Clinical evaluation of pediatric patients with recurrent respiratory papillomatosis.: A longitudinal study at a Saudi Arabian tertiary care center.

OBJECTIVES: To study the clinical evaluation of recurrent respiratory papillomatosis (RRP) patients and the factors associated with the improvement in the Derkay's score as a measure of disease severity. METHODS: A retrospective cohort that included all juvenile RRP patients who were admitted to King Abdulaziz University Hospital, Riyadh, Saudi Arabia, between September 2015 and June 2022 and underwent surgical debulking. RESULTS: A total of 16 patients were eligible to join our study. Among them, 7 patients were males. Hoarseness of voice was the most frequent symptom. The median period of the follow-up was 56 months. Complete remission was achieved in 31.3%. The univariate linear regression model revealed that the cidofovir-treated patients had a significant reduction in the change value of Derkay's score compared to those without treatment (regression coefficient= -5.83, 95% confidence interval [CI]: [-11.5 to -0.143], p=0.045). Also, the increased first Derkay's score decreased the change value and subsequently increased the improvement chance of the disease (regression coefficient= -0.424, 95% CI: [-0.764 to -0.083], p=0.018). However, in the multivariate regression model, both variables showed non-significant results. CONCLUSION: cidofovir treatment and higher Derkay's scores affected the disease improvement.

Effect of Intralesional Steroid Injections Among Patients with Acquired Laryngotracheal Stenosis Undergoing Endoscopic Balloon Dilation Using Pulmonary Function Tests.

Objectives: Laryngotracheal stenosis (LTS) is characterized by an abnormal decrease in the upper airway diameter. The pulmonary function test (PFT) is an effective adjunctive diagnostic tool for upper airway obstruction. LTS can be managed with either open surgery or less invasive endoscopic approaches, among which endoscopic balloon dilation is the main method; this may include concurrent intralesional steroid injection (ILSI), which has the potential of improving the outcomes. However, the effectiveness of ILSI is unclear. We aimed to compare the improvement in PFT parameters among patients with acquired LTS following endoscopic balloon dilation who received and did not receive ILSIs. We also compared the recurrence times and rates between the 2 patient cohorts. Methods: We retrospectively collected data regarding pre- and postoperative PFTs, as well as inter-dilation interval records, obtained between June 2015 and April 2020. Results: We included 34 patients with acquired etiologies. The most common cause of stenosis was intubation (52.9%), followed by trauma (29.4%). Further, 52.9% of the patients received ILSIs. Symptom recurrence was reported in 23 (67.6%) cases, with no significant between-group difference -0.1389 [95% confidence interval (CI): -0.4483, 0.1705]. The mean (standard deviation) duration of the first reintervention was 8.62 (8.00) and 7.38 (3.20) months among patients who did and did not receive ILSIs, respectively (mean difference -1.23, P = .614, 95% CI -6.30, 3.84). Conclusion: Our findings indicated that PFT parameters improved following endoscopic balloon dilation, with forced expiratory volume in 1 second being significantly higher with concurrent ILSI. However, there was no between-method difference in the treatment effectiveness. Additionally, the restenosis recurrence rate was consistent with that reported in the literature.

Is adenotonsillectomy effective in improving central apnea events in patients with obstructive sleep apnea? A systematic review and meta-analysis.

PURPOSE: To evaluate the effects of adenotonsillectomy on improving central sleep apnea events in children with obstructive sleep apnea (OSA). METHODS: We searched four online databases for relevant articles published from inception until October 2022. We included studies that measured the number of central apnea events per sleep and central apnea-hypopnea index (CAHI) or central apnea index (CAI) scores in children with OSA before and after adenotonsillectomy. Our primary outcomes were changes in CAI scores, the number of central apnea events per sleep, and CAHI scores after surgery. Our secondary outcomes were changes in total and mixed apnea events, improvement of sleep outcomes, and differences in oxygen or carbon dioxide saturation during sleep. We performed meta-analyses by pooling the mean changes of all included studies with a 95% confidence interval using Stata 17. Subsequently, we performed subgroup analyses based on the presence of comorbidities. RESULTS: We included 22 studies comprising 1287 patients. Central and total sleep apnea parameters, except for CAHI and mixed apnea index scores, showed significant improvements after surgery. In addition, all respiratory parameters and second and third stages of non-rapid eye movement sleep showed significant postsurgical improvements. Patients with comorbidities showed significant improvements only in the total apnea-hypopnea index, oxygen desaturation index, and minimal oxygen saturation. CONCLUSION: Adenotonsillectomy improves central apnea events in patients with OSA but not in those with comorbidities.

