Transtracheal Pressure for Evaluation of Decannulation Readiness.

BACKGROUND: Pediatric tracheostomy decannulation protocols vary among institutions and may include toleration of Passy Muir Valve (PMV), microlaryngoscopy and bronchoscopy (MLB) findings, and polysomnography evaluation. Transtracheal pressure (TTP) is an objective measurement utilized to evaluate PMV toleration. We aimed to investigate the role of TTP in decannulation candidates and compare TTP measurements with polysomnography and MLB findings. METHODS: A retrospective cohort study of children who underwent TTP measurement during PMV trial between December 2012 and November 2022. RESULTS: A total of 79 patients underwent TTP measurement and MLB evaluation; of these, 16 (20.3%) patients had a capped polysomnography. Twenty-eight (35.4%) patients had TTPs ≤10 cm H2 O, and 51 (64.6%) patients had TTPs >10 cm H2 O. The most common indication for tracheostomy was upper airway obstruction (n = 41, 51.9%), followed by a need for mechanical ventilation (n = 24, 30.4%). Twenty-five (31.6%) patients were decannulated. Patients with TTPs ≤10 cm H2 O had a mean Apnea-Hypopnea Index of 0.17 ± 0.26/h compared with 6.93 ± 7.67/h in those with TTPs >10 cm H2 O, p = 0.0365. Patients with TTPs >10 cm H2 O were found to have a significantly higher occurrence of airway obstruction (96.1% vs. 46.4%, p < 0.0001) and multilevel airway obstruction (70.6% vs. 21.4%, p < 0.0001) on MLB. Neither TTP measured at time of PMV assessment nor capped polysomnography was associated with successful decannulation. CONCLUSIONS: TTP measurements at time of PMV evaluation are associated with polysomnography and MLB findings. One-time PMV measurements were not indicative of decannulation success. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Swallowing Function After Epiglottopexy in Children.

OBJECTIVE: Epiglottopexy has been an increasingly utilized intervention in children with epiglottic prolapse and airway obstruction. Given the role of the epiglottis in protecting the airway during swallowing and the potential effect of repositioning the epiglottis on the passage of the bolus, we aimed to compare swallowing outcomes before and after epiglottopexy in children. STUDY DESIGN: A retrospective cohort study. SETTING: Tertiary care children's hospital. METHODS: Data were extracted from charts of children who underwent epiglottopexy and had a subsequent instrumental swallowing evaluation between January 2018 and September 2022. RESULTS: A total of 93 patients underwent epiglottopexy. Of these, 38 patients met inclusion requirements. The mean age at surgery was 41 ± 47 months. Most patients (n = 37, 97.4%) had significant comorbidities such as secondary airway lesions (n = 33, 91.7%), a genetic or syndromic disorder (n = 25, 69.4%), and dysphagia (n = 29, 76.3%). All patients had a concurrent procedure at the time of epiglottopexy with supraglottoplasty (n = 24, 63.2%) and lingual tonsillectomy (n = 16, 42.1%) being the most common. No changes in initiation or patterns of swallowing were noted postoperatively. A total of 7 (18.4%) patients had worsening swallow function: 2 had new-onset dysphagia, and 5 had worsening pre-existing dysphagia. Liquid or food textures penetrated remained unchanged or improved in most cases. No risk factors for worsening dysphagia were identified in our cohort. CONCLUSION: Children with medical comorbidities undergoing epiglottopexy with additional airway interventions may experience new or worsening dysphagia. However, the procedure is generally safe without notable patterned changes in the swallowing mechanism.

Management of Tracheobronchial Stenosis in Chondrodysplasia Punctata.

Chondrodysplasia punctata (CDP) is a rare congenital syndrome characterized by aberrant, punctate deposition of calcium during endochondral bone formation, resulting in the characteristic finding of epiphyseal stippling on radiographs. While otolaryngologic manifestations such as nasomaxillary hypoplasia and mixed hearing loss are common, tracheobronchial calcification occurs rarely in neonates with CDP. The management of CDP-related airway stenosis is complex and there is limited literature pertaining to outcomes of airway interventions. Herein, we describe the clinical course and outcome of tracheal dilation for a newborn patient with CDP. Laryngoscope, 134:1464-1468, 2024.

