Early Adverse Respiratory Outcomes in Obese Pediatric Tonsillectomy Patients.

OBJECTIVE: To determine if body mass index (BMI) is predictive of adverse respiratory events (ARE) in the obese pediatric population undergoing tonsillectomy. STUDY DESIGN: Case series with chart review. SETTING: Single institution academic otolaryngology practice. METHODS: All patients 3 to 12 years old with BMI ≥95th percentile that underwent tonsillectomy March 1, 2011 to July 15, 2020 were included. The study excluded patients with comorbidities that warranted admission independent of BMI, including Trisomy 21, gross developmental delay, neuromuscular disorders, and congenital heart disease. Perioperative AREs following tonsillectomy were recorded. AREs were defined as postoperative desaturation (SpO2 < 90%), intubation, continuous positive airway pressure (CPAP), or new O2 requirement for >2 hours. RESULTS: Eighteen patients (8%) had at least 1 ARE. There were no children age 5 and older with a BMI 95th percentile to 98.9th percentile who had an early adverse respiratory outcome. Preoperative polysomnogram (PSG) metrics, obstructive apnea-hypopnea index (oAHI), and oxygen saturations (SpO2) nadir was significantly different between patients with and without AREs (mean oAHI 54.3 vs 17.4, P = .02; mean SpO2 nadir 73.1% vs 84.5%, P = .05). There was no significant difference in the BMI z score (2.88 vs 2.45, P = .09) between groups. CONCLUSION: AREs requiring inpatient management are uncommon in obese children after tonsillectomy. BMI is a poor independent indication for admission except at BMI extremes. We found significantly higher oAHI and lower SpO2 nadir on PSG indicate a higher risk for AREs and can guide admission postoperatively. There may be a subset of obese tonsillectomy patients who can be safely discharged home on the day of surgery.

Polysomnogram outcomes in patients with laryngomalacia and obstructive sleep apnoea treated surgically versus non-surgically.

OBJECTIVE: To compare supraglottoplasty versus non-surgical treatment in children with laryngomalacia and mild, moderate and severe obstructive sleep apnoea. METHODS: Patients were classified based on their obstructive apnoea hypopnoea index on initial polysomnogram, which was compared to their post-treatment polysomnogram. RESULTS: Eighteen patients underwent supraglottoplasty, and 12 patients had non-surgical treatment. The average obstructive apnoea hypopnoea index after supraglottoplasty fell by 12.68 events per hour (p = 0.0039) in the supraglottoplasty group and 3.3 events per hour (p = 0.3) in the non-surgical treatment group. Comparison of the change in obstructive apnoea hypopnoea index in the surgical versus non-surgical groups did not meet statistical significance (p = 0.09). CONCLUSION: All patients with laryngomalacia and obstructive sleep apnoea had a statistically significant improvement in obstructive apnoea hypopnoea index after supraglottoplasty irrespective of obstructive sleep apnoea severity, whereas patients who received non-surgical treatment had more variable and unpredictable results. Direct comparison of the change between the two groups did not find supraglottoplasty to be superior to non-surgical treatment. Larger prospective studies are recommended.

Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project.

BACKGROUND: Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year. METHODS/INTERVENTION: A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods. RESULTS: Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019-June 2022, n = 145) compared to the pre-intervention group (January 2016-August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001]. CONCLUSIONS: Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness. TYPE OF STUDY: Prospective Quality Improvement. LEVEL OF EVIDENCE: Level III.

Adenoidectomy may decrease the need for a third set of tympanostomy tubes in children.

OBJECTIVE: To determine whether removing or retaining adenoids at the time of placement of a second set of ear tubes impacts the need for a third set of ear tubes later in childhood. STUDY DESIGN: Single-institution retrospective case series. SETTING: Tertiary academic university hospital. METHODS: We identified pediatric subjects who had undergone a second ear tube placement between 1/1/17 and 9/1/19. Subjects were stratified into two groups: 1) adenoids removed at time of second tympanostomy tube insertion (TT+A) and 2) adenoids retained at time of second tympanostomy tube insertion (TT-A). A subset of children less than age 4 was also studied independently. The primary outcome was number of patients requiring a third set of tympanostomy tubes. RESULTS: A total of 136 subjects met inclusion and exclusion criteria. Among children less than 4 years of age (n = 99), the incidence of requiring a third set of tubes was significantly lower in the TT+A group <4 (12.8%; 6/47) compared to the TT-A group <4 (44.2%; 23/52) (p = 0.0008) with an odds ratio of 0.18 (95%CI 0.067-0.51) and number needed to treat of 3.2. CONCLUSION: Performing adenoidectomy in children less than 4 years of age at the second tympanostomy procedure was associated with a reduced incidence of requiring a third set of ear tubes.