Spirometry in laryngotracheal stenosis: a systematic review and meta-analysis.

PURPOSE: This study aimed to assess the changes in spirometry parameters or indices after relieving laryngotracheal stenosis (LTS) in adult patients. METHODS: A systematic review and meta-analysis of studies from PubMed, Scopus, Web of Science, Cochrane Library, and EBSCO databases was conducted for assessing changes in spirometry values after endoscopic balloon dilatation of LTS in adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Relevant data, such as changes in mean spirometry values between preoperative and postoperative interventions, and findings of receiver operating characteristic curve analyses for predicting the need for surgical intervention, were extracted. RESULTS: Ten studies including 330 patients overall met the inclusion criteria. Significant improvements were observed from preoperative to postoperative mean values of different spirometry parameters and indices. The overall mean differences in peak expiratory flow (ΔPEF), expiratory disproportion index (ΔEDI), and peak inspiratory flow (ΔPIF) were 2.26 L/s (95% CI 2.14-2.38), 27.94 s (95% CI 26.36-29.52), and 1.21 L/s (95% CI 0.95-1.47), respectively. ΔPEF and ΔPIF values increased, while ΔEDI decreased. In predicting the need for surgical intervention, EDI had the highest sensitivity (88%), and forced expiratory volume per second/forced vital capacity had the highest specificity (85%). CONCLUSION: Spirometry is a valuable tool for assessing patients with LTS. PEF, EDI, and PIF were the most commonly reported spirometry parameters that significantly improved after airway stenosis was relieved.

Comparison Between Flap and Primary Closures of Persistent Tracheocutaneous Fistula: A Scoping Review.

Objectives: To compare the susceptibility and complication rates between flap and primary closures for tracheocutaneous fistula (TCF). Methods: We searched 4 online databases (Web of Science, Cochrane Library, PubMed, and Scopus) for relevant articles published from study inception until August 2022. Studies including at least 5 adult or child patients with persistent TCFs who underwent closure surgery via primary or flap repair were included. All included studies reported outcomes of surgical repairs such as successful closure rates and complications. In addition, we performed single-arm meta-analyses for each surgical method using the Open Meta-Analyst software to calculate the pooled event rate with a 95% confidence interval (CI); compared the 2 surgical procedures using the Review Manager software using the risk ratio with 95% CI; and assessed study quality based on the National Heart, Lung, and Blood Institute criteria. Results: Overall, 27 studies with 997 patients were included. No significant difference was observed between the closure success and major complication rates of surgical methods. The primary and flap closures had overall success rates of 0.979 and 0.98, respectively. The overall major complication rates in primary and flap closures were 0.034 and 0.021, respectively; and that of minor were 0.045 and 0.04, respectively. In primary closure, a significant decrease in the success rate with increasing age at the time of decannulation was observed. In addition, the risk of major complications increased with increasing time from decannulation to closure. Conclusions: Both the primary and flap repairs of TCF are effective based on closure success and complication rates; therefore, they are both acceptable therapeutic alternatives, and flap repair can be considered when other techniques have failed. However, further prospective randomized studies comparing these 2 procedures are needed to support our results.

Translation and validation of the Arabic version of the sleep-related breathing disorder scale of the pediatric sleep questionnaire (PSQ-SRBD).

