Diagnosis of Fever Source Following Tonsillectomy and Adenoidectomy in the Pediatric Emergency Department.

OBJECTIVES: This study aimed to describe the epidemiology and diagnoses of children with postoperative fever (a temperature of 38°C or higher) during the week after tonsillectomy and/or adenoidectomy and to assess the yield of the laboratory tests and otolaryngologist consultations of these patients in the pediatric emergency department (ED). METHODS: We conducted a retrospective cohort study that included all children who presented with fever to the pediatric ED of a tertiary university-affiliated medical center between May 2017 and April 2020 during the week after a tonsillectomy and/or adenoidectomy. RESULTS: There were 94 patients who fulfilled study entry criteria during the 3-year study period, representing a 6% rate of postoperative fever for combined tonsillectomy and adenoidectomy and 3% for adenoidectomy alone. Only 9 patients (<10% of the total) were classified as having bacterial infection, whereas the most common cause for the fever was pneumonia diagnosed by chest radiography. None had surgical site infection. There was no significant difference in blood test findings of patients diagnosed with a bacterial infection and patients with a presumed viral infection or an inflammatory response to surgery. CONCLUSIONS: The results of this investigation revealed that the source of fever of the overwhelming majority of children who were referred to the pediatric ED for fever after undergoing tonsillectomy and/or adenoidectomy was pneumonia as determined by chest radiography, which can be performed in an outpatient setting. Blood tests and otolaryngologist consultations were not contributory in classifying the source of fever, questioning the value of their routine use in these patients.

The Outcome of Cerumen Removal in the Pediatric Emergency Department.

OBJECTIVE: Cerumen obstructs the visualization of the tympanic membrane (TM) in up to 40% of children, sometimes posing a challenge to rule out the diagnosis of acute otitis media (AOM) as the source of otalgia (for verbal children), irritability, fever, and febrile seizures. We aim to determine the rate at which removing the cerumen from blocking the view of the TM could change the management of these patients in the pediatric emergency department (PED). METHODS: We retrospectively investigated all medical records of patients who underwent cerumen removal in the PED at a tertiary children's hospital from 2018 to 2019. We analyzed the effect of the procedure on the subsequent workup during their PED visit. RESULTS: Of 482 children who presented to the PED with otalgia, irritability, fever, and/or febrile seizures and who were referred to an otolaryngologist for subsequent treatment after preliminary evaluation in the PED, 176 were included in the study group after having the cerumen removed from one or both ears. Seventy-three of them were given a diagnosis of AOM, 93 had a normal-appearing TM, and 10 had external otitis. Twenty-one percent of those with AOM and 46% of those with a normal TM ( P = 0.008) had blood drawn as part of their workup in their PED visit. The rate of chest x-rays was also significantly less for the AOM group (16% vs 30%, P = 0.03), and they also underwent fewer urine tests ( P = NS). CONCLUSION: Cerumen removal changes the management of children in the PED who present with a possible diagnosis of an ear infection. Cerumen removal could avoid unnecessary laboratory and imaging studies, which could save time, costs, and suffering.

Respiratory complications after adenotonsillectomy in high-risk children with obstructive sleep apnea: A retrospective cohort study.

BACKGROUND: Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10 000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2 years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay. METHODS: Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded. RESULTS: During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE. CONCLUSIONS: Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU.

Gluten-free diet may improve obstructive sleep apnea-related symptoms in children with celiac disease.

