Pediatric tracheostomy: timing of the first tube change.

OBJECTIVES: No consensus exists on appropriate timing for the first tracheostomy tube change. The purpose of this study is to evaluate the safety of early tracheostomy change in the pediatric population. METHODS: A case series of all children undergoing tracheostomy at a tertiary children's hospital between 2008-2013 was retrospectively reviewed. RESULTS: A total of 151 children undergoing tracheostomy were identified. The average age was 48.1±66 months and median age was 10 months. The initial tracheostomy tube change occurred on postoperative day 3 (POD 3) in 65 children (43.0%) safely without any complications. CONCLUSIONS: Early tracheostomy tube change was safely performed in a significant portion of this population. Routine tube change on POD 3 in many children could save resources by reducing the length of ICU and hospital stays.

International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA).

OBJECTIVE: To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea. METHODS: A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG). RESULTS: Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA. CONCLUSION: The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA.

Proposal for the surgical management of children with laryngeal saccular Cysts: A case series.

This case series aims to determine the optimal surgical approach for pediatric laryngeal saccular cysts. A retrospective chart review of patients who underwent surgical treatment for laryngeal saccular cysts was completed; 5 patients were diagnosed and surgically treated. Treatment approaches included aspiration, supraglottoplasty, injection of bleomycin, endoscopic subtotal resection (marsupialization with the laser or endoscopic instrumentation of the cyst), endoscopic extended subtotal excision (subtotal resection plus removal of false vocal fold with lasering or coblation of the inner cyst wall), and transcervical approaches for resection. Based on our outcomes, an endoscopic extended subtotal resection of the cyst will achieve the best outcomes for cysts confined to the larynx or for Type 1 cysts. A transcervical approach for resection of the cyst will achieve the best outcomes for Type 2 cysts that extend into the neck or are extralaryngeal.

Predictors of complicated airway foreign body extraction.

OBJECTIVES: To evaluate outcomes of foreign body aspiration (FBA) and to investigate surgeon and hospital volume as risk factors for a complicated course. STUDY DESIGN: Retrospective case series. METHODS: Children with FBA in a multihospital network were identified from January 2005 to September 2015. Demographic information, surgeon, and hospital location were reviewed. Mean operative time and hospital length of stay were recorded. Cases requiring intensive care unit admission, hospital stay greater than 24 hours, need for more than one bronchoscopy, operative time greater than 1 hour, or death were considered "complicated." RESULTS: A total of 450 cases of airway foreign body extraction were performed. Patient ages ranged from 0.6 to 18.8 years, with a median age of 1.9 years. Bronchoscopy with foreign body extraction was performed by 55 different surgeons at 11 different facilities. There were one to 24 surgeons for each facility, with an average number of 5.4 surgeons per facility. A total of 88 (19.6%) cases were considered complicated, including five (1.1%) deaths. Increased rates of complications were seen with unwitnessed aspiration (P = 0.008) and hyperlucency (P < 0.001) or infiltrates (P = 0.001) on chest radiographs. No significant association was found between surgeon type or facility as related to a complicated case. CONCLUSIONS: Unwitnessed aspiration events and abnormalities on chest radiograph may be associated with a more complicated course in children with FBA. This multihospital study identified a low number of procedures by many surgeons; however, surgeon and hospital volume did not significantly correlate with higher complication rates. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:490-495, 2018.

Environmental contributions to otitis media requiring tympanostomy tubes.

OBJECTIVE: Otitis media requiring tympanostomy tubes (OMwTT) is a prevalent disease process that has been previously shown to have a strong familial link. The impact from the environmental versus genetic contributions to this link is unknown. The objective was to determine the environmental involvement in the development of OMwTT. METHODS: Using an extensive genealogical database linked to medical records, we evaluated the risk of OMwTT in children of probands as compared to children of controls, individually matched 5:1 on sex and birth year, from a conditional logistic regression model. The model included adjustments for geographic and socioeconomic environmental risk factors mapped to residence location of study subjects within 63 small health statistical areas of ∼33,500 persons each. RESULTS: 37,814 case probands diagnosed with OMwTT and 181,339 controls were included in our analysis. Children of probands with OMwTT had an overall 2.5× higher risk of also having OMwTT as compared to the children of controls (p < 10-9), independent of environmental factors (PM2.5 [particulate matter] air pollution, education level of parents, and density of primary care providers). CONCLUSION: After accounting for geographic and socioeconomic differences that may influence risk between cases and controls, our findings suggest evidence of a genetic predisposition in families of OMwTT patients. Further characterization of high-risk pedigrees is needed for future genomic studies.