BACKGROUND/OBJECTIVES: The incidence of sleep-related breathing disorders is underestimated because polysomnography is required to confirm its diagnosis. The pediatric sleep questionnaire-sleep-related breathing disorder (PSQ-SRBD) scale is a self-reported questionnaire completed by a patient's guardian. There is no validated Arabic version of the PSQ-SRBD that can be used in the Arabic-speaking population. Therefore, we aimed to translate, validate, and culturally adapt the PSQ-SRBD scale. We also aimed to evaluate its psychometric properties for the diagnosis of obstructive sleep apnea (OSA). METHODS: The cross-cultural adaptation method consisted of the following steps: forward-backward translation, appraisal of a sample of 72 children (aged between 2 and 16 years) by an expert group, and performing Cronbach's alpha coefficient testing, Spearman's rank correlation coefficient testing, Wilcoxon signed-rank testing, and sign testing. The reliability of the Arabic version of the PSQ-SRBD scale was assessed using a test-retest comparison, and a factor analysis of the items was used to verify construct validity. For statistical purposes, p-values <0.05 were considered to indicate significance. RESULTS: All subscales had adequate internal consistency: 0.799 for snoring and breathing, 0.69 for sleepiness, 0.711 for behavioral problems, and 0.805 for the entire questionnaire. Comparing questionnaire responses administered 2 weeks apart revealed no statistically significant difference in total scores between the two groups (p-values >0.05 by Spearman's rank correlation coefficient test for all domains) and also no statistical difference among 20 out of 22 questions independently (p-value >0.05 by sign test). A factor analysis conducted to assess the structure of the Arabic-SRBD scale revealed good correlational patterns. The mean score before surgery was 0.464 ± 0.166, and this changed to 0.185 ± 0.142 after surgery with a reduction of 0.278 ± 0.184 which was statistically significant (p < 0.001). CONCLUSION: The Arabic version of the PSQ-SRBD scale is a valid tool for the assessment of pediatric OSA patients and can be used to follow-up patients after surgery. Future research will determine this translated questionnaire's applicability.

Adverse Respiratory Events After Pediatric Endoscopic Airway Surgeries.

OBJECTIVE: Perioperative risk stratification of pediatric patients undergoing airway intervention remains crucial in identifying those at a higher risk of requiring postoperative intensive care unit (ICU) care. Here we determined the likelihood of and possible risk factors for developing perioperative adverse respiratory events (PAREs) requiring ICU care after various pediatric endoscopic airway surgeries (EASs). METHODS: We conducted a retrospective chart review of pediatric patients who were aged <18 years and underwent EAS between 2015 and 2021. Early postoperative adverse events within 24 h of surgery were recorded and analyzed. RESULTS: Overall, 99 patients who underwent EAS were included. The age at the time of the intervention ranged from 8 months to 18 years. Fifty-eight patients, median age was 4.83 years, underwent papilloma debulking with no high likelihood of PARE in this patient subgroup (OR = 0.48; 0.16-1.44). Twenty-five patients, median age was 9.72 years, underwent balloon dilation of laryngotracheal stenosis with no increase in the likelihood of PARE in this patient population (OR = 2.02; 0.65-6.28). Early postoperative respiratory events occurred in 16 patients (16.2%). Most of these events (75%) manifested within 4 h after surgery. In a univariate analysis, intervention at the level of the subglottis or 2 or more laryngeal subsites increased the risk of PARE (OR = 6.57; 1.11-12.52 and OR = 3.73; 1.93-22.34, respectively). In a multivariate analysis, only intervention in the subglottic area maintained its effect (OR = 6.84; 1.82-25.65). CONCLUSION: Respiratory adverse events following pediatric EAS are not uncommon, and the majority are encountered shortly after surgery. Intervention in the subglottic area was an independent predictor of PARE.

Safety profile and efficacy of high-dose topical mitomycin-C for choanal atresia repair: A prospective cohort study.