BACKGROUND: Enlarged tonsils and adenoids are the major etiology of obstructive sleep apnea (OSA) in children. Lymphatic hyperplasia is common to both OSA and celiac disease. We aimed to investigate the effect of a gluten-free diet on OSA symptoms in children with celiac disease. METHODS: Children with celiac disease aged 2-18 years were prospectively recruited before the initiation of a gluten-free diet. Children with negative celiac serology who underwent gastrointestinal endoscopies for other indications served as controls. All participants completed a validated OSA-related symptoms questionnaire and the pediatric sleep questionnaire (PSQ) at baseline and 6 months later. RESULTS: Thirty-four children with celiac disease (mean age 6.6 ± 3.5 years) and 24 controls (mean age 7.3 ± 4.6 years, P = 0.5) were recruited. There were no significant differences in gender, body mass index or season at recruitment between the two groups. The rate of positive PSQ scores was higher (more OSA-related symptoms) in the control group compared to the celiac group, both at recruitment and at the 6-month follow-up (33.3% vs. 11.8%, P = 0.046, and 16.7% vs. 0, P = 0.014, respectively). PSQ scores improved significantly in both groups at the 6-month follow-up (P < 0.001 for both). Improvement was significantly higher in the celiac group compared to controls (0.1 ± 0.09 vs.0.06 ± 0.06, respectively, P = 0.04). CONCLUSIONS: Children with celiac disease had fewer OSA-related symptoms than controls, but the degree of improvement following the initiation of a gluten-free diet was significantly higher. These findings suggest that a gluten-free diet may improve OSA-related symptoms in children with celiac disease.

Enhanced visualization of the surgical field in pediatric direct laryngoscopy using a three-dimensional endoscopic system.

BACKGROUND: Direct laryngoscopy and rigid bronchoscopy are currently performed using 2-dimensional endoscopic systems. Our objective was to determine whether a 3-dimensional endoscopic system can enhance visualization of the surgical field in pediatric direct laryngoscopy and rigid bronchoscopy. METHODS: A prospective cohort study was conducted. Thirty three children who underwent direct laryngoscopies in a tertiary referral children's hospital were enrolled. Direct laryngoscopy was performed using both 2- and 3-dimensional endoscopic systems, after which the surgeons scored the quality of the images obtained with each system on a scale from 1 (low) to 5 (high). Comparison of the scores obtained with the 2 endoscopic systems was performed. RESULTS: The 33 study children (mean age 2.3 years, M:F ratio 1:1.6) underwent 47 direct laryngoscopies. The mean score for visualization of the glottis was 4.8 for the three-dimensional system compared to 4.0 for the two-dimensional system (P = .025), 4.7 vs. 3.8, respectively, (P = .019) for the subglottis, and 4.6 vs. 3.9, respectively (P = .031) for visualization of the proximal trachea. The mean score for visualization of the distal trachea was 3.0 vs. 3.7, respectively (P = .020). In a child with recurrent type 3 laryngotracheal cleft a residual tracheo-esophageal fistula could not be detected using the 2D system, but was immediately detected using the 3D system. CONCLUSIONS: Visualization of the glottis, subglottis and proximal trachea during direct laryngoscopy using a 3-dimensional endoscopic system was rated by the surgeons as being superior to the conventional 2-dimensional technique. Further outcome studies that will demonstrate the clinical advantage of the 3D technology are highly required. LEVEL OF EVIDENCE: 2b.

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

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

The Positive Effect of Adenotonsillectomy on Drooling in Children.

OBJECTIVES: (1) To investigate the prevalence and severity of drooling among healthy young children referred for adenotonsillectomy; (2) to evaluate the effect of adenotonsillectomy on drooling. STUDY DESIGN: Prospective study. SETTING: Tertiary referral center. METHODS: Healthy typically developed children aged 18 to 48 months referred to adenotonsillectomy for upper airway obstruction (UAO) were recruited. Age-matched children recruited from the community served as controls. Drooling frequency and severity were assessed at baseline and 2 months following surgery based on 2 subjective scales: the Drooling Infants and Preschoolers Scale (DRIPS) and Thomas-Stonell and Greenberg Saliva Severity Scale (TSGS). RESULTS: Eighty-seven children aged 18 to 48 months were included in the study. Forty-three children referred to adenotonsillectomy (study group) and 44 age-matched controls. There were significant differences in almost all of the DRIPS items between children in the presurgery group compared to controls. Drooling severity and frequency were greater in the former compared to the latter (TGF-s severity: 1.4 ± 1.0 vs 0.6 ± 0.8, P = .001; TGF frequency: 1.3 ± 0.9 vs 0.5 ± 0.6, P < .001). After surgery, the scores for all DRIPS and TSGS items decreased significantly and were comparable to the control group. CONCLUSIONS: The frequency and severity of drooling among otherwise young children referred for adenotonsillectomy were greater than those for healthy controls. Following surgery, both the frequency and severity significantly improved and became comparable to those of controls. These findings suggest that a major improvement in drooling is one of the benefits of a surgical intervention in a child with UAO.