Actinomyces Acute Rhinosinusitis Complicated by Subperiosteal Abscess in an Immunocompromised 12-Year-Old: Case Report and Literature Review.

Objective: To describe a rare case of pediatric actinomycotic rhinosinusitis with orbital subperiosteal abscess and review the current literature to assess methods of diagnosis, treatment modalities, and outcomes with appropriate treatment. Methods: A case report and a review of the literature. Results: A 12-year-old patient with Crohn's disease on infliximab presented with rhinosinusitis with orbital subperiosteal abscess formation. Endoscopic sinus surgery was performed and cultures grew actinomyces. A prolonged course of antibiotics was started, resulting in the complete resolution of the infection. In a literature review, all cases of uncomplicated and complicated actinomyces rhinosinusitis managed with appropriate surgery and prolonged antibiotics resulted in a cure. Our case is the first reported in a pediatric patient and the first taking immunosuppressive medication. Overall, only 3 cases of actinomyces rhinosinusitis in immunosuppressed individuals have been reported, each with uncontrolled diabetes and each also responded well to surgery and appropriate antibiotics. Conclusion: Actinomycosis of the paranasal sinuses poses a diagnostic challenge, with infections varying widely in presentation and extent of disease. A high index of suspicion, appropriate testing, and early aggressive treatment are critical in managing patients with this infection. Our case and prior published studies show that actinomyces rhinosinusitis can be successfully managed with endoscopic sinus surgery, abscess drainage as necessary, and a prolonged course of antibiotics, even in immunocompromised and pediatric populations.

Drug-induced sleep endoscopy findings in surgically-naïve obese vs non-obese children.

OBJECTIVE: To determine if drug-induced sleep endoscopy (DISE) findings are different in obese versus non-obese pediatric patients with obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB). METHODS: Prospective, observational cohort study from June 2017 to June 2018 at a tertiary academic pediatric medical center that included surgically-naïve children ages 2-12 with diagnoses of OSA or sleep-disordered breathing. Subjects with a known diagnosis of craniofacial syndromes, genetic disorders, prior adenoidectomy or tonsillectomy, or chronic tonsillitis as the indication for surgery were excluded. Two groups were assessed for patterns of obstruction based on DISE videos at each anatomic airway level using a previously published DISE scoring system. The groups included obese subjects (BMI ≥ 95th percentile) and non-obese controls (BMI <85th percentile). Each video was graded by two blinded, fellowship-trained Pediatric Otolaryngologists. RESULTS: Fifty-one patients were included, 26 non-obese and 25 obese. Based on anatomic airway level, there was no statistically significant difference in airway obstruction at the velum (p = 0.134), adenoid (p = 0.592), lateral pharyngeal walls (p = 0.867), tongue base (p = 0.977), or supraglottis (p = 0.428) between obese and non-obese children. CONCLUSION: Our prospective study did not associate severity of obstruction with obesity status based on anatomic airway levels. Further studies are needed to elucidate the etiology of the high rate of persistent obstructive sleep apnea in obese children.

Potential Cytochrome P450 Drug-Drug Interaction Among Adult and Adolescent Patients Undergoing Tonsillectomy.