International pediatric otolaryngology group (IPOG) consensus on approach to aspiration.

OBJECTIVE: To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration. METHODS: Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step. RESULTS: Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children. CONCLUSION: Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.

Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do.

Purpose of review: To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls. Recent findings: Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity. Summary: Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.

The Clinical Impact of Vagal Nerve Stimulator Implantation on Laryngopharyngeal Function in Children: A Single-Center Experience.

OBJECTIVE: A vagal nerve stimulator (VNS) has been established as the treatment of choice for children with refractory epilepsy. The outcomes of the procedure have been well documented in adults but are less clear in children. The goal of our study was to review laryngopharyngeal (LP) function following VNS implantation in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care children's hospital. METHODS: Voice, swallowing, and sleep apnea symptoms were extracted from the charts of children who underwent VNS implantation between 2013 and 2021. A questionnaire was sent to parents of implanted children to ascertain the degree of the social and functional impact of the implant. RESULTS: There were 69 patients, aged 2.3 to 21.4 years old, who met the inclusion criteria. LP symptoms were most common during the first year following implantation; 26 patients (37.6%) demonstrated at least 1 symptom (voice alteration, chronic cough, sleep-disordered breathing, or dysphagia), and 15 patients required adjustments to their implant settings. The incidence of symptoms and the need to adjust VNS settings significantly dropped during years 2 to 5 and 6 to 8 (22% vs 7% and 5%, respectively, p = .0002). The mean score of the Pediatric Voice Handicap Index differed greatly from a normal control group on each subscale and the total score. CONCLUSION: LP dysfunction in children following VNS implantation is comparable to adults, with the most burden noticed during the first year after implantation. The presence of voice alterations did not correlate with the presence of dysphagia and sleep-disordered breathing. Thorough evaluation, preferably by a multidisciplinary team, is required to assess LP dysfunction postoperatively.

Epiglottopexy in Infants Younger Than 6 Months Old: A Case Series.

BACKGROUND: Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia. METHODS: A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children's hospital. RESULTS: 13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities. CONCLUSION: Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities.

Review of the Utility of Extended Recovery Room Observation after Adenotonsillectomy.

BACKGROUND: Our institution implemented a post-anesthesia care unit (PACU) extended-stay model (Grey Zone model), where the post-operative level of care for high-risk adenotonsillectomy patients (general care vs. intensive care unit) was decided based on the clinical course of 2-4 h of PACU admission. OBJECTIVE: To assess the correlation between post-tonsillectomy respiratory compromise and the need for respiratory support during an extended stay at PACU. To identify comorbidities associated with a need for intensive care after extended observation. METHODS: A retrospective cohort study of high-risk children who underwent adenotonsillectomy and were admitted to the Grey Zone following surgery. RESULTS: 274 patients met inclusion criteria. 262 (95.6%) met criteria for general care unit transfer (mean oxygen saturation 94.4 ± 5.1%). Twelve (4.4%) patients were transferred from the PACU to the ICU due to respiratory distress (mean oxygen saturation 86.8 ± 11%). Of the patients admitted to general care, 4 (1.5%) secondarily developed respiratory compromise, requiring escalation of care. Three of these maintained oxygen saturation ≥95% throughout the PACU period. There was no difference between the groups with respect to demographic data, rates of morbid obesity, and severity of obstructive sleep apnea. Neuromuscular disease, chronic lung disease, seizure disorder, and gastrostomy-tube status were more prevalent in those requiring ICU level of care compared to the general care unit. CONCLUSIONS: The Grey Zone model accurately identifies patients requiring ICU-level care following adenotonsillectomy, allowing for a safe reduction in the utilization of ICU resources. Due to rare delayed respiratory events, overnight observation in this cohort is recommended. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3582-3587, 2023.

Epiglottopexy for refractory obstructive sleep apnea in children - A single-institution experience.

