Surgical site infections after pediatric open airway reconstruction-A National Surgical Quality Improvement Program-Pediatric analysis.

Objectives: To determine the rate of surgical site infections (SSI) after pediatric open airway reconstruction using a nationwide database. Study Design: Cross-sectional study of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) Database. Methods: The ACS NSQIP-P was queried for open airway surgeries between 2013 and 2019 determining postoperative SSI and wound dehiscence with a random sample of non-airway cases serving as a control group. Results: A total of 637 laryngotracheoplasties (LTP), 411 tracheal resections (TR) and 2100 control procedures were included. LTP and TR were both performed on younger children with more comorbidities than control surgeries (p < .05). Postoperative wound complications occurred more often after airway reconstructions than non-airway cases (6.4% vs. 2.9%, p < .001). Compared to non-airway procedures, LTP (OR: 2.42, 95% CI: 1.62-3.61) and TR (OR: 2.07, 95% CI: 1.28-3.66) developed increased SSI. Multiple logistic regression identified dirty or infected wounds (OR: 4.61, p < .001, 95% CI: 2.35-9.03) and American Society of Anesthesiologists (ASA) Class IV (OR: 3.19, p = .02, 95% CI: 1.12-8.39) as the strongest predictors of SSI after airway reconstruction. Conclusions: SSI after pediatric airway reconstruction occur in 6% of cases and are increased in infected wounds and ASA Class IV surgeries. Recognizing common factors for these complications provide reliable benchmarking to design surgical quality improvement initiatives. Level of Evidence: 4.

Assessment of socioeconomic disadvantage in laryngotracheoplasty outcomes among pediatric patients.

OBJECTIVES: To determine whether socioeconomic disadvantage impacts outcomes after pediatric laryngotracheoplasty. STUDY DESIGN: Case series with chart review. METHODS: All laryngotracheoplasty procedures at a tertiary children's hospital between 2010 and 2019 were included. Primary zip code determined Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure, and children were grouped based on less or more community disadvantage. Primary outcomes included complication and decannulation rates. RESULTS: Eighty-four procedures were included with 69% (58/84) double-stage and 31% (26/84) single-stage reconstructions. Median age at surgery was 3.2 (IQR 2.2-4.9) years, 56% (47/84) were male, and median gestational age was 25 (IQR 24-28) weeks. Children from more disadvantaged communities represented 67% (56/84) of surgeries and were more likely to have higher grade stenosis (89% vs. 64%, P = .02). Postoperative airway complications (20% vs. 18%, P = .99), non-airway complications (14% vs. 18%, P = .75), and total length of stay (7 vs. 6 days, P = .26) were not impacted by ADI grouping. While children from higher community disadvantage were just as likely to be decannulated after double stage surgeries (76% vs. 76%, P = .99), it more often took longer than six months to achieve (90% vs. 61%, P = .04). CONCLUSIONS: Community disadvantage is associated with higher grade airway stenosis and longer times to successful decannulation in children requiring expansion airway surgery. Encouragingly, ADI grouping did not impact complication and decannulation rates. Continued work is needed to understand how socioeconomic metrics influence pediatric open airway surgery.

Traumatic Pediatric Tracheal Rupture After Blunt Force Sporting Injury: Case Report and Review of the Literature.

OBJECTIVE: This paper presents the case of a traumatic tracheal rupture in a pediatric patient. The body of literature of the clinical features, evaluation, and management of this uncommon presentation is discussed. CASE: A 13-year-old boy sustained an intrathoracic tracheal rupture whilst playing Australian Rules football. He developed hallmark clinical features of air extravasation and was intubated prior to transfer to a tertiary pediatric center for further management. After a short trial of conservative management, his respiratory status deteriorated and he was taken to the operating theater for open surgical repair of the defect. CONCLUSION: Traumatic rupture of the trachea is a rare injury in children. This case demonstrates the dynamic nature of this serious injury and the need for multidisciplinary care in achieving the optimal outcome.

Vocal Fold Injection Augmentation for Post-Airway Reconstruction Dysphonia: A Case Series.