OBJECTIVES: To study the effect of dose-adjusted mitomycin-c (MMC) on the recurrence rate of choanal atresia (CA), and the complication rate associated with this concentration. METHODS: This prospective cohort study was conducted between May 2012 and March 2020 at a tertiary referral center. It included patients of all ages who were diagnosed with CA and scheduled to undergo surgical repair. The MMC group received 4.0 mg/mL of topical MMC. Both groups were followed up for the surgical outcomes and complication rates. RESULTS: Twenty-one patients (15 females) underwent 25 CA repair procedures. The mean age was 44.85 months (standard deviation = 72.85). MMC was used in 12 (57.1%) of 21 patients. Revision CA repair was warranted in three of the nine patients who did not receive topical MMC compared to one of the 12 patients who received topical MMC. The MMC group required 1.08 ± 0.29 surgeries (range, 1-2), whereas the non-MMC group required 1.44 ± 0.73 surgeries (range, 1-3). Functional success was achieved in 17 (81%) patients who remained symptom-free until their last follow-up visit. CONCLUSION: High-concentration MMC was considered safe in the pediatric and adult populations. Although high-concentration MMC could reduce the need for revision surgery, further studies are required to determine whether the effect is significant in a larger sample population.

Correlation of airway ultrasonography and laryngoscopy findings in adults with subglottic stenosis: a pilot study.

PURPOSE: Ultrasonography of the airway has potential as an alternative, non-invasive, method to monitor patients with subglottic stenosis in an outpatient setting. This prospective, interventional, double-blinded study aimed to correlate ultrasound-based and laryngoscopy-based subglottic stenosis assessment in adults. METHODS: The study was conducted between July 2020 and March 2021 at a tertiary referral center. Consecutive adult patients with subglottic stenosis were evaluated using airway ultrasonography 1 day prior to scheduled laryngoscopy. The radiologist was blinded to the preoperative endoscopic findings, and the primary surgeon was blinded to the ultrasonographic measurements. The intraoperative subglottic diameter was defined as the outer diameter of an endotracheal tube passing through the subglottis without producing an air leak. RESULTS: Sixteen patients (11 females; age range, 17-66 years; mean = 44.06, SD = 12.79) were included. The ultrasonographic subglottic diameter ranged from 5.20 mm to 8.00 mm (mean = 6.24 mm, SD = 0.90). In 15 of 16 patients, the diameter difference between the ultrasonographic and intraoperative measurements ranged from -0.80 mm to 0.30 mm (mean = -0.20 mm, SD = 0.35). However, patient 6 had a difference of - 2.10 mm between the two measurements, which was attributed to thick laryngotracheal secretions interfering with the ultrasonographic air shadow. Data analysis of all 16 patients showed a statistically significant correlation between the readings obtained by the two techniques (r = 0.84, P = 0.000051). CONCLUSION: This study found a significant correlation between ultrasonography-based and laryngoscopy-based subglottic stenosis assessment in adult patients. It provides a basis for an alternative and potentially reliable method to monitor patients with subglottic stenosis.

Utility of Spirometry Values for Evaluating Tracheal Stenosis Patients Before and After Balloon Dilation.

OBJECTIVES: Tracheal stenosis is defined as a narrowing of the airway distal to the lower edge of the cricoid cartilage. It is initially diagnosed based on clinical presentation and then confirmed using direct laryngobronchoscopy. Other adjunctive diagnostic methods, including spirometry, have been proposed. This study aimed to evaluate the relationship between tracheal stenosis severity and pre- and post-balloon dilatation spirometry parameters in order to assess for significant changes in spirometry values and to evaluate for the effects of stenosis-associated factors on post-dilation spirometry values, including vertical length and grade of the stenosis, as well as the role of wound-modifying agents. METHODS: This retrospective study included adults (>18 years of age) with isolated tracheal stenosis who underwent endoscopic balloon dilations at King Saud University Medical City from June 2015 to May 2019, with detailed documentation of operative findings and valid spirometry measurements pre- and post-balloon dilation. Basic demographic data and operative note details, including information about the percentage of tracheal stenosis, distance of tracheal stenosis from vocal cords, vertical length of stenotic segment, and use of wound-modifying agents (topical mitomycin C or triamcinolone injections), were extracted. RESULTS: Fourteen patients with spirometry measurements obtained on 50 occasions (25 pre-balloon dilation and 25 post-balloon dilation) were included. Each 1-unit increase in the vertical length of the stenosis showed a statistically significant negative relationship (-1.47 L/s) with pre-balloon dilation peak expiratory flow (PEF; P = .034). Post-balloon dilation spirometric values showed statistically significant improvements for most variables. CONCLUSIONS: The vertical length of an isolated tracheal stenosis can be predicted before surgical interventions using PEF values and may be a significant indicator of anticipated post-balloon dilation surgical success. Our study suggested that spirometry is a very useful technique for evaluating patients with tracheal stenosis due to its noninvasiveness, cost-effectiveness, with a good clinical value.

