Expert Consensus Statement: Management of Pediatric Persistent Obstructive Sleep Apnea After Adenotonsillectomy.

OBJECTIVE: To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged. METHODS: An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey. RESULTS: After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care. CONCLUSION: The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research.

Organic vs. Inorganic Tracheobronchial Airway Foreign Body Aspiration: Does Type/Duration Matter?

OBJECTIVE: We sought to determine the time course of clinical and histologic differences between aspirated inorganic and organic foreign bodies. STUDY DESIGN: In-vivo. METHODS: Twenty Sinclair miniature swine (Sus scrofa domesticus) were divided into two groups-inorganic or organic foreign bodies. Either an organic (peanut) or an inorganic (Lego) foreign body was placed within a bronchus and left for 3, 5, 7, 14 or 21 days. The airway was reassessed at the predetermined endpoint at which time endoscopic, gross, and histopathological findings were documented. Specimens were scored with a pathologic scoring system to assess injury severity from the foreign body. RESULTS: Foreign bodies were successfully placed in all 20 swine. Two animals required early euthanasia due to respiratory compromise. The foreign body was identified grossly in eight (40%) animals. An additional three (15%) had microscopic evidence suggestive of a previous foreign body of an undetermined duration. There was no difference in injury severity between organic and inorganic foreign bodies. The 3-day group had injuries limited to the bronchial lining, whereas the longer duration groups had bronchial and adjacent lung parenchymal involvement. There was no difference in injury severity between days 5 and 21. CONCLUSIONS: Airway foreign bodies initially cause bronchial damage. After 5 days, the foreign body causes lung parenchymal changes. There was no difference in airway lesion severity between organic and inorganic foreign bodies. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:490-495, 2021.

Comparison of home sleep apnea testing versus laboratory polysomnography for the diagnosis of obstructive sleep apnea in children.

INTRODUCTION: Obstructive sleep apnea (OSA) affects 1-5% of pediatric patients. Laboratory polysomnography is expensive, not always available, and is inconvenient for patients. Our study investigates the diagnostic ability of an unattended ambulatory monitor for the diagnosis of pediatric OSA. METHODS: A prospective study was conducted in children, ages 2-17. Subjects completed in-lab polysomnography simultaneously with ambulatory monitoring. Caregivers attempted home studies on two subsequent nights to compare the home monitor and the laboratory polysomnogram (PSG). RESULTS: Thirty-three subjects completed simultaneous laboratory polysomnogram with portable monitoring. Twenty patients completed home studies, with 16 completing 2 nights of monitoring. The measurement of AHI by the portable monitor was different than that obtained by the PSG with statistical significance for the comparisons of PSG vs. In-Lab (p = 0.0026), PSG vs. Home 1 (p = 0.033), and PSG vs. Home 2 (p = 0.033). The sensitivity of the portable monitor for diagnosing OSA was best for the In-lab use at 81%, but only 69% and 70% for the uses at home on the 2 nights respectively. Interestingly, the comparison of AHI and lowest oxygen saturation measurements from the home sleep test in children age 6 and older did not differ significantly from the PSG. CONCLUSIONS: This pilot study demonstrated differences between home sleep testing and in-lab polysomnography for the diagnosis of pediatric sleep apnea. These differences were predominantly found to exist in younger children. Larger prospective studies are needed prior to widespread use, but home studies may alleviate issues of access to care and higher costs of laboratory polysomnography.

The Joint Facial and Invasive Neck Trauma (J-FAINT) Project, Iraq and Afghanistan: 2011-2016.