Selective pulmonary artery occlusion to treat hemoptysis associated with pulmonary venous obstruction.

Hemoptysis may occur in patients with pulmonary venous obstruction and prominent decompressing vessels in the airways adjacent to the affected pulmonary veins. The options for treatment of hemoptysis are limited, particularly when efforts to alleviate pulmonary venous obstruction have failed. Here we describe a patient with hemoptysis associated with stenosis of the central left upper pulmonary vein and occlusion of the central left lower pulmonary vein. The left upper pulmonary vein was dilated with balloon catheters and a vascular plug was placed in the left lower pulmonary artery. Vascular engorgement regressed in the left bronchus and hemoptysis has not recurred for 4 years despite recurrence of left upper pulmonary vein stenosis. Selective occlusion of branch pulmonary arteries may be an effective option for the treatment of hemoptysis from bleeding in lung segments with inoperable pulmonary venous obstruction.

Familial link of otitis media requiring tympanostomy tubes.

OBJECTIVES/HYPOTHESIS: Placement of tympanostomy tubes for recurrent or chronic otitis media is the most commonly performed ambulatory procedure in the United States. Etiologies have been speculated to be environmentally based, and studies have suggested a genetic component to the disease. However, no large-scale studies have attempted to define a familial component. The objective of this study was to determine the familial risk of otitis media requiring tympanostomy tubes (OMwTT) in a statewide population. STUDY DESIGN: Retrospective observational cohort study with population-based matched controls. METHODS: Using an extensive genealogical database linked to medical records, the familial risk of OMwTT was calculated for relatives of probands (46,249 patients diagnosed with OMwTT from 1996-2013) compared to random population controls matched 5:1 on sex and birth year from logistic regression models. RESULTS: The median age at time of tympanostomy tube placement was 1 year (interquartile range, 0-2 years). First-degree relatives of patients with OMwTT, primarily siblings, had a 5-fold increased risk of OMwTT (P < 10-16 ). Second-degree relatives were at a 1.5-fold increased risk (P < 10-15 ). More extended relatives (third, fourth and fifth degree) showed a 1.4-fold increased risk (P < 10-15 ). CONCLUSIONS: In the largest population-based study to date, a significant familial risk is confirmed in OMwTT, suggesting otitis media may have a significant genetic component given the increased risk found in close as well as distant relatives. This could be influenced by shared environments given a five-times risk observed in siblings. Further understanding the genetic basis of OMwTT and its interplay with environmental factors may clarify the etiology and lead to better detection of disease and treatments. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:962-966, 2017.

Velopharyngeal Dysfunction Evaluation and Treatment.

Velopharyngeal dysfunction (VPD) can significantly impair a child's quality of life and may have lasting consequences if inadequately treated. This article reviews the work-up and management options for patients with VPD. An accurate perceptual speech analysis, nasometry, and nasal endoscopy are helpful to appropriately evaluate patients with VPD. Treatment options include nonsurgical management with speech therapy or a speech bulb and surgical approaches including double-opposing Z-plasty, sphincter pharyngoplasty, pharyngeal flap, or posterior wall augmentation.

Association between follicular tracheitis and gastroesophageal reflux.

OBJECTIVE: Follicular tracheitis (also known as tracheal cobblestoning) is an entity that is poorly described and of unclear significance. The objective of this study was to better define follicular tracheitis and determine the association between the clinical finding of follicular tracheitis on bronchoscopy and objective evidence of gastroesophageal reflux disease. METHODS: Retrospective chart review of children with recurrent croup having undergone a rigid bronchoscopy and an investigation for gastroesophageal reflux between 2001 and 2013. RESULTS: 117 children with recurrent croup children age 6-144 months were included in the study. Follicular tracheitis was noted on 41% of all bronchoscopies. Fifty-nine percent of all children who underwent bronchoscopy were diagnosed with gastroesophageal reflux on at least one investigation. Forty-nine of 117 children underwent a pH probe study, and 51% were found to have evidence of reflux on this study. Nine children were diagnosed with eosinophilic esophagitis. Three patients underwent a biopsy of the follicular tracheitis lesions, which revealed chronic inflammation. There was no evidence of an association between findings of follicular tracheitis and a positive test for gastroesophageal reflux (p=0.52) or a positive pH probe study (p=0.64). There was no association between follicular tracheitis and subglottic stenosis (p=0.33) or an history of asthma and/or atopy (p=0.19). CONCLUSION: In children with recurrent croup, follicular tracheitis remains an unspecific finding associated with an inflammatory disorder of unknown etiology.