The Clinical Value of Cranial CT Venography for Predicting Fusobacterium necrophorum as the Causative Agent in Children with Complicated Acute Mastoiditis.

BACKGROUND AND PURPOSE: Fusobacterium necrophorum (F necrophorum) is an anaerobic bacteria that causes invasive head and neck infections in children. Several studies have demonstrated an increasing prevalence of F necrophorum as the causative agent in acute mastoiditis in children, with associated high rates of intracranial complications such as epidural abscess and sinus venous thrombosis, to name a few. F necrophorum requires a treatment protocol that differs from the empiric treatment that is tailored to more common pathogens (eg, group A streptococci, Streptococcus pneumonia), and hence expediting the diagnosis is important. For evaluating complicated acute mastoiditis in children, cranial CT venography remains the imaging study of choice in most medical centers due to its availability in emergency situations. Based on our clinical experience, our hypothesis is that children with F necrophorum-associated complicated acute mastoiditis can be differentiated from those with other etiologies using CT venography. MATERIALS AND METHODS: CT venography studies of 76 children hospitalized and treated for complicated acute mastoiditis were retrospectively reviewed. Retrieved imaging data included intracranial complications (epidural abscess, sinus venous thrombosis), cranial bone-related complications, and extracranial complications (subperiosteal abscess, temporomandibular joint abscess, and soft-tissue inflammation). The cohort was divided into children with F necrophorum-related disease (study group) and those with non-F necrophorum-related disease (control group). RESULTS: Thirty-seven children (49%) comprised the study group, and 39 children in whom the causative agents were other bacteria comprised the control group. There were significantly higher rates of complications in the study group: sinus venous thrombosis (P < .001), perisigmoid epidural abscess (P = .036), and extramastoid osteomyelitis (P < .001). Thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with an otogenic variant of Lemierre syndrome) and emphysematous osteomyelitis were found only among children in the F necrophorum-related study group (32% and 22% accordingly). CONCLUSIONS: In children with complicated acute mastoiditis, CT venography findings of emphysematous osteomyelitis and/or thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with the otogenic variant of Lemierre syndrome) should lead the radiologist to suggest F necrophorum-related mastoiditis.

Unilateral Increase of Gustatory Thresholds in Acute Otitis Media: A Pilot Study.

BACKGROUND: To evaluate chorda tympani nerve function as measured by unilateral increases of gustatory thresholds in the presence of ipsilateral acute otitis media. METHODS: Prospective clinical study comparing electrogustometric measurements was conducted to evaluate the taste thresholds of each side of the tongue in a patient during an acute episode of unilateral acute otitis media. Included were patients aged 12-40 who presented to the emergency department and outpatient ear, nose, and throat clinic of a university-affiliate tertiary medical center with unilateral acute otitis media between January 2019 and January 2020 and consented to the study. RESULTS: Eleven patients were initially recruited into the study, and 10 patients aged (mean ± standard deviation) 26.1 ± 11.2 years comprised the final study group. Taste thresholds were significantly elevated on the side ipsilateral to the ear affected by acute otitis media (P < .05). CONCLUSION: Chorda tympani nerve conductance is impaired during the acute stage of acute otitis media. This may have implications in the understanding of peripheral neural properties during acute middle ear inflammatory conditions and on the diagnosis of acute otitis media.