Objective Define the number and type of facial and penetrating neck injuries sustained in combat operations in Iraq and Afghanistan from 2011 to 2016. Compare recent injury trends to prior years of modern conflict. Study Design Case series with chart review. Setting Tertiary care hospital. Methods The Joint Theater Trauma Registry (JTTR) was queried for facial and neck injuries from Iraq and Afghanistan from June 2011 to May 2016. Injury patterns, severity, and patient demographics were analyzed and compared to previously published data from combat operations during January 2003 to May 2011. Results A total of 5312 discrete facial and neck injuries among 922 service members were identified. There were 3842 soft tissue injuries (72.3%) of the head/neck and 1469 (27.7%) facial fractures. Soft tissue injuries of the face/cheek (31.4%) and neck/larynx/trachea (18.8%) were most common. The most common facial fractures were of the orbit (26.3%) and maxilla/zygoma (25.1%). Injuries per month were highest in 2011 to 2012 and steadily declined through 2016. The percentage of nonbattle injuries trended up over time, ranging from 14.7% to 65%. Concurrent facial/neck soft tissue trauma or fracture was associated with an overall mortality rate of 2.44%. Comparison of our data to that previously published revealed no statistical difference in concurrent mortality (3.5%-2.2%, P = .053); an increase in orbital fractures ( P < .005), facial nerve injury ( P < .0005), and ear/tympanic membrane perforations ( P < .0005); and a decrease in mandible fractures ( P < .005). Conclusion Penetrating neck and facial injuries remain common in modern warfare. Assessing injury characteristics and trends supports continued improvements in battlefield protection and identifies areas requiring further intervention.

Chief of Residents for Quality Improvement and Patient Safety: A Recipe for a New Role in Graduate Medical Education.

INTRODUCTION: The San Antonio Uniformed Services Health Education Consortium (SAUSHEC) is the largest group of residency programs in the Department of Defense. In an effort to provide improved Quality Improvement and Patient Safety (QI/PS) training for its residents, SAUSHEC created the position of Chief of QI/PS for Residents in the academic year 2014-2015. The Chief of QI/PS for Residents was based in the Internal Medicine residency program but also assisted with SAUSHEC-wide QI/PS projects. This is the first such job in the Department of Defense. METHODS: Here, we detail the accomplishments during this first academic year, including the alignment of the job with the stated QI/PS-related goals of the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review. Efforts focused within the Internal Medicine residency program included QI/PS curriculum development, improvement upon monthly morbidity and mortality (M&M) conferences, and facilitating resident participation in QI projects. The 2014-2015 academic year Internal Medicine residency QI/PS project focused on increasing comfort and discussions with patients regarding advance directives; this also served to emphasize the humanistic side of potential QI/PS projects. The Chief of QI/PS for Residents also spearheaded hospital-wide initiatives, including the creation of a quarterly hospital-wide M&M conference, coordinating resident involvement in QI/PS-related committees, and facilitating feedback of patient safety report responses to trainees. RESULTS: We focus on the portion of the QI/PS curriculum involving the presentation of a mock Root Cause Analysis (RCA) and provide the results of a pre- and postpresentation survey of resident knowledge of RCAs. In order to quantify the efforts over the entire academic year, we also report the results of a resident self-assessment of QI/PS aptitude and competencies, including changes in these measures over the academic year. Finally, we discuss challenges faced and outline future goals for the position. CONCLUSION: The SAUSHEC Chief of QI/PS for Residents is the first such designated position in the Department of Defense. As QI/PS continues to increase as a focus area for physician training, we anticipate that other programs will create similar positions. We provide ideas for how a Chief of QI/PS for Residents can be involved at a program and hospital-wide level and quantify the success of different efforts.

Effect of high-dose vocal fold injection of cidofovir and bevacizumab in a porcine model.