Effect of inhaled fluticasone propionate on laryngotracheal stenosis after balloon dilation: a randomized controlled trial.

PURPOSE: Laryngotracheal stenosis describes various airflow compromising conditions leading to laryngeal and tracheal narrowing, including subglottic and tracheal stenosis. Direct laryngobronchoscopy is the diagnostic gold standard for laryngotracheal stenosis. This study aimed to explore the effect of inhaled fluticasone propionate as adjuvant medical therapy in patients with laryngotracheal stenosis after balloon dilation. METHODS: This prospective randomized controlled trial was conducted from April 2019 to April 2020. Fourteen adults (≥ 18 years) with laryngotracheal stenosis consented to participate. All patients underwent endoscopic balloon dilation. Seven patients were treated with inhaled fluticasone propionate, and seven acted as controls. Detailed documentation of operative findings and pre- and post-balloon dilation spirometry measurements were recorded. Basic demographic data and operative details, including information about the percentage of laryngotracheal stenosis, distance of laryngotracheal stenosis from the vocal cords, the stenotic segment vertical length, and the largest endotracheal tube used before and after dilation were noted. RESULTS: Spirometry measurements were obtained on 34 occasions (17 before and 17 after balloon dilation). The two groups were similar in spirometry values after treatment. Both groups had significantly improved on most spirometry values after balloon dilation. CONCLUSION: We found that using inhaled steroids after balloon dilatation in patients with laryngotracheal stenosis had no benefit over non-user patients in spirometry parameters during the short postoperative follow-up. To confirm this outcome, we recommend a large-scale double-blind study with a longer follow-up period.

Development of mucoadhesive hydrogels based on polyacrylic acid grafted cellulose nanocrystals for local cisplatin delivery.

To fabricate a mucoadhesive hydrogel with superior properties for local delivery of cisplatin (CDDP) to colorectal cancer, a hardcore bottle-brush polymer (HCBBP) was developed through grafting of poly(acrylic acid) (PAA) on cellulose nanocrystals (CNC) at 6, 9 and 12 CNC:PAA w/w ratios. The developed materials were characterized by acid-base titrations, FT-IR, electron microscopy, muco-rheological behaviour in the presence of mucin, in vitro drug release and anticancer activity against human HCT-116 colorectal cancer cells. The results showed CNC-g-PAA9 to have superior rheological behavior in the presence of mucin compared to CNC and other gels under study indicating beneficial mucoadhesive characteristics. CNC-g-PAA9:CDDP complex showed slow CDDP release causing a significant increase in IC 50 of the drug (> 3-fold) against HCT116 cells. The developed CNC-PAA9 hydrogel showed no intrinsic cytotoxicity on its own. The results point to a great promise for CNC-g-PAA9 as mucoadhesive hydrogels for local platinum delivery in colorectal cancer.

Microbiological profiles of tracheostomy patients: a single-center experience.

BACKGROUND: This study compared the prevalence of common microorganisms in obstructed and non-obstructed cases across the four quarters on the first post-tracheostomy year. METHODS: A retrospective chart review of the microbiological profiles of all adult patients who underwent a tracheostomy was conducted between June 2015 and September 2019 at our hospital. Based on the tracheostomy indications, patients were allocated to obstructed or non-obstructed group. Any patient with at least one positive sample was followed up quarterly for a year. The first culture result obtained was recorded at least one month following the last antibiotic dose in each quarter. RESULTS: Out of the 65 tracheal aspirate results obtained from 58 patients (mean age, 57.5±16.48 years), the most common procedure and indications were surgical tracheostomy (72.4%) and non-obstructed causes (74.1%), respectively. Moreover, 47.7% of the culture results indicated Pseudomonas aeruginosa, which showed significantly different proportions across the quarters (p=0.006). Among obstructed patients, P. aeruginosa was the most common (35%), followed by methicillin-resistant Staphylococcus aureus (MRSA; 23.5%). CONCLUSIONS: The most common post-tracheostomy microorganism was P. aeruginosa. MRSA showed a strong association with tracheostomy for obstructive indications.

