Development of a Medical Complexity Score for Pediatric Aerodigestive Patients.

OBJECTIVE: To develop a complexity scoring system to characterize the diverse population served in pediatric aerodigestive clinics and help predict their treatment outcomes. STUDY DESIGN: A 7-point medical complexity score was developed through an iterative group consensus of relative stakeholders to capture the spectrum of comorbidities among the aerodigestive population. One point was assigned for each comorbid diagnosis in the following categories: airway anomaly, neurologic, cardiac, respiratory, gastrointestinal, genetic diagnoses, and prematurity. A retrospective chart review was conducted of patients seen in the aerodigestive clinic who had ≥2 visits between 2017 and 2021. The predictive value of the complexity score for the selected outcome of feeding progression among children with dysphagia was analyzed with univariate and multivariable logistic regression. RESULTS: We analyzed 234 patients with complexity scores assigned, showing a normal distribution (Shapiro Wilk P = .406) of the scores 1-7 (median, 4; mean, 3.50 ± 1.47). In children with dysphagia, there was waning success in the improvement of oral feeding with increasing complexity scores (OR, 0.66; 95% CI, 0.51-0.84; P = .001). Tube-fed children with higher complexity scores were incrementally less likely to achieve full oral diet (OR, 0.60; 95% CI, 0.40-0.89; P = .01). On multivariable analysis, neurologic comorbidity (OR, 0.26; P < .001) and airway malformation (OR, 0.35; P = .01) were associated with a decreased likelihood to improve in oral feeding. CONCLUSIONS: We propose a novel complexity score for the pediatric aerodigestive population that is easy to use, successfully stratifies diverse presentations, and shows promise as a predictive tool to assist in counseling and resource use.

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair.

PURPOSE: The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing. METHODS: A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale. RESULTS: A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups. CONCLUSIONS: There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.

Evolving Management of Acute Mastoiditis: Analysis of the Pediatric Health Information System Database.

OBJECTIVE: The optimal management of acute mastoiditis remains controversial. Most existing studies are retrospective single-institutional experiences with small cohorts. Our objectives were to analyze the treatment of acute mastoiditis by pediatric centers across the United States and changes in management over time. STUDY DESIGN: Retrospective analysis. SETTING: Administrative database study using Pediatric Health Information System. METHODS: Patients ≤18 years of age who were admitted with a principal diagnosis of acute mastoiditis from January 1, 2010 to December 31, 2019 were included. Trends were assessed by Cochran-Armitage Trend Test. χ2 and Wilcoxon rank sum tests were used to compare outcomes between the surgical and nonsurgical groups. RESULTS: A total of 2170 patients met the inclusion criteria, with 1248 (57.5%) requiring surgical management. The rate of surgical procedures decreased significantly over time. The rate of myringotomy decreased from 64% in 2010 to 47% in 2019 (p < .001), and mastoidectomy decreased from 22% in 2010 to 10% in 2019 (p < .001). On admission, 29% of the cohort presented with mastoiditis-related complications. Patients treated surgically were younger (p < .001), more likely to present with complications (37.5% vs 17.5%, p < .001), required longer length of stay (3.7 vs 2.3 days, p < .001), and had higher intensive care unit utilization (8.6% vs 2.2%, p < .001). However, the rate of 30-day readmission, emergency department return, and in-hospital mortality were all similar. CONCLUSION: Acute mastoiditis has been successfully treated with declining rates of a surgery over time. Younger patients who present with complications are more likely to be managed surgically, and the overall outcomes remain excellent.

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility in Children: A Systematic Review.

OBJECTIVE: To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility in children. DATA SOURCES: Ovid Medline, Embase, Web of Science, and CENTRAL databases. REVIEW METHODS: A systematic review of the medical literature was performed following the PRISMA guidelines. An a priori protocol was defined to identify all articles that presented quantifiable outcome data in children aged <18 years who underwent surgical treatment to improve glottal competence for dysphagia. Two authors independently determined references meeting the inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled via a random effects model where possible. The quality of studies was graded with the MINORS criteria. RESULTS: An overall 398 publications were screened, with 9 meeting inclusion criteria. A total of 115 patients were included. Of these, 75% had preoperative swallowing symptoms. Surgical intervention for dysphagia included 61 injection laryngoplasties, 11 medialization laryngoplasties, and 10 reinnervations (ansa cervicalis to recurrent laryngeal nerve). The articles consistently reported success in improving dysphagia symptoms, and limited meta-analysis demonstrated a mean improvement after surgical intervention in 79% (95% CI, 67%-91%) of children. The reported rate of minor and major complications was 15% (95% CI, 1%-29%). The MINORS scores ranged from 5 to 12. CONCLUSION: Surgical management of unilateral vocal fold immobility in properly selected children can be an effective treatment for dysphagia when symptoms are present. Selection of surgical modalities relies on patient- and surgeon-related factors, and the rate of success is high across different interventions in treating these complex children.