OBJECTIVES: Perform a follow-up study to investigate the histologic impact of high-dose intralaryngeal cidofovir injections in porcine vocal cords, either alone or in combination with bevacizumab, and compared to saline controls. STUDY DESIGN: This was an in vivo study involving 24 pigs with blinded pathologist review of specimens. Six groups were created, with four subjects in each group. Each subject received 10 or 20 mg of either cidofovir or bevacizumab alone, or in combination, injected into the right vocal cord. The left vocal fold was used as a saline control. Three separate injections were made at 2-week intervals. Larynges were harvested at 8 and 12 weeks, stained with hematoxylin and eosin and trichrome stain, and reviewed for histologic changes by two blinded pathologists. RESULTS: Minimal inflammation, edema, and atypia were noted with all treatments. Increased glandular inflammation was noted with 10 mg bevacizumab (P < 0.05), which decreased when combined with 10 mg cidofovir (P < 0.05). No lamina propria or muscle fibrosis was observed. Drug duration had no statistically significant histologic impact. CONCLUSION: High-dose cidofovir and bevacizumab do not induce detrimental vocal fold changes. Combination cidofovir and bevacizumab do not cause vocal fold scarring. Further work is needed to assess systemic concentration with this high-dose combination in humans. LEVEL OF EVIDENCE: N/A. Laryngoscope, 127:671-675, 2017.

Blunt cerebrovascular injury following craniomaxillofacial fractures: A systematic review.

OBJECTIVES: Blunt cerebrovascular injury (BCVI) is a known sequela of high-energy craniomaxillofacial (CMF) trauma and can result in stroke or death. The objective of this systematic review is to 1) identify CMF trauma patients who may benefit from BCVI screening and 2) describe the optimal diagnostic and treatment modalities. STUDY DESIGN: Systematic review of the literature (1946-2013). METHODS: An a priori study protocol was created using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The authors conducted a search of Ovid/Medline, PubMed, and Cochrane databases for articles related to BCVI and CMF fractures. All abstracts were reviewed, and data was extracted to determine the incidence of BCVI in the setting of CMF trauma. Individual fracture patterns were analyzed using descriptive statistics. RESULTS: Twenty-one studies met inclusion criteria. The overall incidence of CMF fracture-associated BCVI was 0.45%. The majority of patients (86.6%) sustained BCVI in the setting of high-energy trauma. The distribution of CMF fractures among BCVI patients was the mandible (12.5%), followed by the maxilla (11.8%). Computed tomographic angiography (CTA) was the most common diagnostic modality. A total of 63.1% of patients with BCVI were managed medically. The mortality among CMF patients with BCVI was 23.9%, and stroke rate was 47.1%. CONCLUSION: Blunt cerebrovascular injury is a rare but devastating complication of blunt trauma. The recommended screening modality is CTA, and the most common treatment is antiplatelet/anticoagulant medication. Mandibular and LeFort fractures were the most common isolated CMF injury associated with BCVI, highlighting the need for prospective trials to expand current screening criteria. LEVEL OF EVIDENCE: N/A. Laryngoscope, 127:79-86, 2017.

A Multidisciplinary Approach to Castleman Disease of the Neck.

Castleman disease (CD) is a rare lymphoproliferative disorder that occurs in adults and rarely in the pediatric population. The disease is characterized by slowly enlarging masses that can form anywhere within the lymphatic system. It is an uncommon cause of a neck mass in both children and adults that presents insidiously and nonspecifically. A 21-year-old woman was referred to the otolaryngology service because of an asymptomatic neck mass found incidentally on computed tomographic imaging 15 months earlier. On repeat imaging, the lesion was characterized as a homogenously enhancing soft tissue mass and appeared stable in size compared with previous studies. Given the nondiagnostic radiologic features, tissue sampling was pursued, first using fine-needle aspiration and ultimately excisional biopsy. The excision revealed histopathology consistent with unicentric, hyaline-vascular CD. Excision is the gold standard for treatment of this variant of CD. The patient was referred to the hematology/oncology service but was subsequently lost to follow-up. This case illustrates a rare cause of a neck mass in a young adult and exemplifies the extremely broad differential in this setting. In addition, it highlights the importance of a systematic and thorough approach to diagnosing neck masses in children and adults.

How Does TeamSTEPPS Affect Operating Room Efficiency?