OBJECTIVES: Post airway reconstruction dysphonia (PARD) is common and has a significant effect on the quality of life of patients. Vocal fold injection augmentation (VFIA) is one treatment that can be used to improve glottic insufficiency in some patients. The goal of this study was to characterize the use and outcomes of VFIA for PARD. METHODS: Retrospective chart review from January 2007 to July 2018 at a tertiary pediatric care center. Consecutive patients with PARD who underwent VFIA, who had a preoperative voice evaluation and a follow-up evaluation within 3 months after VFIA (fat, carboxymethylcellulose gel, hyaluronic acid). RESULTS: Thirty-four patients (20 female) underwent VFIA. The mean age at the time of the injection was 13.6 years (SD 6.1). Twenty patients (58.8%) had a history of prematurity and a mean of 1.8 open airway surgeries. After injection, 29/34 patients (85.3%) noted a subjective voice improvement. The baseline Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) overall severity score decreased by a mean of 5.7 (SD = 19.6) points, P = .12. Total pediatric Voice Handicap Index (pVHI) improved by 6.0 (SD = 19.5) points, from 57.4 (SD = 20.0) to 51.4 (SD = 17.2), P = .09. Functional pVHI subscore demonstrated a significant improvement, with a decrease of 3.4 (SD = 7.3) points, P = .02. All procedures were performed as an overnight observation and no complication occurred. CONCLUSION: Patients with PARD represent a complex subset of patients. VFIA is a straightforward intervention that may improve voice perception. Many patients reported subjective improvement despite minimal objective measurement. Further work is warranted to elucidate the role of injection in management of PARD.

Pediatric Airway Surgeries in COVID 19 Era.

To outline a set of recommendations on the management of pediatric cases who requiring airway surgery in the context of COVID 19 pandemic. A set of recommendations have been prepared based on National and International published scientific literature and recent updates on COVID 19. These has been implemented in our tertiary care centre. Due to the evolving nature of COVID 19 and existing knowledge gaps, these recommendations may have to be revised periodically. The incidence of COVID 19 is very low (1-5%) in the pediatric age group with relatively good prognosis. Pediatric airway surgeries should be restricted to emergency cases only. The decision of postponement of the surgical cases should be taken by the team of senior pediatric airway surgeons. Flexible laryngoscopy should be avoided. Foreign body cases should undergo a computed tomography scan to avoid diagnostic bronchoscopies. All the measures should be taken to prevent direct contact of aerosol so powered instruments should not be used unless mandatory. Protective draping method should be adopted to prevent aerosol exposure. As paediatric airway surgeries are aerosol generating procedure where the risk of contracting COVID 19 by the surgeons and support staff is very high, we suggest recommendations to prevent the contact with infected aerosol. We assure these recommendations are easy to follow and can impact good quality outcome during this pandemic crisis.

Pediatric airway surgery under spontaneous respiration using high-flow nasal oxygen.

OBJECTIVES: In pediatric airway surgery, SponTaneous Respiration using IntraVEnous anesthesia and Hi-flow nasal oxygen (STRIVE Hi) has not been well explored. Here, we report our experience of using STRIVE Hi in endoscopic evaluations and surgeries of the pediatric airway. METHODS: This retrospective review was based on 45 airway procedures conducted under STRIVE Hi, performed by a single surgeon at a single institute from May 2017 to September 2018. After induction of anesthesia, continuous infusion with propofol and remifentanil was provided to ensure an adequate level of anesthesia and supply of humidified oxygen via a nasal cannula. Monitoring was conducted using a transcutaneous CO2 sensor and a pulse oximeter, and the oxygen reserve and bispectral indexes were measured. No muscle relaxant was administered. RESULTS: The median age of the patients was 16.0 months (range: 1-215 months) and the median weight was 10.2 kg (range: 2.4-38.5 kg). The median duration of spontaneous respiration was min 40 (range: 10-140 min). The airway procedures included diagnostic microlaryngoscopy, tracheocutaneous fistula excision, balloon dilation, supraglottoplasty, laryngeal cleft repair, injection laryngoplasty, papilloma excision, and subglottic cyst removal. During these procedures, STRIVE Hi facilitated evaluation of dynamic obstruction of the airway and the immediate outcome of surgical treatment and provided a good surgical view. Intubation and the termination of spontaneous respiration were required in only five patients. CONCLUSIONS: STRIVE Hi is an effective and feasible anesthesia option in pediatric airway surgery. It provides unobstructed surgical access and is applicable to a wide range of procedures.

Rigid dilatation of pediatric laryngotracheal stenosis as an adequate alternative to balloon dilatation.

INTRODUCTION: Endoscopic balloon dilation (EBD) is the mainstay of endoscopic therapy for laryngotracheal stenosis (LTS), although there is no evidence that it achieves better results than traditional rigid laryngeal dilators. Rigid bougie dilators are less expensive and easier to use, and confer the advantage of providing tactile information about the stenosis to the surgeon. We analyzed the outcome of endoscopic rigid bougie dilatation of LTS in a large series of children and compared it to the reported results of EBD in the same setting. PATIENTS AND METHODS: All cases of pediatric LTS treated by endoscopic rigid dilatation in a tertiary referral center between 2006 and 2015 were retrospectively studied. They were divided into a primary dilatation group (PDG) and a post-reconstruction dilatation group (PRG). The PDG children had no history of reconstructive airway surgery, and dilatation was the major treatment approach. The PRG children underwent dilatations after airway reconstruction surgery as part of routine postoperative management. A successful primary outcome was defined as improvement of dyspnea and achievement of a functional airway without reconstructive laryngotracheal surgery or need for a tracheostomy at final follow-up. RESULTS: Sixty-two children (68 cases, mean age 5.1 years, range 0.7-17.2) underwent 156 endoscopic rigid dilatations. Successful outcome was achieved in 48 cases (70.6%), 73.0% in the PDG and 67.7% in the PRG. There were no procedure-related adverse events. CONCLUSIONS: Endoscopic rigid dilatation is a relatively inexpensive and efficacious tool in endoscopic management of pediatric LTS. Its success rates are in the same range as those of EBD.

