngomalacia and correlate findings with quality of life (QOL). STUDY DESIGN: Prospective cross-sectional study. METHODS: Seventy-two patients with laryngomalacia were examined; the mean age was 8.8 weeks. Parents answered questions from the Infant and Toddler Quality of Life Questionnaire-47 (ITQOL-SF47). Fiberoptic laryngoscopy and endoscopic examination of swallowing (FEES) were performed. The presence of laryngomalacia-associated characteristics and swallowing status were recorded. Patient age, sex, presence of reflux, clinical severity, anatomical findings, and swallowing results were evaluated through logistic regression. Independent sample t tests were used to compare responses on the ITQOL-SF47. Overall laryngomalacia ITQOL-SF47 scores were compared to the scores of a large healthy sample population. RESULTS: Forty-three (60%) patients had mild laryngomalacia, and 61 (85%) patients had findings suggesting gastroesophageal reflux disease. The most common abnormality was shortened aryepiglottic folds. Ten patients failed FEES. Patients with moderate laryngomalacia (χ = 7.62; P = .006) or prolapsing cuneiforms (χ = 4.79; P = .029) were more likely to fail FEES. Laryngomalacia severity impacted parental perception of their child's health (P < .05). Parents of children who demonstrated aspiration or penetration reported significant emotional impact (mean = 56.9; t = 2.74; P = .008). The mean ITQOL-SF47 scores of patients were significantly lower in certain sections than the reported general sample population. CONCLUSIONS: Epiglottal prolapse correlated with severity of laryngomalacia and cuneiform prolapse with swallowing dysfunction. Perceptions of worsening health and physical ability were related to severity of disease. Swallowing dysfunction had a significant emotional impact on parental daily life. Infants with laryngomalacia have a lower QOL LEVEL OF EVIDENCE: 3 Laryngoscope, 126:1232-1235, 2016.

Laryngomalacia and swallowing function in children.

OBJECTIVES/HYPOTHESIS: 1) To determine the prevalence of dysphagia in children with laryngomalacia, 2) To ascertain whether severity of laryngomalacia influences the presence of swallowing dysfunction, and 3) To examine whether patients with medical comorbidities and laryngomalacia have a higher prevalence of swallowing dysfunction. STUDY DESIGN: Retrospective cohort study. METHODS: All patients seen in the aerodigestive center at our institution between January 2007 and December 2012 with the diagnosis of laryngomalacia were included. Swallowing function was assessed by symptoms, clinical swallowing evaluations (CSE) performed by speech pathologists, modified barium swallow (MBS) studies, and fiberoptic endoscopic evaluations of swallowing (FEES). RESULTS: There were 324 patients with laryngomalacia identified (41.4% female, 58.6% male). Severity of laryngomalacia was categorized in 279 patients, with 62.7% mild, 28.7% moderate, and 8.6% severe. Gastroesophageal reflux disease (GERD) was diagnosed in 69.8% of patients. Other medical comorbidities included Down syndrome (3.1%), neurological impairment (6.5%), and congenital heart disease (0.9%). Symptoms of dysphagia or feeding difficulty were present in 163/324 (50.3%), and failure to thrive was present in 31/324 patients (9.6%). At least one abnormal swallowing assessment was present in 97/120 (80.8%) patients presenting with subjective dysphagia and 43/65 (66.2%) patients without subjective dysphagia. A total of 140/185 (75.7%) patients had at least one abnormal baseline swallowing assessment. There was no significant relationship between severity of laryngomalacia and presence of abnormal swallowing function based on symptoms, CSE, MBS, or FEES. However, patients with greater severity were more likely to have failure to thrive. There was not a significant association between the presence of swallowing dysfunction or disease severity and medical comorbidities such as Down syndrome, neurological impairment, or congenital heart disease. However, GERD was more likely to be present in patients with moderate and severe laryngomalacia than in patients with mild disease. CONCLUSIONS: Swallowing dysfunction is common in children with laryngomalacia regardless of disease severity or other medical comorbidities. Swallowing studies are frequently abnormal in laryngomalacia patients presenting both with and without subjective symptoms of dysphagia. Dysphagia assessment should be considered as part of the evaluation of infants with laryngomalacia. LEVEL OF EVIDENCE: 4.

Objective endoscopic findings in patients with recurrent croup: 10-year retrospective analysis.

OBJECTIVE: (1) To determine the incidence and severity of subglottic stenosis on endoscopic evaluation in a pediatric population of patients with recurrent croup. (2) To determine the incidence of abnormal findings on bronchoalveolar lavage and esophageal biopsy in a pediatric population with recurrent croup. METHODS: Case series with historical chart review of clinical data for pediatric patients (age ≤18 years) at a tertiary care children's hospital who underwent endoscopic evaluation of the upper aerodigestive tract with a diagnosis of recurrent croup over a ten-year period (2002-2012). Subglottic stenosis was graded on Myer-Cotton scale. Lipid-laden macrophages on bronchoalveolar lavage were noted as none/small/moderate/large with evidence of reflux noted as moderate or large. Esophageal biopsy specimens were evaluated for evidence of esophagitis. Data is expressed as mean±SEM. RESULTS: 1825 charts were reviewed of which 197 met inclusion criteria. Mean age at endoscopy was 53±3 months. Subglottic stenosis was noted in 41 patients (20.8%) with 95.1% being mild or Grade I. Abnormal findings on bronchoalveolar lavage were noted on 9.5% of bronchoalveolar lavage specimens. Abnormal esophageal biopsies were noted on 19.9% of specimens. Esophagitis was noted on 8.8% of biopsy specimens. CONCLUSIONS: Subglottic stenosis is a risk factor for recurrent croup. Evidence suggestive of reflux may be noted on bronchoalveolar lavage or esophageal biopsy, but these findings may not correlate with subglottic stenosis in recurrent croup patients.