OBJECTIVE: To evaluate the effect of TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) on operating room efficiency for the otolaryngology service at a tertiary care medical center. STUDY DESIGN: Retrospective database review. SETTING: Otolaryngology department at tertiary care medical center. SUBJECTS AND METHODS: To assess the impact of implementing an evidence-based patient safety initiative, TeamSTEPPS, on operating room efficiency in the otolaryngology department, the operative times, time lost to delayed starts, and turnover times during the year following the implementation of TeamSTEPPS were compared with the values from the prior year. RESULTS: The study compared 1322 cases and 644 turnovers in the year prior to TeamSTEPPS implementation with 1609 cases and 769 turnovers in the following year. There were no statistically significant decreases in operating room efficiency in the year after the TeamSTEPPS rollout. CONCLUSION: Operating room efficiency was preserved after the rollout of a rigorous evidence-based patient safety initiative that requires active participation from all operating room team members.

An electrical cause of stridor: pediatric vagal nerve stimulators.

Vagal nerve stimulators (VNS) are surgically implantable medical devices which are approved by the food and drug administration (FDA) for treatment of medically refractory epilepsy in children. Two children with seizures disorders presented to the pediatric otolaryngology clinic with complaints of stridor and sleep apnea following implantation of VNS devices. Both children were evaluated with flexible laryngoscopy, direct laryngoscopy and bronchoscopy. The children were noted to have contraction of their vocal folds and supraglottis and the settings of their VNS were adjusted until no further contractions were noted. Each child had resolution of their symptoms following adjustment.

The pediatric sedation unit: a prospective analysis of parental satisfaction.

UNLABELLED: As financial pressures drive health care to be more cost-effective and efficient, performing procedures outside the main operating room (MOR) is becoming more common. Pediatric sedation units (PSU) have proven both effective and safe at providing anesthesia for children. However, there is limited data available regarding the PSU and its potential application in pediatric otolaryngology. OBJECTIVE: To evaluate the experience of performing pediatric outpatient procedures in a PSU through a parental satisfaction survey. METHODS: Pediatric otolaryngology procedures performed in the PSU were prospectively recorded in a database. A prospective survey analysis was performed that measured parental satisfaction with scheduling/registration for surgery, nursing care, surgeon care, facility environment, timing/duration, and overall satisfaction. Parents completed this survey for outpatient procedures performed in either the PSU or in the MOR. The same attending surgeon was involved in all cases, with the only independent variable being the location of the surgery. Fifty surveys were collected for each group, and the surveys scores were statistically compared using nonparametric statistical analysis. RESULTS: Parental satisfaction was high in both the PSU and OR, with mean overall satisfaction scores of 4.8 and 4.9 (respectively) on an ordinal scale from 1 to 5. Parents reported greater clarity in preoperative information in the MOR (mean 4.8) compared to the PSU (mean 4.6) (p<0.006). Also, parents reported that MOR procedures started on time more often than those in the PSU (90-64%, p<0.002). There were no significant differences between locations in any other survey metrics, with mean satisfaction scores ranging from 4.5 to 5.0. CONCLUSIONS: The PSU is a satisfactory patient experience for outpatient procedures in pediatric otolaryngology at our institution. However, this parent survey has identified education prior to surgery and timeliness of surgery as two areas to improve to meet the satisfaction standard provided by the OR.

Pediatric voice analysis: comparison of 2 computerized analysis systems.