Pediatric invasive fungal rhinosinusitis in immunocompromised children with cancer.

OBJECTIVES: 1) To determine the factors that predispose towards invasive fungal rhinosinusitis (FS) in immunocompromised children with cancer, and 2) to propose practice guidelines for management of pediatric FS in immunocompromised patients. METHODS: Retrospective chart review of 9 patients who developed invasive FS compared to 8 patients who did not develop invasive FS during the study period. Presenting signs and symptoms, nasal endoscopic findings, radiographs, laboratory studies, histologic and microscopic samples, and outcomes were compared. RESULTS: Seventeen consecutive pediatric immunocompromised patients with hematologic and lymphoid neoplasms underwent nasal endoscopy and biopsy for possible FS. Nine patients were diagnosed with 10 episodes of FS; 1 patient developed FS with different organisms on 2 separate occasions separated by 6 months; 8 patients were not diagnosed with FS. Eight patients had acute myelogenous leukemia (AML); 6 patients had acute lymphoblastic leukemia (ALL); 1 patient had Burkitt's lymphoma, 1 patient had undifferentiated leukemia; and 1 patient had biphenotypic acute leukemia. All patients with FS had an absolute neutrophil count (ANC) 600 or less (range 0-600). All patients with FS had either persistent fevers or sinus symptoms (facial pain, nasal congestion, rhinorrhea). Sinus CT scans were abnormal in all patients with FS and without FS. Two patients with FS had maxillary sinus retention cysts. Operative endoscopic findings were helpful diagnostically when necrosis or ulceration was found. All patients in the non-FS group normalized their ANCs; 2 of the 9 patients in the FS group did not normalize their ANC. These 2 patients died from disseminated FS or from complications due to their immunosuppression. CONCLUSION/SIGNIFICANCE: All patients with FS had either persistent fevers or symptoms localized to the sinuses (facial pain, nasal congestion, or rhinorrhea). Endoscopic examination was helpful when necrosis was detected. We recommend directed biopsies of suspicious lesions, the middle and inferior turbinate, in immunocompromised, neutropenic pediatric patients with cancer who present with either persistent fevers or localizing symptoms to the sinuses. We favor the use of "rush" biopsies over frozen sections because of the better-quality sections and ability to perform appropriate stains.

The effect of age on pediatric tympanoplasty outcomes: a comparison of preschool and older children.

OBJECTIVES: Determine whether the outcome of tympanoplasty in preschool children is different from that of older children. STUDY DESIGN: Retrospective case series. METHODS: Retrospective review of children having undergone a primary tympanoplasty by 4 surgeons for a tympanic membrane perforation between 2002 and 2013. RESULTS: Data from 50 children age 2-4, 130 children age 5-7 and 105 children age 8-13 years old were reviewed. Median follow-up was 7.5 months. On crude analysis, the incidence of anatomical success was not significantly different between the different age groups (p=0.38), the success rate was respectively 69.4%, 68.5% and 79.1% with an overall rate of 72.5%. 5.9% of all children required later insertion of tympanostomy tubes, 10.2% in preschool children. The post-operative audiology results were similar for all groups with a mean improvement of 9dB in the air-bone gap. When limiting the analysis to the 155 children having at least 6 months of follow-up, the rate of success was respectively 50.0%, 60.8% and 74.0% (p=0.10). After multivariate analysis controlling for the effect of surgeon, approach and etiology, the odds ratio of perforation was respectively 5.48, 2.27 and 1.00 for the different age groups. CONCLUSION: Children younger than 4 years of age have the worst outcome after tympanoplasty. It remains uncertain whether the benefits of hearing improvement and quality of life may outweigh that of a high rate of a residual, usually smaller, perforation. Prospective studies are needed to confirm these results and delineate the patient characteristics and technique most likely to lead to successful results.

Emergency department use among children with tracheostomies: Avoidable visits.

