Amanda G. Ruiz

Surgical management of type I and II laryngeal cleft in the pediatric population

INTRODUCTION Laryngeal clefts (LC) are congenital malformations of the upper aerodigestive tract that can cause dysphagia, aspiration, and subsequent pulmonary complications. This investigation assessed the outcomes of multidisciplinary evaluation and surgical management of type I and II LC (LC1-2) at a tertiary childrens hospital. MATERIALS AND METHODS A retrospective chart review was used to identify patients who underwent repair of LC1-2 by a single surgeon. RESULTS Twenty-five patients who underwent surgical management for LC1-2 were identified. Twenty patients with LC-1 and 5 with LC-2 were included. Most common presentations were aspiration on modified barium swallow (MBS) (76%) and recurrent pulmonary infections (60%). Gastroesophageal reflux disease (GERD) was a concurrent co-morbidity in 68%. Of the 19 patients who presented with preoperative aspiration on MBS, 52.6% had evidence of improvement on their first MBS. This improved to 78.9% at the time of their most recent MBS (10 with resolution of aspiration, 5 with improved tolerance of consistencies). Two patients failed to improve from surgical repair and two had worsened aspiration on most recent MBS. CONCLUSION Endoscopic repair of laryngeal clefts is a well-tolerated procedure. Concurrent GERD and positive bronchoalveolar lavage (BAL) cultures are common and require management prior to definitive repair. Given the multidimensional nature of swallowing disorders and aspiration, a comprehensive team approach in the evaluation, management, and surveillance of these patients is a valuable complement to surgical repair since not all aspiration may resolve.

A Pediatric Grading Scale for Lingual Tonsil Hypertrophy.

Lingual tonsil hypertrophy (LTH) is a common finding for children with residual obstructive sleep apnea (OSA) following an adenotonsillectomy. Secondary to the significant morbidity associated with OSA, identification and treatment of residual OSA are paramount. A dedicated LTH grading scale for children does not exist. The current adult LTH scale is impractical for children. Imaging is not routine for children, since it frequently requires sedation. We present a pediatric LTH grading scale with substantial interrater reliability to facilitate standardization of endoscopy findings and promote outcomes-based research for OSA surgery in children.

The current state of pediatric drug‐induced sleep endoscopy

The purpose of this investigation was to assess current drug‐induced sleep endoscopy (DISE) practice patterns at centers that have published on the technique, to identify areas of agreement, and to identify areas of disagreement that may represent opportunities for improvement and standardization.

Characteristics of children under 2 years of age undergoing tonsillectomy for upper airway obstruction

INTRODUCTION To study characteristics of children less than 2 years who underwent a tonsillectomy for sleep disordered breathing (SDB) or obstructive sleep apnea (OSA) to assess for factors associated with requesting a preoperative polysomnogram (PSG) and to identify predictors of upper airway obstruction in this group. MATERIALS AND METHODS A retrospective chart review of children under 2 years who underwent a tonsillectomy over a 7-year period at a tertiary care pediatric hospital was undertaken. Patient demographics, characteristics and polysomnography results, when applicable, were collected. In order to determine if the gathered demographics of our cohort differed from the non-surgical population, we compared our data with available Colorado data for each variable. Children were stratified by OSA severity using their obstructive apnea-hypopnea index (OAHI). RESULTS 197 (2.2%) of 9038 patients who underwent tonsillectomy for SDB or OSA were ≤ 24 months. The proportions of male, African-American, Hispanic, obese, underweight, premature, syndromic and daycare patients in our cohort were significantly different than in the general population. In a multivariate model, the odds of African-Americans having severe OSA were 12.5 times greater than the odds of Caucasians. The odds of patients with syndromes or craniofacial anomalies were 11 times greater (p < 0.0001), and the odds of patients in daycare were 2.2 times lower (p = 0.04) of undergoing a PSG before tonsillectomy. Weight did not influence polysomnogram requests. CONCLUSIONS In children under 2 years, ethnicity seems to be a predictor of OSA severity. African-American, prematurity, daycare and Down syndrome patients were significantly more represented in our study population. PSG is more likely to be requested for syndromic children.

Friedman tongue position: age distribution and relationship to sleep-disordered breathing.

