Derek J. Lam

Comparison of anatomic, physiological, and subjective measures of the nasal airway

Background Studies comparing different categories of nasal measures have reported inconsistent results. We sought to compare validated measures of the nasal airway: anatomic (acoustic rhinometry), physiological (nasal peak inspiratory flow), and subjective experience (Nasal Obstruction Symptom Evaluation Scale and a visual analog scale [VAS]). Methods This prospective cross-sectional study of 290 nonrhinologic patients included upright and supine rhinometry (minimum cross sectional area [MCA] and volume) and flow (mean and maximum) measurements, as well as subjective measures. Associations between measures were evaluated with Spearman correlations and multivariate linear regression, adjusting for age, sex, race, body mass index, and smoking history. Results Correlations between objective (rhinometry and flow) and subjective categories of nasal measures ranged from –-0.16 to 0.03 (mean correlation, -0.07 ± 0.05), with 0 significant correlations of 16 tested. Correlations between anatomic (rhinometry) and physiological (flow) categories ranged from 0.04 to 0.15 (mean correlation, 0.10 ± 0.03), with 0 significant correlations of 16 tested. In contrast, within each category (rhinometry, flow, and subjective), all correlations were significant (13 correlations, all p < 0.001) and ranged from 0.62 to 0.99. Of 16 adjusted associations between objective and subjective measures, 14 were not significant (p > 0.05); only upright and supine MCAs were significantly associated with the VAS (both, p < 0.05). Conclusion Validated anatomic, physiological, and subjective nasal measures may assess different aspects of the nasal airway and provide complementary information. Future studies should be directed at developing a composite measure including components from all three categories of nasal measurement.

A comparison of nasendoscopy and multiview videofluoroscopy in assessing velopharyngeal insufficiency.

OBJECTIVES: 1) To compare nasendoscopy (NE) and multiview fluoroscopy (MVF) in assessing velopharyngeal gap size; and 2) to determine the relationship between these assessments and velopharyngeal insufficiency (VPI) severity. STUDY DESIGN AND SETTING: Retrospective review of consecutive patients with VPI at a tertiary care childrens hospital, assessed with NE and MVF between 1996 and 2003. RESULTS: 177 subjects. NE and MVF gap areas were correlated (R = 0.34, 95% CI 0.26-0.41). In adjusted analysis, VPI severity was associated with: 1) NE gap area (OR = 2.78, 95% CI 1.96-3.95), 2) MVF gap area (OR 1.64, 95% CI 1.37-1.95), 3) age <5 years (OR 3.30, 95% CI 1.47-7.38), and 4) previously repaired cleft palate (OR 0.48, 95% CI 0.25-0.94). CONCLUSIONS AND SIGNIFICANCE: NE and MVF assessments provide complementary information and are correlated. Both are associated with VPI severity. However, the “birds-eye view” provided by NE has a stronger correlation with VPI severity than MVF.

Pediatric sleep apnea and craniofacial anomalies: A population-based case–control study†‡§¶

To investigate the association between craniofacial anomalies and diagnosis with obstructive sleep apnea (OSA) in a large, population‐based sample of children.

Outcomes of Mandibular Distraction Osteogenesis in the Treatment of Severe Micrognathia