OBJECTIVE: To assess the frequency of potential drug-drug interactions affecting cytochrome P450 (CYP)-mediated metabolism of opioids among adult and adolescent patients who underwent adenotonsillectomy. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care university hospital. PATIENTS AND METHODS: A retrospective review was conducted of 279 patients who underwent adenotonsillectomy at the University of Rochester. The discharge medication list was reviewed for all patients, and their postoperative medications were compared with a reference list published by the Food and Drug Administration and the University of Indiana's Department of Clinical Pharmacology (Flockhart Table) to determine whether CYP-inducing or CYP-inhibiting medication was present. RESULTS: Out of 279 patients, 197 different medications were taken postoperatively. Approximately 70% of patients were taking 2 medications in addition to the standard postoperative analgesics (acetaminophen, hydrocodone, oxycodone, morphine, and/or ibuprofen). The 5 most commonly prescribed medications excluding the posttonsillectomy medications were oral contraceptives, ondansetron, amoxicillin, albuterol, and methylprednisolone. Four percent of patients were taking a medication that inhibits CYP3A4; <1% were taking a medication that induces CYP3A4; and 15% were taking a medication that inhibits CYP2D6. CONCLUSIONS: Nearly 20% of the patients in this cohort were taking a medication that may alter opioid metabolism through induction or inhibition of CYP3A4 or CYP2D6. Some of these interactions have the potential to be more clinically relevant than others, particularly interactions that can lead to enhanced toxicity of opioids due to accumulation of active metabolites.

Potential Cytochrome P450 Drug-Drug Interactions among Pediatric Patients Undergoing Tonsillectomy.

OBJECTIVE: To evaluate the frequency of potential cytochrome P450 (CYP) drug-drug interactions affecting opioid metabolism among children undergoing adenotonsillectomy. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: A retrospective review was conducted of 1000 patients undergoing adenotonsillectomy at Children's Hospital of Wisconsin. The discharge medication reconciliation form was reviewed. Each patient's list of medications was compared with various published sources to determine whether medications causing CYP inhibition or induction were present. RESULTS: There were 157 unique medications with systemic absorption given postoperatively to this patient cohort. Eight percent of patients were on at least 5 medications after surgery other than their posttonsillectomy medication. The 5 most commonly prescribed medications were albuterol, cetirizine, fluticasone nasal spray, montelukast, and polyethylene glycol. Per a list of known CYP inducers and inhibitors published by the US Food and Drug Administration, 30 (3%) patients were on a medication that inhibited CYP3A4; 1 patient was on a CYP3A4 inducer, prednisone; and 46 (5%) patients were on a medication that inhibited CYP2D6. CONCLUSIONS: A small fraction of patients undergoing adenotonsillectomy are on medications that potentially alter the metabolism of opioid pain medications. Given the narrow therapeutic index of opioids and increased sensitivity to opioids among patients with obstructive sleep apnea, drug-drug interactions need to be considered as they relate to whether an opioid is appropriate and at what dose.

Efficacy and rebound rates in propranolol-treated subglottic hemangioma: A literature review.

OBJECTIVE: Propranolol has recently become the treatment of choice for management of subglottic and airway hemangiomas. This literature review aimed to determine the success rate of propranolol for managing these lesions as well as the rate of rebound growth following propranolol treatment cessation. STUDY DESIGN: Literature search involving MEDLINE and Scopus to identify English-language articles. METHODS: Studies were identified using hemangioma, subglottic or airway, and propranolol for search terms. Studies were eligible for inclusion if they reported the treatment used, individual deidentified patient data, and contained patients without medical or surgical treatment prior to propranolol therapy RESULTS: Initial review included 107 abstracts. Twenty-four articles including case reports and case series met inclusion criteria and were included in the qualitative analysis. Forty-nine patients were included. Twenty-eight (57%) were treated with propranolol alone, and 20 (41%) were treated with a combination of propranolol and a corticosteroid. Thirty-seven (76%) of patients were treated with a dose of 2 mg/kg/d of propranolol. The initial treatment was successful in 43 (88%) of patients. Rebound growth occurred in four (9%) patients. Overall, six (12%) patients underwent surgical resection. CONCLUSIONS: Propranolol is efficacious for treating subglottic hemangiomas. Rebound growth does occur in a small subset of patients during the propranolol wean. Close observation for children during weaning of propranolol therapy for subglottic hemangioma is essential. Adjunctive management strategies need to be used in patients with rebound growth. Laryngoscope, 127:2665-2672, 2017.

Salivary botulinum toxin injection may reduce aspiration pneumonia in neurologically impaired children.