IMPORTANCE: This research contributes to the pediatric objective voice measurement database while identifying comparable measurements between 2 available voice analysis systems. OBJECTIVE: To compare selective normative pediatric acoustic variables between the Multi-Dimensional Voice Program (MDVP) and the Voice Evaluation Suite (VES) computerized voice analysis systems. Additionally, it describes the first comprehensive pediatric database analyzing fundamental frequency, jitter, shimmer, and noise to harmonic ratio using the VES. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study with planned data collection conducted at a tertiary referral otolaryngologic clinic. Participants were 335 children, aged 4 to 18 years, with normal voices. INTERVENTIONS: Objective voice data were collected on the MDVP and the VES systems. MAIN OUTCOMES AND MEASURES: Fundamental frequency, jitter, shimmer, and noise to harmonic ratio. RESULTS: The fundamental frequencies agreed with previous pediatric normative values. There was not a statistically significant difference between MDVP and VES measurements of mean fundamental frequency (P = .23). Jitter percentage (P < .001), shimmer percentage (P < .001), and noise to harmonic ratio (P < .002) for all children were statistically different between the 2 voice evaluation systems. CONCLUSIONS AND RELEVANCE: These data show that the measured fundamental frequency of normal voices in children is comparable between the MDVP and VES voice analysis systems. Jitter, shimmer, and noise to harmonic ratio values are not interchangeable between voice analysis systems. The voice analysis system should be reported when providing voice measurement outcomes in the literature.

Operation airway: the first sustainable, multidisciplinary, pediatric airway surgical mission.

OBJECTIVE: This study aimed to describe the development and implementation of the first sustainable, multidisciplinary, pediatric airway surgical mission in an underserved country. METHODS: This prospective, qualitative study was conducted for the first 4 Operation Airway missions in Quito, Ecuador. The major goals of the missions were to assist children with aerodigestive abnormalities, create a sustainable program where the local team could independently provide for their own patient population, develop an educational curriculum and training program for the local team, and cultivate a collaborative approach to provide successful multidisciplinary care. RESULTS: Twenty patients ages 4 months to 21 years were included. Twenty-three bronchoscopies, 5 salivary procedures, 2 tracheostomies, 1 T-tube placement, 1 tracheocutaneous fistula closure, 2 open granuloma excisions, and 6 laryngotracheal reconstructions (LTRs) were performed. All LTR patients were decannulated. A new type of LTR (1.5 stage) was developed to meet special mission circumstances. Two videofluoroscopic swallow studies and 40 bedside swallow evaluations were performed. One local pediatric otolaryngologist, 1 pediatric surgeon, 3 anesthesiologists, 7 intensivists, 16 nurses, and 2 speech-language pathologists have received training. More than 25 hours of lectures were given, and a website was created collaboratively for educational and informational dissemination (http://www.masseyeandear.org/specialties/pediatrics/pediatric-ent/airway/OperationAirway/). CONCLUSION: We demonstrated the successful creation of the first mission stemming from a teaching institution with the goal of developing a sustainable, autonomous surgical airway program.

Military otolaryngology resident case numbers and board passing rates during the Afghanistan and Iraq wars.

OBJECTIVE: During the wars in Iraq and Afghanistan, the US military has continued to train medical residents despite concern that postgraduate medical education at military training facilities has suffered. This study compares the experience of otolaryngology residents at military programs with the experience of their civilian counterparts. STUDY DESIGN: Retrospective review. SETTING: Academic military medical centers. SUBJECTS AND METHODS: Resident caseload data and board examination passing rates were requested from each of the 6 Department of Defense otolaryngology residency programs for 2001 to 2010. The American Board of Otolaryngology and the Accreditation Council for Graduate Medical Education provided the national averages for resident caseload. National board passing rates from 2004 to 2010 were also obtained. Two-sample t tests were used to compare the pooled caseloads from the military programs with the national averages. Board passing rates were compared with a test of proportions. RESULTS: Data were available for all but one military program. Regarding total cases, only 2001 and 2003 showed a significant difference (P < .05), with military residents completing more cases in those years. For individual case categories, the military averages were higher in Otology (299.6 vs 261.2, P = .033) and Plastics/Reconstruction (248.1 vs 149.2, P = .003). Only the Head & Neck category significantly favored the national average over the military (278.3 and 226.0, P = .039). The first-time board passing rates were identical between the groups (93%). CONCLUSION: Our results suggest that the military otolaryngology residency programs are equal in terms of caseload and board passing rates compared with civilian programs over this time period.

Effect of vocal fold injection of cidofovir and bevacizumab in a porcine model.