PURPOSE: To characterize high emergency department (ED) use by children with tracheostomies and complex chronic conditions, to distinguish avoidable from unavoidable ED visits, and to describe the financial impact of avoidable visits. METHODS: Children with tracheostomies in a pediatric tertiary care center with the highest ED utilization were identified via analysis of administrative data. Six experts in interdisciplinary dyads reviewed the records from all ED visits for these children, and distinguished avoidable from unavoidable visits. Hospital cost data for avoidable visits is described. RESULTS: Among 75 children with tracheostomies and complex chronic conditions, 23 (31%) were high ED utilizers. These 23 children accounted for 74% of all ED discharges the total group of 75 children from 2008 to 2011. Four of these 23 children with high utilization were excluded, leaving 19 subjects for review. These 19 children had 312 ED visits, of which 103 (33%) were deemed avoidable. Leading reasons for avoidable visits were uncomplicated upper respiratory infections, gastrointestinal infections, and enteral feeding system problems. Avoidable visits cost the hospital {$}67,940. CONCLUSIONS: One-third of ED visits by children with tracheostomies and complex chronic conditions may be avoidable. Increased ambulatory access to interdisciplinary teams of providers familiar with these children's unique needs might reduce avoidable ED visits and improve health outcomes. Further studies on how this model of ambulatory care might affect ED utilization and total healthcare costs are needed.

Comparison of topical medication delivery systems after sinus surgery.

OBJECTIVES: To compare the distribution patterns of topical medication delivery systems in the sinonasal region and upper respiratory tract after functional endoscopic sinus surgery. STUDY DESIGN: Prospective descriptive evaluation. METHODS: Four topical delivery systems (spray bottle, atomizer, nebulizer, and bulb syringe) were studied. Using a dye solution as a marker, we independently applied the four topical delivery systems to a population of patients with chronic rhinosinusitis who had undergone functional endoscopic sinus surgery. The anatomic distributions were videotaped using flexible fiberoptic endoscopy. Three blinded observers independently rated the anatomic distribution of dye using a 4 point scale. Statistical analysis was performed using analysis of variance (ANOVA) and Dunn posttesting. RESULTS: Seven participants completed the study. All participants had undergone bilateral maxillary antrostomies, bilateral total ethmoidectomies, and bilateral sphenoidotomies. Five sinonasal sites and the larynx were evaluated for dye deposition. Interobserver agreement reached 95.6%. There was no statistical difference between the atomizer and spray bottle. The bulb syringe was statistically superior to the nebulizer in all sinonasal sites and statistically superior to the atomizer and spray bottle in the ethmoidal region. Dye was rarely seen within the larynx. CONCLUSIONS: The delivery systems tested were shown to have significant differences in their capability to place dye in specific sinonasal areas. Because topical medications are commonly administered to postoperative patients, these differences may have important clinical implications.

The financial impact of unrepaired cleft lip and palate in the Philippines.

OBJECTIVES: There are over 96 million people in the Philippines. Close to 77 thousand persons in this country have orofacial clefting. We estimate nearly 64 thousand are unrepaired. Unemployment and underemployment because of the communication disorders associated with unrepaired clefts will affect family income and hence tax revenues. The purpose of this study is to understand the financial impact of unrepaired cleft lip and/or palate on families and identify how that would translate to the Philippine government in tax revenues. METHODS: The incidence of orofacial cleft in the Philippines was estimated to be at least 1 in 750 people, with only 16% anticipated to be repaired under current conditions. Assuming a 21% unemployment rate in subjects with untreated clefts, and a tax rate of 6-12.4%, projected lost personal income and federal tax revenue was calculated. RESULTS: In 2012 alone the financial impact on the families may be as much as $US 73-88 million in lost revenue from unemployment and underemployment. This would cost the government between $8.0 and $9.8 million dollars in lost tax revenue. Over a 20 year period at least $US 1.7 billion dollars in family income would be affected costing the government at least $US 194 million in taxes. CONCLUSION: By appropriately caring for the cleft population tax revenues should increase substantially. The development of the infrastructure for surgical care of this problem would be costly but could be more than offset by revenues. Inattention to surgically correctable causes of communication disorders is not affordable.

Foreign body impaction as presentation of eosinophilic esophagitis.