BACKGROUND: Refractory obstructive sleep apnea (OSA) is a common condition in children with medical comorbidities, leading to a significant impact on quality of life. Drug-induced sleep endoscopy (DISE) has become the standard of care in identifying the levels of obstruction in children with refractory OSA. Epiglottopexy has been shown to improve OSA symptoms in adults and healthy children with epiglottic prolapse in a few studies, with minimal long-term complications. The objective of our study was to evaluate the role of epiglottopexy in children with refractory OSA. METHODS: A retrospective chart review of children with refractory OSA who were found to have epiglottic prolapse on DISE, and underwent epiglottopexy between January 2018 and November 2021 at a pediatric tertiary care hospital. RESULTS: 42 patients (age 8.1 ± 5.1 years) met inclusion criteria. Thirty patients (71.4 %) suffered from neurodevelopmental disease or congenital syndrome, and 14 patients (33.3 %) were gastrostomy-tube dependent. All patients had at least one prior surgical procedure to address their OSA. Thirty-six patients (85.7 %) were diagnosed with refractory OSA by polysomnography prior to surgery, with an average apnea-hypopnea index (AHI) of 12.4 ± 9.7/h. Forty patients (95.2 %) required an additional procedure in conjunction with epiglottopexy including lingual tonsillectomy (n = 27, 64.3 %), supraglottoplasty (n = 14, 33.3 %), tonsillectomy with or without revision adenoidectomy (n = 9, 21.4 %) and tongue base suspension (n = 1, 2.4 %). Twenty-one patients had repeated polysomnography; 4 patients were found to have residual severe OSA post-operatively (average AHI 17.4 ± 11.4/h), while the remaining patients demonstrated clinical improvement and a significant reduction in OSA severity, with an average AHI of 1.5 ± 2.2/h. Regression analysis identified pre-operative oxygen nadir <75 % to be associated with residual OSA postoperatively. Following surgery, 7 patients were found to have new-onset or worsening dysphagia, 6 of whom were diagnosed with complex medical comorbidities. CONCLUSIONS: Epiglottopexy, as part of multi-level airway surgery, is associated with a significant improvement in the severity of refractory OSA. Dysphagia may complicate the post-operative course, particularly in children with medical comorbidities.

Evaluation of Current Triological Society Thesis Trends and Membership Demographics.

OBJECTIVES: (1) Identify the time required for completion, submission, and acceptance of a Triological Thesis and trends for thesis acceptance. (2) Determine the current Triological Society demographics and identify variances based on separated age groups of the current membership. STUDY DESIGN: Retrospective review of The Triological Society database and survey of candidates and fellows. METHODS: Data from the records of all candidates and fellows of the Triological Society were reviewed to determine the number of years from candidate to active fellow status for all members inducted into the Triological Society from 1990 to 2018. In addition, all current candidates, active and senior fellows were surveyed online to capture demographic data and opinions regarding the Triological Society. RESULTS: Since 1990, there has been a steady increase in the number of candidates and theses accepted. Of candidates successfully completing theses, 73% did so within 3 years and 90% within 5 years. Based on the 514 of 809 (64%) active and senior fellows responding to the survey, 83% reported being male and 15% female. Also, 73% reported as Caucasian, 12% Asian, 2% Hispanic, 2% Black, 0% Native American, and 2% Mixed Race. Of the 93 of 178 (52%) active candidates (those authorized to prepare a thesis) responding to the survey, 70% reported as male, 28% female, 58% Caucasian, 17% Asian, 6% Hispanic, 5% Black, 0% Native American, and 3% Mixed Race. CONCLUSIONS: The Triological Society continues to grow, and its membership is becoming more diverse, including more women and wider ethnic diversity. Candidates should plan for submitting their thesis as early as possible as data demonstrates the greatest likelihood of success if done within 3 years. LEVEL OF EVIDENCE: NA Laryngoscope, 133:73-78, 2023.

Sponsorship and Negotiation for Women Otolaryngologists at Midcareer: A Content Analysis.