IMPORTANCE: Recurrent respiratory papillomatosis (RRP) is a common and often chronic disorder. Intralaryngeal bevacizumab has gained recent interest as an adjuvant therapy for RRP. However, no histologic model has been published describing the effects of bevacizumab on the vocal fold. OBJECTIVE: To investigate the histologic effects of bevacizumab injections into the vocal fold and compare these findings with those for cidofovir and saline control injections. DESIGN AND SETTING: In vivo animal study involving eighteen 1-year-old Yorkshire crossbreed pigs, with a blinded review of pathologic findings conducted in a veterinary research laboratory. INTERVENTIONS: The pigs were randomly divided into six study groups receiving 2.5 or 5.0 mg of cidofovir or bevacizumab alone or in combination. Each pig received an injection of 0.5 mL of the test drug in the right vocal fold and 0.5 mL of saline in the left vocal fold. These injections were performed 4 times during the course of 8 weeks. One pig from each group was killed humanely and the larynges harvested 2 weeks after the last injection. The remaining pigs were killed 4 months after the last injection on the remaining pigs. The vocal folds were fixed and stained with hematoxylin-eosin and trichrome and reviewed for histologic changes by 3 blinded pathologists. MAIN OUTCOMES AND MEASURES: Histologic changes to the vocal folds. RESULTS: Minimal inflammation, edema, and atypia were found in all treatment groups. No appreciable histologic differences were found among the 3 treatment groups and their controls. No difference was seen in the vocal folds that were harvested late (4 months) vs early (2 weeks) after last injection. No fibrosis was found in any of the specimens. CONCLUSIONS AND RELEVANCE: No histologic evidence suggests that intralaryngeal cidofovir or bevacizumab alone or in combination resulted in significant changes to the porcine vocal fold. Future studies may build on this model to test higher dosages and/or may combine injections with potassium titanyl phosphate laser therapy.

Outcomes of isolated basilar skull fracture: readmission, meningitis, and cerebrospinal fluid leak.

OBJECTIVE: To determine rates of cerebrospinal fluid (CSF) leak, meningitis, and readmission in pediatric and adult patients with isolated basilar skull fracture. STUDY DESIGN: Cross-sectional analysis of a statewide database. SUBJECTS: Patients with isolated basilar skull fracture (1995-2010). METHODS: Patients were identified within the California Office of Statewide Health Planning and Development database using ICD-9 diagnosis codes. RESULTS: A total of 3563 pediatric and 10,761 adult patients met inclusion criteria. In-hospital rates of meningitis (0.48% and 0.64%, P = .3360) and CSF leak (2.33% and 1.75%, P = .0270) were similar among children and adults, respectively. Rates of 90-day meningitis (0.17% and 0.37%, P = .0714) and CSF leak (0.40% and 0.40%, P = .9823) were also similar. Thirty-day readmission was 4.6% for children compared with 12.4% for adults (P < .001). For both pediatric and adult patients, extra-axial hematoma (odds ratio [OR] [confidence interval {CI}] 1.65 [1.05-2.59] and 1.61 [1.34-1.95]) and comorbidities (OR [CI] 2.19 [1.11-4.34] and 1.28 [1.04-1.59]) were associated with significant increases in 30-day readmission. Loss of consciousness greater than 1 hour (OR, 3.05; 95% CI, 1.53-6.08) and CSF leak (OR, 3.28; 95% CI, 1.41-7.64) increased the likelihood of pediatric readmissions. Lack of insurance (OR, 0.67; 95% CI, 0.50-0.90) and female gender (OR 0.83; 95% CI, 0.70-0.99) reduced the likelihood of adult readmission. CONCLUSION: Meningitis and CSF leak following isolated basilar skull fractures are uncommon. Readmission within 30 days was more common in adults than in children. CSF leak, hematoma, and prolonged loss of consciousness increased the likelihood of readmission in children. Intracranial injury, male gender, having insurance, and comorbidities increased the likelihood of readmission in adults.