Proposing an Endotracheal Tube Selection Tool Based on Multivariate Analysis of Airway Imaging.

OBJECTIVES: We aimed to comprehensively investigate different upper airway segments in adults, determine the predictors of the size of each segment, and identify an appropriate endotracheal tube (ETT) size chart. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care center. MATERIALS AND METHODS: The data for patients aged >18 years who underwent neck computed tomography were screened. Patients with existing tumors, trauma, or any pathology that can alter the normal airway anatomy and those with intubation, tracheostomy, or nasogastric tubes were excluded. Computed tomography software was used to measure the anteroposterior diameter (APD), transverse diameter (TD), and cross-sectional area (CSA) at the glottic, proximal subglottic, distal subglottic, and tracheal levels. Multiple regression analysis was used to identify the predictors of the airway size. RESULTS: One hundred patients were reviewed. The TD was consistently smaller than or equal to the APD at each level in all but 3 patients. The mean CSA and TD (170 mm2 and 11.3 mm, respectively) of the glottis indicated that the glottis was most often the narrowest level, followed by the proximal subglottis where the mean CSA and TD were 192.1 mm2 and 12.7 mm, respectively. Moreover, the mean APD was the smallest at the level of the trachea (20.1 mm). Multiple regression analysis confirmed that height and sex were the predominant predictors of measurements for the 4 airway segments. In addition, age was associated with the TD and CSA of the distal subglottic and tracheal segments, respectively. CONCLUSION: One-third of our participants exhibited a proximal subglottic diameter that was equal to or smaller than the glottic diameter. Our findings also suggested that the height and sex of the patients are important variables for the selection of an appropriate ETT size.

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

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

Comparison Between Mathematical and Software Calculation Methods for the Measurement of the Cross-sectional Area in Upper Airway Imaging.

Objectives This study aimed to compare the results of a software calculation method (SCM) and the mathematical calculation method (MCM) in measuring the cross-sectional area (CSA) at four different upper airway segments. Methods The data from the retrospective chart reviews of patients older than 18 years who had undergone computed tomography (CT) of the neck at our tertiary care center between September 2014 and September 2018 were reviewed. Data of patients who were intubated, tracheostomized, had nasogastric tubes, tumors, craniofacial anomalies, trauma, or any pathology that may affect the normal airway anatomy were excluded. We measured the anteroposterior (APD) and transverse diameter (TD) utilizing the CT software. CSA was calculated using both the mathematical formula (MCM) and software (SCM) at the glottis, proximal subglottis, distal subglottis, and tracheal levels. A paired sample t-test was used to determine the significant difference between SCM and MCM at each level. Results The data of 100 patients (59% female) were reviewed. There was a significant difference between the SCM and MCM at all four levels. The mean differences between the SCM and MCM were -33.63 mm2, -24.20 mm2, 6.04 mm2 (p < 0.001) at the glottis, proximal subglottis, and trachea, respectively. The mean difference at the distal subglottis was -4.08 mm2 (p = 0.01). Conclusion Our study found a significant difference between the SCM and MCM in measuring the CSA of the four airway segments. Theoretically, the SCM is more accurate and precise than MCM in measuring CSA; however, we could not prove the superiority of either method.

Iatrogenic injury to a vesicourachal diverticulum during laparoscopic appendectomy successfully managed conservatively.

A vesicourachal diverticulum is a rare congenital anomaly that arises from the incomplete closure of the urachus at the bladder end. We describe a 12-year-old boy who presented with severe persistent right iliac fossa pain associated with subjective fever, nausea, vomiting, and anorexia. A computed tomography (CT) scan of the abdomen and pelvis revealed findings consistent with appendicitis. The patient underwent a laparoscopic appendectomy; however, his postoperative course was remarkable for a low urine output and urine leakage from the suprapubic port site. A CT cystography showed a vesicourachal diverticulum and conservative management was offered. This management consisted of Foley catheter placement, hourly monitoring of the patient's urine output, antibiotic prophylaxis, daily laboratory investigations and a cystography performed after 7 days. Overall, injury to the vesicourachal diverticulum is rare, and surgeons should be aware of this rare clinical entity and exercise caution during port placement. Surgeons should also have a high index of suspicion to identify these injuries and appropriately manage the condition early.