PURPOSE Friedman tongue position (FTP) may play an important role in the evaluation of children with sleep-related breathing disorders (SRBD), but there are no previous data on FTP distribution by age. The objective of the current study was to determine the distribution of FTP by age and examine the relationship between FTP and snoring in children. METHODS Prospective cross-sectional study of 199 children (mean age, 6.8 years; 59% male) had tongue position assessed by FTP as part of their clinical examination of the oral cavity during routine ENT visits at a tertiary care childrens hospital. The FTP and snoring frequency of participants was examined across the entire age range as well as by comparing those older (middle childhood and above) and younger than 5 years of age. RESULTS Tongue position did not correlate with age or snoring frequency. The proportion of children with FTP III/IV was not significantly different in children younger than five years of age compared to older than five. Habitual snoring was not associated with having a higher FTP. Among children who snored <3 times per week, those who had previously undergone tonsillectomy did have higher FTP compared to those who had not (p=0.007). BMI-%-for-age was significantly correlated with FTP (p=0.003). The percent of children having FTP class III/IV differed significantly between ethnicities (22% of whites, 26% of others, 45% of hispanics, 53% of African-Americans; p=0.011). Inter-rater reliability among pediatric otolaryngologist was excellent (kappa=0.93, p<0.001). CONCLUSIONS There does not appear to be an association between FTP with age or snoring frequency in children. The excellent inter-rater reliability for FTP among pediatric ENT providers suggests the null findings are not due to rater bias. These findings may serve as an important reference for those studying the role of tongue position in pediatric SRBD and complement previous studies examining FTP among children with known OSA or snoring.

Indications, Clinical Course, and Postoperative Outcomes of Urgent Adenotonsillectomy in Children

IMPORTANCE Children undergoing urgent adenotonsillectomy have been poorly described in literature. OBJECTIVE To characterize the clinical course and outcomes of patients who underwent urgent adenotonsillectomy. DESIGN, SETTING, AND PARTICIPANTS A 7-year retrospective medical record review of patients undergoing urgent adenotonsillectomy (study group) at a tertiary care pediatric hospital was undertaken. Comparisons were made between the study group and the control group consisting of children undergoing adenotonsillectomy following diagnostic polysomnography. INTERVENTIONS Retrospective medical record review with no study interventions. MAIN OUTCOMES AND MEASURES Demographics, hospital course, and clinical outcomes. RESULTS A total of 35 patients (21 boys [60%] and 14 girls [40%]; mean age, 3.8 years) were identified as having undergone urgent adenotonsillectomy defined as severe obstructive sleep apnea with associated hypoxemia unresponsive to oxygen. The control group included 301 patients who received a diagnostic polysomnogram prior to nonurgent adenotonsillectomy. Patients undergoing urgent adenotonsillectomy patients were more likely to be younger than 3 years (54%) than nonurgent patients (P < .001) and were characterized by elevated obstructive apnea-hypopnea indices (average, 39.4 events per hour). Persistent desaturation below 80% despite at least 0.5 L of supplemental oxygen was the most common admission indication (83%). Obesity was the most frequent comorbidity (9 patients [31%]). Two patients (6%) experienced a major postoperative complication requiring intervention. Fifteen patients (43%) were discharged with supplemental oxygen. Two patients (6%) were admitted to the hospital more than 72 hours after surgery. CONCLUSIONS AND RELEVANCE Patients requiring urgent adenotonsillectomy are marked by younger age, elevated obstructive apnea-hypopnea indices, and persistent desaturations below 80% unresponsive to supplemental oxygen. Following surgery, some children have a dramatic improvement in gas exchange and will no longer require supplemental oxygen.

Auditing of operating room times: A quality improvement project

OBJECTIVE A quality improvement project to evaluate operating room efficiency and utilization and to identify areas for improvement. METHODS A retrospective assessment of a single surgeons surgical cases over a 6-month period at a tertiary childrens hospital. Primary outcomes included case timing defined as T1, T2, T3 and T4. (T1)-Patient enters OR-to-procedure start. (T2)-Procedure start-to-procedure end. (T3)-Procedure end-to-patient exits OR. (T4)-Patient exits OR-to-next patient enters OR (turnover). Comparison to existing literature was performed and results were presented to stakeholders. RESULTS A total of 180 surgical cases were reviewed, 92 adenotonsillectomies (T&A), 33 Bilateral Pressure Equalization Tube Placement (PET) and 55 microlaryngoscopies and bronchoscopies (MLB). All outcomes were calculated by case type, except T4, and compared to available published data. T2 was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A and PET. However, T4 was considerably longer at our institution (average 31.09). Overall OR efficiency was 20.58%. CONCLUSIONS The operating room represents one of a hospitals most costly resources. Ensuring that this resource is designed, staffed and utilized efficiently is of major importance to both the quality of patient care and financial productivity. Surgeons are key components of operating room efficiency, utilization and other measurements of institutional performance. How surgeons schedule and perform cases directly impacts, and is impacted by, these measurements of performance. For fields dominated by high volume, short duration procedures such as pediatric otolaryngology, T4 may be the most important variable in determining OR efficiency. By utilizing modern electronic medical records, surgeons can easily track OR time points thereby determining the potential causes of and solutions for OR inefficiency.