OBJECTIVES: Neurologically impaired children often drool and aspirate saliva leading to recurrent aspiration pneumonia and frequent hospitalizations. Salivary botulinum toxin injection is known to reduce sialorrhea. This study evaluates whether this intervention affects the frequency and duration of respiratory infections including aspiration pneumonia and hospitalizations in neurologically impaired children. METHODS: Retrospective review of patients treated with salivary botulinum toxin at a tertiary care pediatric hospital from January 2009 to December 2013. Each patient was their own control and 180 day pre-injection and post-injection time periods were compared. Outcomes evaluated included: number of hospital days, intensive care unit days, days of antibiotic treatment, chest X-rays, and infiltrates on chest X-ray. RESULTS: 13 patients accumulated 539 hospital days. All children were gastrostomy tube dependent. 54% were tracheostomy tube dependent. Amongst all patients, the total hospital days decreased from 385 to 154 (P=0.02), the mean days treated with antibiotics decreased from 214 to 47 (P=0.02), and the number of chest X-ray confirmed infiltrates decreased from 20 to 6 (P=0.02) after injection. CONCLUSION: In this review, there was a decrease in hospitalized days, antibiotic usage, and chest X-ray infiltrates after the salivary botulinum toxin injection. A prospective study is needed to evaluate whether this treatment can prevent aspiration pneumonia in neurologically impaired children.

A Comparison of Bipolar Electrocautery and Chemical Cautery for Control of Pediatric Recurrent Anterior Epistaxis.

OBJECTIVE: To compare the outcome of children with anterior epistaxis treated intraoperatively with either bipolar electrocautery or silver nitrate chemical cautery. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care pediatric otolaryngology practice. SUBJECTS: Children aged 2 to 18 years treated with either intraoperative bipolar electrocautery or silver nitrate chemical cautery of the anterior nasal septum for recurrent anterior epistaxis. METHODS: Any reported bleeding event after surgery was recorded. The mean time from surgery to recurrent epistaxis was compared between groups. RESULTS: Fifty patients underwent bipolar electrocautery, while 60 patients underwent silver nitrate chemical cautery. Within 2 years, 1 (2%) patient in the bipolar electrocautery group and 13 (22%) patients in the silver nitrate chemical cautery group had recurrent epistaxis (P = .003). Two years after treatment, there was no difference between treatment groups. Overall, 4 patients (8%) had recurrent epistaxis postoperatively in the bipolar electrocautery group at a mean of 4.34 years after treatment, while 17 (28.3%) patients recurred after a mean of 1.53 years of treatment in the silver nitrate chemical cautery group (P = .01). CONCLUSION: Compared to those treated with chemical cautery, those treated with bipolar electrocautery had a longer nosebleed-free period and a lower incidence of recurrent epistaxis within 2 years of treatment. Beyond 2 years, the treatment methods are equivocal. Bipolar electrocautery may be a superior treatment in children who will not tolerate in-office chemical cautery, in those with a risk of severe bleeding, or when it can be combined with other operative procedures.

Medical and surgical management of congenital laryngomalacia: a case-control study.

OBJECTIVE: To compare the growth of infants with moderate to severe laryngomalacia who underwent supraglottoplasty to the growth of those treated with medical therapy alone. STUDY DESIGN: Case-control study of patients treated between 2008 and 2013. SETTING: Tertiary care pediatric otolaryngology practice. SUBJECTS AND METHODS: Fifty-one infants newly diagnosed with moderate to severe congenital laryngomalacia. Seventeen infants underwent supraglottoplasty and 34 matched controls had medical management, which included acid suppression therapy, speech and swallowing therapy, and/or high-calorie formula. The primary outcome measure was weight percentile recorded at the second clinic visit and at the last available follow-up. The secondary outcomes were the need for primary or revision supraglottoplasty, tracheostomy or gastrostromy, or the development of or persistence of failure to thrive. RESULTS: There was no difference in the mean weight percentile between the surgical and nonsurgical groups at the time of last follow-up (P = .89). The mean change in weight percentile during the study period was 32% (95% CI, 15%-48%) in the supraglottoplasty group and 31% (95% CI, 22%-40%) in the medical group (P = .97). Five of 5 (100%) patients with failure to thrive managed surgically and 10 of 10 (100%) managed medically were above the fifth percentile at the end of the follow-up period. One (3%) patient in the medical management group required tracheostomy and gastrostomy tube placement. CONCLUSIONS: Medical management and close observation of infants with moderate to severe congenital laryngomalacia may be a viable alternative to supraglottoplasty in appropriately selected infants.