IMPORTANCE Patients with severe micrognathia are predisposed to airway obstruction. Mandibular distraction osteogenesis (MDO) is an alternative to tracheotomy that lengthens the mandible in order to improve the retrolingual airway. This study presents outcomes from one of the largest cohorts reported. OBJECTIVE To assess the rate and predictors of surgical success and complications among (1) patients who underwent MDO prior to other airway procedures (MDO first), and (2) patients who required an initial tracheotomy and were subsequently treated with MDO (tracheotomy first). DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at a tertiary care pediatric medical center of patients diagnosed as having micrognathia resulting in symptomatic airway obstruction (Pierre Robin sequence) and who underwent MDO from September 1995 to December 2009. INTERVENTIONS Electronic medical records were reviewed. Multivariable regression analysis was used to assess for predictors of outcome. MAIN OUTCOMES AND MEASURES Rates of surgical success (defined as either tracheotomy avoidance or decannulation) and complications. Potential predictors included demographics, syndrome presence, follow-up time, and surgical history. RESULTS A total of 123 patients (61 in MDO-first subgroup, 62 in tracheotomy-first subgroup) underwent MDO during the study period. Median age at time of distraction was 21 months (range, 7 days-24 years). Surgical success and complication rates were 83.6% and 14.8% in the MDO-first subgroup and 67.7% and 38.7% in the tracheotomy-first subgroup. Tracheotomy-first patients were more likely to have a syndromic diagnosis (66.0% vs 43.0%; P = .009) and were older at the time of MDO (median age, 30 months vs 5.1 months; P < .001). Poorer odds of success were associated with the need for 2 or more other airway procedures (odds ratio [OR], 0.14 [95% CI, 0.02-0.82]) in the MDO-first subgroup and craniofacial microsomia or Goldenhar syndrome (OR, 0.07 [95% CI, 0.009-0.52]) in the tracheotomy-first subgroup. CONCLUSIONS AND RELEVANCE Mandibular distraction osteogenesis has a high rate of success in avoiding tracheotomy. Patients who required a tracheotomy before MDO had a lower success rate in achieving decannulation and a higher rate of complications. However, these patients also had a higher rate of syndromic diagnoses and associated comorbidities. Patients with Goldenhar syndrome have a decreased likelihood of surgical success.

Assessment of pediatric obstructive sleep apnea using a drug-induced sleep endoscopy rating scale.

Assess the reliability of a Sleep Endoscopy Rating Scale (SERS) and its relationship with pediatric obstructive sleep apnea (OSA) severity.

Endoscopic anterior–posterior cricoid split for pediatric bilateral vocal fold paralysis

Children with bilateral true vocal fold immobility (BTVFI) may present with significant airway distress necessitating tracheostomy. The objective of this study was to review our preliminary experience with the anterior–posterior cricoid split (APCS), an endoscopic intervention used as an alternative to tracheostomy in children with BTVFI.

Intranasal Steroid Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement

Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.

Predictors of Obtaining Polysomnography Among Otolaryngologists Prior to Adenotonsillectomy for Childhood Sleep-Disordered Breathing

STUDY OBJECTIVES (1) To assess the predictors for obtaining polysomnography (PSG) in children undergoing adenotonsillectomy (AT) for sleep-disordered breathing, and (2) to estimate the adherence to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline recommendations for pre-AT PSG. METHODS This was a retrospective cohort study of children who were seen in the Pediatric Otolaryngology Clinic and underwent AT for sleep-disordered breathing over a 13-month period at a single tertiary care childrens hospital. Patients with and without pre-AT PSG were compared using bivariate and logistic regression analysis to identify predictors for PSG. Electronic medical records were reviewed for demographic variables, medical comorbidities, and PSG data. Adherence to AAO-HNS guideline recommendations was estimated by calculating the proportion of patients who had a PSG among those who met the recommended criteria for pre-AT PSG. RESULTS Mean age was 6.6 ± 3.6 years with 53% male. A total of 65 of 324 children (20%) underwent PSG prior to AT. The only factor significantly associated with pre-AT PSG was age 1 to 3 years (odds ratio 4.5, 95% confidence interval [2.2, 9.0], P < .001). Among patients who met AAO-HNS criteria for pre-AT PSG, 28 of 128 (20%) underwent PSG compared to 35 of 186 (19%) who did not meet criteria (odds ratio 1.0, 95% confidence interval [0.6, 1.9], P = .87). CONCLUSIONS Among children who underwent AT, the only significant predictor of obtaining pre-AT PSG was age 1 to 3 years. The rate of adherence to the AAO-HNS guideline recommendations was low (20%), which represents an educational opportunity.

Practice patterns in the management of post-tonsillectomy hemorrhage: An American Society of Pediatric Otolaryngology survey

OBJECTIVES To evaluate practice patterns amongst pediatric otolaryngologists in the management of post-tonsillectomy hemorrhage. METHODS A cross-sectional survey of the American Society of Pediatric Otolaryngology membership was administered electronically. The survey contained questions related to practice type, availability of resident and fellow call coverage, and management of different scenarios of post-tonsillectomy hemorrhage. Anonymous responses were collected and tabulated. RESULTS The response rate was 157/443 (35%). For patients presenting with a convincing history of post-tonsillectomy hemorrhage but no clot or bleeding on exam, the most common management was overnight observation (55%) or discharge home with close follow-up (29%). In patients presenting with tonsillar clot but no active bleeding, the most common management was operating room for control (50%), followed by observation (25%) and bedside topical treatment (13%). In the same scenario with a cooperative teenager, bedside topical treatment was most common (45%), followed by operating room for control (27%) and observation (16%). In patients presenting with active tonsillar bleeding, operating room for control was most common (83%) while few (6%) attempted bedside treatment. If the patient was a cooperative teenager, 38% attempted bedside treatment while 52% would still go to the operating room. CONCLUSIONS There is substantial variation in the management of post-tonsillectomy hemorrhage amongst the pediatric otolaryngologists. Further studies to determine outcomes associated with differing treatment strategies would be useful in establishing practice recommendations.