Evaluating the yield of gastrointestinal testing in pediatric patients in aerodigestive clinic

To improve understanding of the interrelatedness of airway and esophageal diagnoses by evaluating the yield of procedural and radiographic testing of the gastrointestinal tract in children with airway conditions by their referring diagnoses in a pediatric aerodigestive clinic.

Accuracy of Parental Perception of Nighttime Breathing in Children with Down Syndrome

Objective In 2011, the American Academy of Pediatrics published a guideline for children with Down syndrome (DS), recommending a polysomnogram (PSG) by age 4 years regardless of symptoms. Their rationale was based on 2 publications with small cohorts, where at least 50% of the children had no obstructive sleep apnea (OSA) symptoms but their PSG results were abnormal. The American Academy of Otolaryngology—Head and Neck Surgery Foundation published a clinical practice guideline recommending PSG prior to adenotonsillectomy for these children. This study aimed to assess parents’ accuracy of their children’s breathing patterns as compared with PSGs in a larger cohort of children with DS. Study Design Case series with chart review. Setting Tertiary care academic pediatric hospital. Subjects and Methods Sleep intake forms assessing frequency of parent-observed apnea, snoring, and restless sleep were analyzed. None of the children had a previous tonsillectomy. Two groups were analyzed according to symptoms: infrequent (<3 nights per week on all questions answered) and frequent (≥6 nights per week on at least 1 question). OSA severity was categorized as follows: normal, <2 events per hour; mild, 2 to 4.9; moderate, 5 to 9.9; and severe, ≥10. Results A total of 113 children met inclusion criteria: 34% (n = 38) had infrequent symptoms, and 66% (n = 75) had frequent symptoms. Parents were unable to predict the presence or absence of OSA by nighttime symptoms (P = .60). The risk of OSA for children with frequent symptoms versus those with infrequent symptoms was 1.04 (95% CI, 0.89-1.3). Conclusion Parents of DS children are unable to predict the presence or absence of OSA by nighttime symptoms, nor are they able to determine its severity.

Dornase Alfa Ototoxic Effects in Animals and Efficacy in the Treatment of Clogged Tympanostomy Tubes in Children: A Preclinical Study and a Randomized Clinical Trial

Importance Many treatments for clogged tympanostomy tubes (TTs) have been proposed, but none have met scientific rigor for safety and efficacy, including the popular empirical use of ototopical antibiotic drops. Dornase alfa, a recombinant molecule with the unique property of cleaving DNA, may be ideal in treating clogged TTs because both middle-ear effusion and the plug are abundant with DNA. Objective To investigate the ototoxic effects of dornase alfa in a chinchilla model and its efficacy in a clinical trial in children with clogged TTs. Design, Setting, and Participants The safety profiles of dornase alfa (full-strength and 1:10 strength) were evaluated in chinchilla middle ears using serial auditory brainstem response. The efficacy of ototopical dornase alfa (full-strength) was evaluated in children with clogged TTs in a prospective, single-blind randomized clinical trial. The animal study included 21 chinchillas and was conducted at Loma Linda University, Loma Linda, California, and the clinical trial was conducted at Children’s Hospital Colorado, Aurora. A total of 40 children (50 ears with tubes) were enrolled. Interventions In the animal study, chinchillas were assigned to 3 groups: controls (saline), full-strength dornase alfa, or 1:10 dornase alfa dilution. Children were randomly assigned to receive either topical dornase alfa or ofloxacin for clogged TT, 5 drops each ear twice a day for 7 days. Main Outcomes and Measures Animal study: Auditory brainstem responses. Randomized trial of children participants: The primary outcome was patency of TT at day 14 assessed by otoscopy and tympanometry. Results The chinchilla study showed similar auditory brainstem response degradation during a 6-hour period between the control (n = 5) and treatment groups (n = 21). In the clinical trial, a total of 40 clogged TTs (in 33 children, including 25 boys [76%]; mean age, 4.3 years; median [range] age, 3.4 [1.0-14.3] years) were analyzed. The number of unclogged TTs was higher in the dornase alfa group (13 [59%]) compared with the ofloxacin group (8 [44%]), with a difference of 15% (odds ratio, 1.8; 95% CI, 0.54-6.72). Conclusions and Relevance The chinchilla model suggests that dornase alfa is likely nonototoxic. The pilot clinical trial failed to show efficacy of dornase alfa to unclog TTs. With the difference seen between the treatment groups, a sample size estimate could be calculated for a future large-scale trial. Trial Registration ClinicalTrials.gov identifier: NCT00419380