OBJECTIVE: To explore challenges and opportunities for supporting midcareer women otolaryngologists in the areas of negotiation and sponsorship. STUDY DESIGN: Qualitative approach using semistructured interviews. SETTING: Online multi-institutional interviews. METHODS: This study was performed from June to August 2021. Women otolaryngologists representing diverse subspecialties, training, and practice environments were recruited via a purposive criterion-based sampling approach. Semistructured interviews were transcribed, coded, and analyzed via an inductive-deductive approach to produce a thematic content analysis. RESULTS: Among the 12 women interviewees, who represented 7 subspecialties, the majority were Caucasian (58%) and in academic practice (50%). The median residency graduation year was 2002 (range, 1982-2013). Participants expressed several challenges that women otolaryngologists face with respect to negotiation, including the absence of systematic formal negotiation training, gendered expectations that women experience during negotiations, and a perceived lack of power in negotiations. Obstacles to effective sponsorship included difficulty in the identification of sponsors and the influence of gender and related systemic biases that hindered sponsorship opportunities. CONCLUSION: Notable gender disparities exist for negotiation and sponsorship in the midcareer stage for women otolaryngologists. Women start at a disadvantage due to a lack of negotiation training and access to sponsors, which is exacerbated by systemic gender bias and power differentials as women advance in their careers. This study highlights opportunities to improve negotiation and sponsorship for women, with the goal of promoting a more diverse workforce.

Tackling the Minority Tax: A Roadmap to Redistributing Engagement in Diversity, Equity, and Inclusion Initiatives.

Academic medical centers striving to implement diversity, equity, and inclusion (DEI) and antiracism initiatives often ask faculty to volunteer substantial time to committee work, recruitment, mentoring, community, and administrative responsibilities. These requests are not in lieu of current workload and seldom count toward scholarship; the service may go unrecognized, unrewarded, and uncompensated. URiM faculty (underrepresented in medicine) providing such service thus pay a minority tax when precious time is syphoned away from career-advancing activities and personal growth. The resulting strain on available resources has social, psychological, and monetary ramifications that can undermine the long-term objectives of DEI initiatives. We examine the facets of the minority tax, consider the current state of diversity, and present a roadmap to redistribute, reform, and reduce URiM taxation through shared engagement in DEI initiatives. Key interventions include ascribing value to DEI efforts, implementing evidence-based policies to reduce bias, and promoting mentorship, sponsorship, and allyship.

Pediatric sleep outcomes after endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy.

BACKGROUND: The purpose of this study was to evaluate the efficacy of sleep endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy in patients with sleep disordered breathing (SDB), including polysomnography (PSG) and swallowing outcomes. METHODS: A retrospective review was performed of all patients undergoing simultaneous lingual tonsillectomy and epiglottopexy over the study period. PSG objective measures were recorded pre- and postoperatively, along with demographic data, comorbidities, and descriptive data of swallowing dysfunction in the postoperative setting. RESULTS: A total of 24 patients met inclusion criteria for consideration, with 13 having valid pre- and postoperative PSG data. Successful surgery was achieved in 84.6% of patients, with no difference based on presence of medical comorbidities including Trisomy 21. Median reduction in obstructive apnea-hypopnea index (oAHI) with the procedure was 69.9%. Four patients (16.7%) had postoperative concern for dysphagia, but all objective swallowing evaluations were normal and no dietary modifications were necessary. CONCLUSION: Combination lingual tonsillectomy and epiglottopexy in indicated patients has a high rate of success in this single-institutional study without new dysphagia in this population. These procedures are amenable to a combination surgery in appropriately selected patients determined by sleep state endoscopy in the setting of SDB evaluated with drug-induced sleep endoscopy.

The impact of standardized huddle tools on case duration in pediatric microlaryngoscopy/bronchoscopy.