Hospital Admissions in Pediatric Patients With Tracheostomies Based on Rurality and Insurance Status.

OBJECTIVE: Determine whether rurality or public insurance status is associated with greater 30-day readmission after tracheostomy in pediatric patients. STUDY DESIGN: Retrospective cohort. SETTING: Pediatric Health Information System (PHIS) Database. METHODS: Patients within PHIS who underwent tracheostomy from 2013 to 2017 were included. Rural status was defined by rural-urban commuting area codes. Insurance status was based on the primary payer. All-cause 30-day readmissions and tracheostomy-related readmissions were recorded. Multivariate logistic regression was performed to test for differences in readmissions between cohorts. RESULTS: Among patients, 1092 were rural, and 4329 were publicly insured, with no significant association between rurality and insurance. Compared to nonrural patients, rural patients were more frequently white, less frequently ventilator dependent, and more likely discharged home rather than to a care facility. Publicly insured patients were more frequently non-white. Twenty-eight percent of patients were readmitted within 30 days of discharge. Odds of 30-day readmission were lower in rural patients (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.68-0.95, p = .01) but higher in publicly insured (OR: 1.24, 95% CI: 1.09-1.42, p = .001) controlling for age at tracheostomy, sex, race, and ventilator dependence. The odds of tracheostomy-related admission did not differ by rurality but were higher in publicly insured children (1.39, 95% CI: 1.03-1.88, p = .03). CONCLUSION: Readmission within 30 days following tracheostomy was more likely in publicly insured patients and less likely in rural patients. These findings help identify at-risk patients when considering discharge planning and follow-up. More work is needed to understand long-term tracheostomy outcomes in these groups.

Feasibility and accuracy of laryngeal ultrasound for the assessment of vocal cord mobility in children.

OBJECTIVE: Transcutaneous laryngeal ultrasonography has been utilized to document vocal cord mobility in the adult perioperative thyroidectomy setting with variable success. The aims of this study were to assess the feasibility of using transcutaneous ultrasound in vocal cord visualization in children, to determine the accuracy in detecting vocal cord immobility compare to flexible laryngoscopy, and to identify any barriers that may affect its utility. METHODS: This is a prospective blinded-assessor study. Transcutaneous laryngeal ultrasound and flexible laryngoscopy were performed in two pediatric settings: perioperative thyroid surgery and inpatient consultation for airway, voice, or swallowing concerns. The video recordings of ultrasound and laryngoscopy were assessed by two fellowship-trained pediatric otolaryngologists independently. RESULTS: A total of 83 paired laryngoscopy and ultrasound assessments were performed, 39 for perioperative thyroidectomy and 44 for inpatient consultation. The majority had normal vocal cord mobility (65/83, 78%), while 16 had unilateral cord palsy and 2 had bilateral palsy. The vocal cords were successfully visualized on ultrasound in 82/83 (99%) evaluations. Compared to gold standard laryngoscopy, the sensitivity for diagnosing vocal cord palsy on ultrasound was 53-83%, and the specificity was 97-98%. The sensitivity for detecting asymmetric vocal cord movement was 56-88%, and the specificity was 99%. The agreement between ultrasound and laryngoscopy diagnoses were 87-94% (κ = 0.58-0.83, moderate to near perfect agreement). The intra-rater agreement was 95-100% (κ = 0.64-1.0), and inter-rater agreement was 90% (κ = 0.66). Both subjects with bilateral vocal cord palsy had incorrect ultrasound diagnoses by both observers. CONCLUSION: We were able to utilize transcutaneous laryngeal ultrasound to successfully visualize vocal cord mobility in almost all pediatric patients with a high degree of specificity. The modality has limitations in the assessment of bilateral vocal cord palsy, and its sensitivity was observer-dependent.

Aortopulmonary collaterals: An etiology for pediatric tracheostomy hemorrhage.

OBJECTIVE: To report a single-institution's experience of symptomatic aortopulmonary collaterals presenting as tracheostomy tube hemorrhage. STUDY DESIGN: Retrospective case series and Contemporary Review. SETTING: Tertiary care children's hospital. METHODS: Retrospective review, from 2015 to 2020, of patients <18 years old who were treated for tracheostomy hemorrhage with endovascular embolization of aortopulmonary collateral (APC) vessels. RESULTS: 4 patients were identified, 2 males and 2 females, ages 15 months-to 14 years-old, with a range of cyanotic congenital heart diseases. Direct laryngoscopy and bronchoscopy were necessary for excluding proximal airway sources. Chest computed tomography angiography did not localize pulmonary hemorrhage, but helped identify aortopulmonary collaterals. Cardiac catheterization was both diagnostic and therapeutic with use of endovascular embolization techniques by pediatric interventional cardiology and interventional radiology. Previously reported APC-related pulmonary hemorrhages occurred in significantly different settings compared to our patients, and evaluation by an otolaryngologist was key to rule out upper airway etiologies. CONCLUSION: Symptomatic aortopulmonary collaterals is an important etiology in pediatric tracheostomy tube hemorrhage in patients with cyanotic congenital heart disease.