Pediatric nasopharyngeal fibrolipoma: A case report and review of the literature.

A 3-year-old female presented for evaluation of progressive snoring since birth. MRI revealed a fatty-appearing mass measuring 2.4 cm × 1.5 cm x 3.0 cm arising from the predental space of C1 and extending anteriorly through the prevertebral space into the retropharyngeal space. The patient underwent endoscopic trans-oral excision of the mass using electrocautery and blunt dissection, and pathological analysis yielded a diagnosis of fibrolipoma. CT imaging twelve months post-surgery showed no recurrence, and the patient remains symptom free two years later. Very few reported cases of nasopharyngeal fibrolipomas exist, and this is the first report of 2-year clinical follow-up.

Utilization of a handheld metal detector protocol to reduce radiation exposure in pediatric patients with esophageal coins.

OBJECTIVE: The primary objective of this study is to assess the utility of a handheld metal detector for identification and surveillance of patients with known esophageal coin ingestion to reduce repeat x-rays and associated radiation exposure. METHODS: Prospective study of children presented to the emergency department with esophageal coins confirmed by an initial x-ray were enrolled. The otolaryngology team used the handheld metal detector to detect and localize the coin on patient. If admitted for observation, the metal detector was used to ensure coin persistence prior to going to operating room for removal. No further x-rays were done if same location is confirmed. RESULTS: A total of 19 patients (10 months-14 years) with 20 esophageal coins were enrolled. 14 patients (73.7%) were initially detected in the emergency department by the metal detector. 11 (58%) asymptomatic patients admitted for period of observation, repeat x-rays were avoided in 10 (90.9%) patients prior to removal in the OR. All proximal esophageal coins were detected with the metal detector. There were 5 (26.3%) patients who failed initial detection of coin, and all of these were in the mid-distal esophageal location with depth from skin >7 cm. CONCLUSION: A handheld metal detector is rapid, cost-effective surveillance tool to reduce exposure to radiation from repeated x-rays in patients with esophageal coins. In contrast to all prior published studies, which did not objectively examine depth, the distance of the coin from skin surface appears to be a major limitation. Parents have provided positive feedback on the protocol.

Physicians' knowledge and attitudes in Saudi Arabia regarding implantable cardiac defibrillators.

OBJECTIVES: To evaluate knowledge and attitude of physicians involved in the management of patients with heart failure regarding implantable cardioverter-defibrillator (ICD). METHODS: We conducted personal interviews with physicians involved in treating patients with heart failure. Between October 2015 and February 2016, the study was conducted in hospitals in the Riyadh region where no cardiac electrophysiology service was available. Every participant was met in person and received an oral questionnaire that aimed to assess basic knowledge regarding ICD indications and benefits. RESULTS: Sixty-three physicians were met from 13 hospitals (14 consultants and 49 specialists). Forty-one percent of participants use the recommended cut-off level of left ventricular ejection fraction (LVEF) which is ≤35% as the LVEF criterion for ICD referral in patients with cardiomyopathy. Only 50% of the consultants use ≤35% as the LVEF criterion for ICD referral. Seventy percent of the participants thought that ICD may improve heart failure symptoms. Forty-eight percent of physicians have a defined channel to refer patients to higher centers for ICD implant. There was no statistically significant difference between physicians' knowledge when we categorized them according to three different factors: (1) physician's specialty (cardiology vs. internal medicine); (2) physician's degree (consultant vs. specialist); and (3) physician's location (inside vs. outside Riyadh city). CONCLUSION: There is a lack of knowledge of current clinical guidelines regarding ICD implantation for patients with heart failure at general hospitals in Saudi Arabia. This finding highlights the need to improve the dissemination of guidelines to practitioners involved in managing patients with heart failure in an effort to improve ICD utilization.