OBJECTIVE: Equipment necessary to perform pediatric microlaryngoscopy/bronchoscopy (MLB) varies considerably depending on the selected interventions. In procedures with equipment variability, surgical case length may be increased due to the need to procure items intraoperatively. We hypothesized that use of standardized huddle tools listing necessary equipment would be associated with a shortened case duration in MLB. METHODS: As part of a quality improvement initiative at our academic, tertiary care pediatric hospital, a standardized huddle sheet was created that listed options of equipment for MLB. Listed items included telescope/bronchoscope size, laryngoscope selection, interventional equipment, suspension, microscopes, and topical medications. The tool was completed by otolaryngology and shared with the circulating nurse at the beginning of the day so equipment needs could be anticipated. The tool was introduced to staff in November 2017 and to trainees in February 2018. To assess intervention impact, monthly median surgical case duration and room turnover time were retrospectively tracked using control chart analysis from March 2017 to June 2019. RESULTS: At baseline, the centerline case duration was 49 min. Two months following introduction of the huddle sheet to trainees, the centerline duration decreased to 43 min. This change was sustained throughout the period studied. No changes in room turnover time were observed during this period. CONCLUSIONS: Standardized huddle tool use prior to MLB was associated with a median decrease of 6 min of operating room time without a change in operating room turnover time. Use of similar tools in procedures with significant equipment variability may be beneficial.

Single Visit Evaluation and Tympanostomy Tube Placement for the Treatment of Acute Otitis Media in Children.

OBJECTIVE: To review our experiences with development of a single visit surgery (SVS) program for children with recurrent acute otitis media (AOM) undergoing tympanostomy tube (TT) placement the same day as their otolaryngology surgical consultation. STUDY DESIGN: Retrospective cohort analysis. METHODS: Retrospective series of patients participating in SVS from inception March 1, 2014 to April 30, 2020 were analyzed, with attention to factors associated with increasing interest and participation in SVS and parent experiences/satisfaction. RESULTS: A total of 224 children had TT placed through SVS for AOM management. The average age of patients was 18.1 months (standard deviation 7.8 months), and 130 (58.0%) were male. The median interval between initial contact to schedule SVS, and the SVS date was 15 days (interquartile range 9-23 days). When analyzing year-over-year volumes from inception of SVS, notable increases were seen in 2016 and 2017 after a radio advertisement was played locally. A marked increase in volume was noted after implementation of a Decision Tree Scheduling (DTS) algorithm for children with recurrent AOM. Sixty-six (28.8%) procedures were performed after institution of DTS. A parent survey demonstrated high levels of satisfaction with the SVS experience. Estimations of savings to families in terms of time away from work demonstrated potential for indirect healthcare benefits. CONCLUSIONS: SVS for TT placement was a successful, alternative model of care for management of children with AOM. Marketing strategies regarding SVS, and the inclusion of SVS pathway in DTS platforms increased rates of interest and choice of this option. Parents of children undergoing TT through SVS were satisfied with the overall experience. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2823-2829, 2021.

The Clarion Call of the COVID-19 Pandemic: How Medical Education Can Mitigate Racial and Ethnic Disparities.

Public health crises palpably demonstrate how social determinants of health have led to disparate health outcomes. The staggering mortality rates among African Americans, Native Americans, and Latinx Americans during the COVID-19 pandemic have revealed how recalcitrant structural inequities can exacerbate disparities and render not just individuals but whole communities acutely vulnerable. While medical curricula that educate students about disparities are vital in rousing awareness, it is experience that is most likely to instill passion for change. The authors first consider the roots of health care disparities in relation to the current pandemic. Then, they examine the importance of salient learning experiences that may inspire a commitment to championing social justice. Experiences in diverse communities can imbue medical students with a desire for lifelong learning and advocacy. The authors introduce a 3-pillar framework that consists of trust building, structural competency, and cultural humility. They discuss how these pillars should underpin educational efforts to improve social determinants of health. Effecting systemic change requires passion and resolve; therefore, perseverance in such efforts is predicated on learners caring about the structural inequities in housing, education, economic stability, and neighborhoods-all of which influence the health of individuals and communities.

Prioritizing Diversity in Otolaryngology-Head and Neck Surgery: Starting a Conversation.

Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.