Novel method for laryngotracheal reconstruction: combining single- and double-stage techniques.

OBJECTIVES: Traditional open techniques for laryngotracheal reconstruction are either single- or double-stage procedures. Some patients may benefit from the presence of a long, single-tube stent, such as an endotracheal tube, but their predicted need for a 2-stage procedure and a persistent tracheostomy is high. We describe a novel technique for airway reconstruction that combines the methods of both single- and double-stage procedures. METHODS: We present a retrospective review of 4 patients. All patients underwent laryngotracheal reconstruction by a single surgeon. After the operation, the airway was stented with nasotracheal intubation. A small stent, fashioned from an endotracheal tube, was placed in the tracheostoma to keep it patent. The patients subsequently underwent extubation and replacement of the tracheostomy tube. RESULTS: The study included 1 patient with grade 4 subglottic stenosis, 2 patients with grade 3 subglottic stenosis, and 1 patient with a posterior glottic scar. All were tracheostomy tube-dependent. Serial bronchoscopy was used to follow the patients for a minimum of 9 months after the operation. All 4 patients have since met the criteria for decannulation. CONCLUSIONS: This hybrid reconstruction merges the advantages of both the single- and double-stage procedures. It adds versatility to the surgical toolbox for airway reconstruction.

Consistency of voice frequency and perturbation measures in children.

OBJECTIVE: Evaluate normal pediatric voice frequency and perturbation measures with Voice Evaluation Suite (VES) and Multi Dimensional Voice Program (MDVP), determine the consistency of these measures over time, and understand which measures might be most useful for evaluating children with voice disorders. STUDY DESIGN: Prospective, longitudinal study of normal voices of 50 children aged 4 to 17 years. SETTING: Pediatric otolaryngology clinic within tertiary hospital. SUBJECTS AND METHODS: Two tests of sustained utterances from each child were evaluated by 2 computerized voice analysis programs for frequency and perturbation. Intraclass correlation coefficient (ICC) was used to assess the reliability between the samples. RESULTS: Children (male/female, 1.08:1) with a mean age of 8.34 years were tested on an average of 54.2 minutes apart. Each test included 4 utterances; 1 was analyzed by MDVP, and 3 grouped utterances were averaged and evaluated by VES. Fundamental frequency had excellent reliability (ICC = 0.95) in both VES and MDVP. Jitter, shimmer, and noise to harmonic ratio were poorly reliable (ICC ≤ 0.4) in MDVP but had good to excellent reliability (ICC 0.66-0.8) in VES. CONCLUSION: Single, sustained utterances in children provide consistent measures of frequency. Perturbation is not reliably measured by such testing, but averaging multiple samples yields improved consistency. Evaluating acoustic measure stability in spontaneous speech and in sustained utterances cued by a tuning frequency can provide further insight on pediatric voice consistency.

Quantitative distinction of unique vocal fold subepithelial architectures using optical coherence tomography.

OBJECTIVES: The primary objective of this study was to quantitatively analyze ex vivo porcine, fetal human, and adult human vocal folds by use of optical coherence tomography (OCT). A secondary objective was to quantitatively discriminate among 1-, 2-, and 3-layer lamina propria structures. METHODS: We performed an analysis of the vocal folds of 10 adult pig, 3 adult human, and 2 fetal human vocal fold specimens using OCT and histologic techniques. We present a quantitative comparison of the OCT results and histologic findings. RESULTS: We found that OCT allowed for the visualization of the subepithelial vocal fold architecture of all imaged tissue, and that it revealed distinct characteristic signal intensities for each type of specimen. CONCLUSIONS: Optical coherence tomography was developed for in vivo imaging of biological microstructures. This study demonstrates the ability of OCT to differentiate between the vocal fold architectures of 3 histologically distinct types of vocal folds. Future studies aim to develop a quantitative optical imaging algorithm that can be used to facilitate an in vivo longitudinal clinical investigation of the changes that occur in this layered structure over time and maturation.