Predictors of Intensive Care Unit Stay After Pediatric Supraglottoplasty.

IMPORTANCE: Supraglottoplasty is a common procedure performed without evidence-based postoperative management plans. Patients are routinely admitted to the intensive care unit (ICU) postoperatively, but this may not be necessary in all cases. OBJECTIVE: To determine (1) whether routine admission to the ICU after supraglottoplasty is warranted in all patients who undergo this procedure and (2) which factors predict requirement for ICU-level care. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series and analysis of immediate postoperative outcomes of all children aged 1 month to 18 years who underwent supraglottoplasty at 1 tertiary-care children's hospital from January 1, 2008, through January 31, 2014. Exclusion criteria included preoperative admission to the ICU, preoperative need for positive-pressure ventilation, history of major airway reconstruction, or any concomitant other major procedure. EXPOSURE: Supraglottoplasty. MAIN OUTCOMES AND MEASURES: Need for ICU-level care as defined by need for intubation, positive-pressure ventilation, multiple doses of racemic epinephrine, or oxygen via nasal cannula at greater than 4 L/min within the first 24 hours. RESULTS: Of 223 patients identified, 25 (11.2%) met our criteria for ICU-level care. Nine patients required intubation. Twenty of the 25 patients met ICU criteria within 4 hours of surgery. Univariate analysis was performed on 38 risk factors. Risk factors for ICU requirement that remained statistically significant on multivariable analysis (P < .05) included surgical duration longer than 30 minutes (odds ratio [OR], 4.48 [95% CI, 1.51-13.19]; P = .007), nonwhite race (OR, 4.42 [95% CI, 1.54-12.66]; P = .006), and a preoperative diagnosis of gastroesophageal reflux disease (OR, 0.10 [95% CI, 0.09-0.36]; P < .001). CONCLUSIONS AND RELEVANCE: Our study suggests that most children undergoing supraglottoplasty do not require ICU-level care postoperatively. Those who require ICU-level care are likely to be identified within the first 4 hours after surgery. Consideration for routine ICU admission should be given to those with longer surgical duration and those of nonwhite race.

Mitigation of tracheobronchomalacia with 3D-printed personalized medical devices in pediatric patients.

Three-dimensional (3D) printing offers the potential for rapid customization of medical devices. The advent of 3D-printable biomaterials has created the potential for device control in the fourth dimension: 3D-printed objects that exhibit a designed shape change under tissue growth and resorption conditions over time. Tracheobronchomalacia (TBM) is a condition of excessive collapse of the airways during respiration that can lead to life-threatening cardiopulmonary arrests. We demonstrate the successful application of 3D printing technology to produce a personalized medical device for treatment of TBM, designed to accommodate airway growth while preventing external compression over a predetermined time period before bioresorption. We implanted patient-specific 3D-printed external airway splints in three infants with severe TBM. At the time of publication, these infants no longer exhibited life-threatening airway disease and had demonstrated resolution of both pulmonary and extrapulmonary complications of their TBM. Long-term data show continued growth of the primary airways. This process has broad application for medical manufacturing of patient-specific 3D-printed devices that adjust to tissue growth through designed mechanical and degradation behaviors over time.

Role of polysomnography in the development of an algorithm for planning tracheostomy decannulation.

OBJECTIVE: To examine the role of polysomnography (PSG) in helping determine readiness of tracheostomized patients for decannulation. STUDY DESIGN: Case series with chart review of pediatric patients who underwent PSG with tracheostomy tube in place with the goal of decannulation. SETTING: Tertiary care pediatric center. SUBJECTS AND METHODS: Twenty-eight tracheostomized patients who underwent PSG from January 2006 to March 2012 were included. Outcome measures were successful decannulation, PSG results, surgical procedures, and medical comorbidities. RESULTS: Of the 28 patients, 20 (71.4%) were decannulated and 8 (28.6%) were not. One (3.6%) patient failed long-term decannulation. The average apnea-hypopnea index (AHI) with a capped tracheostomy for those successfully decannulated was 2.75 (range, 0.6-7.6), while the AHI for those not decannulated was 15.99 (range, 3.2-62). Factors associated with success or failure to decannulate were assessed, and an algorithm was developed to plan for successful decannulation. Laryngotracheal reconstruction was a significant factor in those successfully decannulated. Those who were not decannulated had multiple medical comorbidities, multilevel airway obstruction, need for additional surgery, or chronic need for pulmonary toilet. CONCLUSIONS: Polysomnography may be a useful adjunctive study in the process of determining a patient's readiness for decannulation. Our current algorithm for decannulation includes upper airway endoscopy with identification of levels of obstruction, followed by surgical correction of those obstructions; capped PSG to determine patency of the airway and help assess lung function; and overnight intensive care unit admission for capping trial, with decannulation the following day if well tolerated.