Double Carina: A Novel Tracheo-Bronchial Anomaly Found During a Pediatric Airway Evaluation.

OBJECTIVES: To present a novel pediatric airway anomaly encountered on direct laryngoscopy and bronchoscopy, further characterized with computed tomography imaging of the chest. STUDY DESIGN: Case report and literature review. METHODS: Review of the clinical presentation, operative findings, and imaging findings of an infant who presented with respiratory distress in the setting of multiple congenital abnormalities. A brief literature review supplements the case presentation. RESULTS: While multiple tracheobronchial anomalies have long been reported, this is the first report of a double or false carina: a system of symmetric paired upper and lower bronchi connected by a central conduit. Operative evaluation was limited given the narrow lumen, and postoperative imaging aided in further characterization of the pediatric airway. CONCLUSIONS: This is the first report of a novel tracheobronchial anomaly presenting as a double carina. Tracheobronchial anomalies are diverse and should be considered when performing operative airway evaluations. Imaging can be a helpful adjunct with anatomic characterization.

A Simple Endoscopic Technique for Measuring the Cross-Sectional Area of the Upper Airway in a Rabbit Model.

OBJECTIVE: Validate an accurate and reproducible method of measuring the cross-sectional area (CSA) of the upper airway. SUBJECTS AND METHODS: This is a prospective animal study done at a tertiary care medical treatment facility. Control images were obtained using endotracheal tubes of varying sizes. In vivo images were obtained from various timepoints of a concurrent study on subglottic stenosis. Using a 0° rod telescope, an instrument was placed at the level of interest, and a photo was obtained. Three independent and blinded raters then measured the CSA of the narrowest portion of the airway using open source image analysis software. RESULTS: Each blinded rater measured the CSA of 79 photos. The t testing to assess for accuracy showed no difference between measured and known CSAs of the control images ( P = .86), with an average error of 1.5% (SD = 5.5%). All intraclass correlation (ICC) values for intrarater agreement showed excellent agreement (ICC > .75). Interrater reliability among all raters in control (ICC = .975; 95% CI, .817-.995) and in vivo (ICC = .846;, 95% CI, .780-.896) images showed excellent agreement. CONCLUSIONS: We validate a simple, accurate, and reproducible method of measuring the CSA of the airway that can be used in a clinical or research setting.

Ectopic Thymic Cyst of the Subglottis: Considerations for Diagnosis and Management.

OBJECTIVES: To share the diagnostic and management challenges created by an extremely rare airway lesion-the subglottic ectopic thymic cyst. STUDY DESIGN: Case report and literature review. METHODS: We review the presentation, management, and clinical course of an infant who presented with a subglottic mass that was histologically confirmed as a thymic cyst. A brief literature review supplements the case presentation Results: We present the third described case of an ectopic thymic cyst presenting as a subglottic mass. The differential diagnosis of subglottic masses in neonates consists primarily of subglottic hemangioma and mucous retention cysts. Otolaryngologists must be prepared for unexpected findings when dealing with critical airways. We compare the presentation and management of our patient with the 2 previously described cases. We propose an embryologic theory for the origin of these rare lesions. CONCLUSIONS: An ectopic thymic cyst is a rare and unexpected cause of neonatal stridor. Management of pediatric airway lesions must allow for unexpected findings at the time of diagnostic and therapeutic endoscopy. The appropriate management of subglottic thymic cysts is poorly defined, but close surveillance for recurrence is mandatory.

Bronchial Compression and Tracheosophageal Fistula Secondary to Prolonged Esophageal Foreign Body.

INTRODUCTION: Foreign body ingestion is a common pediatric problem that can have a delayed presentation, as presented herein. CASE REPORT: We present the case of a 15-year-old female who developed bronchial compression and an acquired tracheoesophageal fistula secondary to a longstanding esophageal foreign body. DISCUSSION: There are several challenges in diagnosis and management of this unusual situation. We review the literature regarding prolonged retention of foreign bodies and the challenges in diagnosis in the developmentally disabled child. CONCLUSION: Providers must have a high suspicion for foreign bodies in the case of unusual symptoms present in children with neurodevelopmental delays.