Put your money where your mouth is.

Suspicion for battery ingestion should be maintained for any round radiopaque foreign body. Presence of the classic "double ring" sign on plain film should prompt emergent operative removal, although it is not pathognomonic.

Fatigue in Children With Unilateral and Bilateral Hearing Loss.

OBJECTIVE: To determine whether children with unilateral hearing loss (UHL) experience similar levels fatigue as children with bilateral hearing loss (BHL) or normal-hearing (NH). DESIGN: Cross-sectional study. SETTING: Two tertiary care otolaryngology practices. PARTICIPANTS: Children, 5 to 18 years old, with UHL or BHL and their parents. MAIN OUTCOME MEASURES: PedsQL Multidimensional Fatigue Scale (MFS) survey. RESULTS: Overall response rate was 90/384 (23%). Mean age of child participants was 10.7 years old (standard deviations [SD] 3.1); 38 (42%) were men and 52 (58%) were women. Sixty-nine (77%) children had UHL, 21 (23%) had BHL. Children with BHL (mean 65, SD 21) and UHL (mean 75, SD 17) reported greater levels of fatigue than children with NH (BHL difference -15, 95% confidence interval [CI] -25 to -5; UHL difference -6, 95% CI -13-1.2). Parent-proxy reports for children with BHL (mean 67, SD 20) and UHL (mean 76, SD 20) reported more fatigue than NH (BHL difference -22, 95% CI -33 to -12; UHL difference -14; 95% CI -20 to -8). Sub-section scores for general, sleep, and cognitive fatigue were higher for children with BHL and UHL than NH. CONCLUSION AND RELEVANCE: Children with UHL and BHL reported significantly more fatigue than children with NH, and children with BHL reported more fatigue than UHL. These findings underscore the need to increase auditory rehabilitation and educational resources for children with UHL and support the use of the PedsQL MFS questionnaire as a measure to follow disability experienced by children with HL as they undergo hearing rehabilitation.

Bronchial stenting in infants with severe bronchomalacia: Technique and outcomes.

OBJECTIVES: To report the first use of a balloon expandable bare metal stent for treating infant bronchomalacia. BACKGROUND: Infant bronchomalacia often requires prolonged mechanical ventilation and can be life-threatening. Effective treatment for severe infant bronchomalacia continues to be elusive. We present three cases of bronchial stenting for no-option or treatment refractory infant bronchomalacia. METHODS: Three consecutive cases of stenting to relieve conservative treatment refractory severe infant bronchomalacia were performed between February 2019 and December 2020. Initial diagnosis was confirmed with Computed Tomography (CT) angiography. Patients underwent rigid micro laryngoscopy, bronchoscopy, and flexible bronchoscopy to evaluate the airway. Initial conservative management strategies were pursued. Patients failing initial conservative management strategies were considered for rescue bronchial stenting. RESULTS: Our initial clinical experience with a coronary bare metal stent for these procedures has been favorable. The stent was easy to deploy with precision. We did not encounter stent embolization or migration. There was sufficient stent radial strength to relieve bronchomalacia without causing restenosis or erosion. There was no significant granulation tissue formation. In one patient, the stent was removed after 12 months of somatic growth; this was uneventful and bronchial patency was maintained. There were no complications in any of our patients regarding stent placement and reliability. CONCLUSION: In cases of three infants with severe bronchomalacia, we found that bronchial stenting with the bare metal coronary stent was effective in relieving bronchial stenosis.

Predictors of Pediatric Tracheostomy Outcomes in the United States.

OBJECTIVES: To investigate the outcomes of pediatric tracheostomy as influenced by demographics and comorbidities. STUDY DESIGN: Retrospective national database review. SETTING: Fifty-two children's hospitals across the United States. SUBJECTS AND METHODS: Hospitalization records from Pediatric Health Information System database dated 2010 to 2018 with patients younger than 18 years and procedure codes for tracheostomy were extracted. The primary outcome was total length of stay. The secondary outcomes were 30-day readmission, mortality, and posttracheostomy length of stay. RESULTS: A total of 14,155 children were included in the analysis. The median total length of stay was 77 days and increased from 59 to 103 days between 2010 and 2018 (P < .001). The median posttracheostomy length of stay was 34 days and also increased from 27 to 49 days (P < .001). On multivariate regression analyses, the total and posttracheostomy lengths of stay were significantly increased in children younger than 1 year, patients of black race, hospitals in the non-West regions, those discharged to home, and those with comorbidities. Socioeconomic indicators such as insurance type and estimated household income were associated with no difference or small effect sizes. Regions and comorbidities were associated with differences in 30-day readmission (overall 26%), while in-hospital mortality was primarily associated with age and comorbidities (overall 8.6%). CONCLUSION: Pediatric tracheostomy requires substantial health care resources with length of stay escalating over recent years. Age, race, region, discharge destination, and comorbidities were associated with differences in length of stay.