International Pediatric Otolaryngology Group (IPOG) consensus on scoring of pediatric Drug Induced Sleep Endoscopy (DISE).

OBJECTIVES: To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea. METHODS: The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus. RESULTS: A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids. CONCLUSION: This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients.

Nasal foreign bodies incidentally detected on dental radiography.

Two nasal foreign bodies were discovered by a dental practitioner on a routine radiographic examination of a 15-year-old autistic patient. Going over past radiographs, one of the nasal foreign bodies was detected in a radiograph performed 2 years previously. No nasal complaints or other clues to the problem were apparent. The patient was referred to the emergency room, and the foreign bodies were removed by an Ear Nose and Throat specialist, under general anesthesia. This paper reviews the diagnosis and treatment of nasal foreign bodies, and highlights the important role of the dental practitioner in the proper detection and diagnosis, prompt referral for management, and reduction in related complications.

A case of an unfortunate tooth fairy visit to a ventilator-dependent child.

An 8-year-old boy recently sustained a cerebellar arteriovenous malformation rupture, and subsequently suffered from severe neurological injury and became ventilator-dependent through a tracheostomy. During a routine clinic visit, the parents reported that a loose baby tooth had fallen out and disappeared 7 days earlier. The physical examination was unremarkable, but a chest X-ray demonstrated a foreign body in the left lung and secondary atelectasis. A rigid bronchoscopy extracted what turned out to be a tooth from the left lower lobe bronchus, with no associated sequelae. Aspiration of a tooth is rare, and it is mostly seen in children and elderly patients following trauma, endotracheal intubation, and dental procedures. Only a few previous studies emphasized the increased risk of foreign body aspiration among neurological impaired children. This unique report describes a child in his physiological exfoliation period, which is characterized by the spontaneous shedding of 20 teeth over the course of several years. In severely neurologically impaired children, this period carries a risk of aspiration of teeth and secondary pulmonary damage. Therefore, treating physicians and caregivers must be aware of this risk, and routine dental check-ups are advised in a neurological impaired child during this period.

Expression of Th17 and Treg lymphocyte subsets in hypertrophied adenoids of children and its clinical significance.

Adenoid hypertrophy is the most common cause of upper airway obstruction and sleep-disordered breathing in children, yet its pathogenesis remains unclear. The identification of the novel helper T cell subsets, Th17 cells and regulatory T cells (Tregs) could provide new insight into our understanding of the mechanisms involved in the development of this condition. The purpose of this study is to evaluate the adenoidal lymphocyte subsets to describe the percentage of various lymphocyte subsets in hypertrophied adenoids and correlate them with symptom severity. Twenty consecutive children undergoing adenoidectomy were included, and lymphocytes were isolated from their adenoids. T cell subpopulations were detected by flow cytometry using a fluoresceinated monoclonal antibody directed against a number of cell markers (CD4+, CD8+, CD25+, FOXP3 IL17+, and others). We found a significant negative linear correlation between the Th17/Treg ratio and the patients' clinical scores (R = -0.71 p < 0.005). The correlation was independent of age and gender. Decreased ratios of Th17/Treg subpopulations may play a role in the pathogenesis of adenoid hypertrophy.

Three dimensional printed models of the airway for preoperative planning of open Laryngotracheal surgery in children: Surgeon's perception of utility.