Esophageal foreign body is a frequent pediatric presentation, and eosinophilic esophagitis (EoE) is an important underlying disease. To determine characteristics common in the presentation of esophageal foreign body indicative of underlying EoE and reach a recommendation for the appropriate scenario in which to obtain esophageal mucosal biopsy, 312 pediatric esophageal foreign bodies requiring operative removal were reviewed. Patients older than 18 years or with a known history of esophageal surgery or pathology were excluded. Eligibility criteria were met in 271 cases. Twenty-seven patients were biopsied, and 18 were diagnosed with EoE. The following factors were identified in the EoE population: food impaction (89%), older age (average 12.2 years), male sex (78%), atopic disease (61%), previous esophageal foreign body or frequent dysphagia (83%), and endoscopic abnormalities (100%). These factors are all associated with an underlying diagnosis of EoE, and patients meeting these criteria should be strongly considered for intraoperative esophageal mucosal biopsy.

Management of sleep apnea in the cleft population.

PURPOSE OF REVIEW: Obstructive sleep apnea is prevalent in children with facial clefts. As there are increasing concerns that sleep disordered breathing and obstructive sleep apnea may lead to cognitive difficulties, it is imperative that the otolaryngologist and cleft surgeon be aware of the concerns for sleep disorders and implement appropriate interventions for the management. RECENT FINDINGS: Micrognathia associated with Robin Sequence has long been understood to have significant potential for sleep apnea. Positioning, nasopharyngeal airway, tongue-lip adhesion and mandibular distraction have been used to improve the breathing in this set of children. Screened by symptoms, a large proportion of children with clefts will have a positive sleep study. Syndromic children seem to be more prone to this, even though nonsyndromic children are also at risk. Children who have had secondary management of velopharyngeal insufficiency with pharyngeal flap and sphincter pharyngoplasty seem to be at greater risk of sleep disorder. Specific directed therapies should provide the optimum results for the correction including tonsillectomy with partial adenoidectomy, revision pharyngoplasty, maxillary advancement and continuous positive airway pressure for sleep. SUMMARY: Awareness of the risk of sleep disorders and the possible treatments in children with cleft deformities is very important for the otolaryngologist.

Yolk sac tumor of the thyroid gland: a case report.

Extragonadal yolk sac tumors are uncommon and usually seen in sacrococcygeal, mediastinal, intracranial, and retroperitoneal sites. Yolk sac tumors of the head and neck region are rare, and the few reported cases have arisen in neonates or infants in conjunction with a teratoma or other germ cell tumor subtypes. We report a unique case of a pure yolk sac tumor presenting as a primary lesion in the right thyroid lobe of a 10-year-old girl. The diagnosis was suspected after fine-needle aspiration, and extensive sampling of the thyroidectomy specimen revealed no teratoma or other germ cell tumor. Serum α-fetoprotein levels were markedly elevated 6 days after excision, and imaging disclosed numerous bilateral pulmonary nodules suggestive of metastatic disease but did not reveal a mediastinal mass. The tumor has shown a favorable response to bleomycin, etoposide, and cisplatin chemotherapy. To the best of our knowledge, this is the 1st description of a primary pure yolk sac tumor of the thyroid.

Indicators of a more complicated clinical course for pediatric patients with retropharyngeal abscess.

OBJECTIVE: Determine clinical signs or symptoms associated with a more complicated clinical course in patients with retropharyngeal abscesses (RPAs). DESIGN: Retrospective chart review at a tertiary care level Children's hospital. Main Outcome Measures Age, presenting signs and symptoms, laboratory tests, imaging results, antibiotic therapy, surgical approach, pathogens isolated, and duration of hospitalization were evaluated to determine any factors associated with a more complicated clinical course (CCC). RESULTS: Fifteen of one hundred thirty pediatric patients with RPA were identified with a complicated clinical course (CCC). Eight of the fifteen required more than one procedure before the abscess resolved. Patients with multiple abscess sites had a statistically significantly greater chance of requiring multiple procedures to clear the infections (p<0.001). Another seven presented with airway obstruction requiring an admission into the Pediatric Intensive Care (PICU) and/or intubation. All the patients requiring admission to the PICU presented with signs or symptoms of airway obstruction compared to ten of the one hundred fifteen patients (8.7%) with a smooth clinical course (SCC) (p<0.001). Five patients from the CCC group required a bronchoscopy to secure the airway; seven patients required intubation following incision and drainage of the abscess for an average of 5+/-3 days. There was no statistically significant difference between the two groups with respect to pathogens isolated, or antibiotics used. CONCLUSION: Our study suggests that patients with a CCC are more likely to present with airway obstruction or multiple abscess sites than patients with SCC.