BACKGROUND: Preoperative planning of open laryngotracheal surgery is important for achieving good results. This study examines the surgeon's perception of the importance of using life size 3D printed models of the pediatric airway on surgical decision making. METHODS: Life-size three-dimensional models of the upper airway were created based on CT images of children scheduled for laryngotracheal-reconstruction and cricotracheal resection with anastomosis. Five pediatric airway surgeons evaluated the three-dimensional models for determining the surgical approach, incision location and length, graft length, and need for single or double-stage surgery of seven children (median age 4.4 years, M:F ratio 4:3). They rated the importance of the three-dimensional model findings compared to the direct laryngoscopy videos and CT findings for each domain on a validated Likert scale of 1-5. RESULTS: The mean rating for all domains was 3.6 ± 0.63 ("moderately important" to "very important"), and the median rating was 4 ("very important"). There was full agreement between raters for length of incision and length of graft. The between-rater agreement was 0.608 ("good") for surgical approach, 0.585 ("moderate") for incision location, and 0.429 ("moderate") for need for single- or two-stage surgery. CONCLUSION: Patient-specific three-dimensional printed models of children's upper airways were scored by pediatric airway surgeons as being moderately to very important for preoperative planning of open laryngotracheal surgery. Large-scale, objective outcome studies are warranted to establish the reliability and efficiency of these models.

[Postcricoid vascular lesion in an infant].

A 7-months-old female presented with coughing spells while feeding. Flexible laryngoscopy revealed a round bluish mass, emanating from the postcricoid area when the child cried or strained and disappeared when she relaxed. She was treated with systemic steroids for a month and was doing well. There was no change in the lesion. On examination at age 18 months the lesion disappeared. In a review of the literature, the authors found 6 articles describing 19 children with postcricoid vascular lesions. Seven children did not have significant related problems and did well without any treatment. Eight cases had significant co-morbidity. Treatment for symptomatic children included systemic or intralesion steroids, laser ablation and open resection. Postcricoid vascular lesion is a rare entity with a typical appearance. The recommended workup includes flexible laryngoscopy and videofluoroscopy. There are several treatment options for symptomatic children.

Sleep position and breathing in late pregnancy and perinatal outcomes.

STUDY OBJECTIVES: Body position during sleep has been related to breathing in adults with obstructive sleep apnea (OSA). While sleep-disordered breathing is common, little information is available on the relation between sleep position and maternal breathing in pregnancy. We examined associations between the supine position, maternal breathing, and perinatal outcomes. METHODS: Women with a singleton, uncomplicated pregnancy were recruited and underwent an ambulatory overnight sleep study between 33 to 36 weeks using the Watch-PAT device. Their medical records were also reviewed. RESULTS: A total of 148 pregnant women were recruited (mean age: 33 ± 4 years; mean body mass index: 27.6 ± 4.0 kg/m²). They spent approximately one-half of their sleeping time in a supine position. The group's mean apnea-hypopnea index (AHI) was 3.6 events/h in the supine position and 2.9, 2.6, and 2.1 events/h for the prone, right, and left positions, respectively. Median AHI and oxygen desaturation index were higher and SpO2 nadir was lower in the supine versus nonsupine position (P < .0001, P < .0001, and P = .006, respectively). Peripheral oxygen saturation nadir was associated with the percentage of time spent sleeping in the supine position (P = .02). No correlations were found between supine sleep position and perinatal outcomes. There were no differences in the distributions of body positions between women with and those without OSA. CONCLUSIONS: Women in the third trimester of pregnancy with or without OSA spent large proportions of sleeping time in a supine position. Supine position was associated with more respiratory events and more and deeper oxygen desaturation events. They were not associated with perinatal outcomes. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Fetal Outcome of Sleep Disordered Breathing During Pregnancy; URL: https://clinicaltrials.gov/ct2/show/NCT00931099; Identifier: NCT00931099.

Parental concern as an indicator of the severity of Obstructive Sleep Apnea in children.

INTRODUCTION: An accepted screening question for Obstructive Sleep Apnea (OSA) in children is "Does your child snore". However, this has no correlation to severity. The purpose of this study is to evaluate a simple 2-item questionnaire that reflects the degree of parental concern to predict the severity of Obstructive Sleep Apnea (OSA) in children as measured by Polysomnography (PSG). METHODS: Prospective analysis of parental concern regarding their children referred for PSG due to suspected OSA. Parents of all study children completed the brief Parental Concern Scale (PCS) questionnaire that we devised and the validated Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder questionnaire (PSQ-SRBD). The PCS consisted of 1 question on the need for surgery and 1 question on concerns about the child's breathing. Both questionnaires were compared to PSG results. RESULTS: Ninety-five children (mean age 4.2 ± 2.5 years, 52% males, mean body mass index z score 0.45 ± 1.8) were recruited. Twenty-three children (24%) had moderate-severe OSA and were referred for adenotonsillectomy. Correlations were found between the need for surgery score and the apnea-hypopnea index (r = 0.22, P = .029), as well as the mean SpO2 levels (r = -0.24, P = .02). The likelihood for the diagnosis of moderate-severe OSA by PSG increased as parental ranking for the need for surgery increased (P = .003). The need for surgery score was the only predictor for moderate-severe OSA (P = .039). CONCLUSION: Querying parents on their perception of their child's need for surgery is a practical, and easy-to-use tool that can help the clinician in prioritizing referral to PSG.

Coagulation tests or standardized questionnaire, which is better as a predictor of bleeding? A prospective study among children before tonsillectomy and/or adenoidectomy.

OBJECTIVE: The value of pre-operative coagulation testing for adenotonsillar surgery is controversial. The purpose of this study was to evaluate the role of routine coagulation tests and a standardized questionnaire in children before tonsillectomy and/or adenoidectomy. RESULTS: A total of 143 children were prospectively enrolled in the study between 2013 and 2017, 81 males (56.6%) and 62 females (43.4%), age range 1 to 18 years (median age 5 years). Eighteen bleeding events were documented, three of them required treatment in the operating room. Abnormal coagulation tests were not associated with higher odds of bleeding after surgery. Higher risk of bleeding (p = 0.01) was associated with an abnormal standardized medical questionnaire.

Combined trans-stomal endotracheal approach to peri-stomal tracheal pathologies in children.

IMPORTANCE: Peristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved. OBJECTIVE: We evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies. METHODS: The medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed. RESULTS: In total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure. CONCLUSION: Combined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies.

Decreased cerebral oxygen saturation levels during direct laryngoscopy with spontaneous ventilation in children.

INTRODUCTION: Direct laryngoscopy in children is usually performed with spontaneous ventilation and monitored by pulse oximetry. It is currently unknown if spontaneous ventilation has an effect on cerebral oxygenation. We hypothesized that cerebral oxygenation may be impeded during direct laryngoscopy with spontaneous ventilation in children. OBJECTIVE: Our objective was to determine if children who undergo direct laryngoscopy under general anesthesia with spontaneous breathing experience significant reductions in cerebral oxygen saturation levels, and whether or not these reductions are accompanied by decreases in peripheral oxygen saturation levels. METHODS: This pilot study included 16 consecutive children who underwent direct laryngoscopy under general anesthesia and spontaneous ventilation. The INVOS™ system, which is currently used to monitor cerebral oxygen saturation levels during neurosurgery and cardiothoracic surgery, consists of a processing unit and 2 sensors that are applied to the patient's forehead. We used it to record cerebral oxygenation levels throughout the procedure. Peripheral pulse oximetry was recorded simultaneously, and the results were compared to the levels recorded by the INVOS™ system. RESULTS: Cerebral oxygen saturation levels decreased by more than 20% from baseline in 7/10 children with tracheostomy and in 2/6 children without tracheostomy, while peripheral oxygen saturation levels remained intact in all the children. The mean time from induction of anesthesia to significant decrease in the cerebral oxygenation level (rSO2) was 14 ± 6 min for the tracheostomy group and 14.5 ± 1.5 min for the no tracheostomy group. CONCLUSIONS: Children who undergo direct laryngoscopy under general anesthesia with spontaneous ventilation may display reductions in brain oxygenation levels that are not detected by standard pulse oximetry, which reflects only peripheral oxygenation levels. Further study is required to explore the possible effect of this phenomenon in children who undergo direct laryngoscopy.