A growth spurt in pediatric sleep research

The awareness and understanding of the spectrum of pediatric sleep disorders has increased significantly in the last 20 years. While parents have always struggled with snoring children or behavioral difficulties around bedtime, only recently have parents and clinicians become aware of the potential long-term negative consequences of leaving these problems unaddressed. The diagnosis and management of pediatric sleep disorders can be uniquely challenging because of difficulties in assessing both the burden of disease and its downstream effects in the very young who are unable to clearly articulate their sleep-related experiences or relevant outcomes. Investigations in this age-group frequently require proxy parental assessments of sleep habits and outcomes or other innovative alternative methods of subjective assessment combined with objective measures that must be customized to the pediatric population. The impact of untreated sleep disorders during critical periods of early development on later cognition, behavior, and quality of life is potentially significant and far-reaching. This lends urgency to the need for more thorough and systematic investigation across the spectrum of pediatric sleep disorders. Nature and Science of Sleep (NSS) is a relatively new international, peer-reviewed, open-access journal covering all aspects of sleep science and sleep medicine, including the neurophysiology and functions of sleep, the genetics of sleep, sleep and society, biological rhythms, dreaming, sleep disorders and therapy, and strategies to optimize healthy sleep. Interestingly, despite the broad topics covered by NSS, in the first 100 articles published in NSS, over 10% were specific to sleep disorders in the pediatric age-group. These articles include three review articles that discuss the specific pediatric sleep diagnoses described in the International Classification of Sleep Disorders,1 the neurocognitive and behavior outcomes after treatment for sleep disordered breathing (SDB),2 and the relationship between pediatric sleep disorders and attention deficit-hyperactivity disorder (ADHD).3 In his review of pediatric sleep physiology and sleep disorders, El Shakankiry1 provides a concise summary of the unique features of pediatric sleep architecture and physiology that vary with age and are distinct from adult norms. Also discussed are the most common methods of assessing pediatric sleep, including key features of the sleep history and physical examination and objective investigations including polysomnography and actigraphy. A thorough review of the spectrum of pediatric sleep disorders is then presented according to the classification system described in the International Classification of Sleep Disorders, Revised 2001. These include dyssomnias (problems with falling or staying asleep or excessive daytime sleepiness, which includes obstructive sleep apnea and inadequate sleep hygiene), parasomnias (behaviors or physiologic processes that interrupt sleep after sleep onset such as somnambulism or nightmares), and sleep disorders associated with medical conditions such as epilepsy or sudden infant death syndrome. Unlike this broad overview of pediatric sleep disorders, a review by Kohler et al2 focuses on studies investigating the relationship between SDB and neurocognitive and behavioral outcomes, an area that has seen explosive growth in the number of articles published in recent years. Among the many studies that have examined this relationship, the article by Kohler et al utilized relatively strict criteria for review, requiring the use polysomnography to diagnose SDB and validated measures of neurocognitive performance and behavior. On the basis of the studies meeting these criteria, the authors were able to conclude that children with SDB have consistent neurocognitive impairments in executive function, attention, and general intellectual ability. Problems with behavior appear less consistent, but the most frequently reported were somatic complaints, depression, and social problems. All of these deficits do improve with treatment, primarily in the form of adenotonsillectomy. However, the authors point out that there are only two studies that include a control group and use objective validated measures of both SDB and neurocognitive outcomes at baseline and in follow-up. In addition, the majority of treatment studies focus on primary school-aged children with little follow-up data extending beyond 1 year, highlighting the need for more rigorous prospective studies with longer follow-up. With respect to the behavioral impact of sleep disturbances, a related review by Cassoff et al3 explores the evidence for the impact of sleep loss and other sleep disturbances on symptoms of ADHD. In addition to discussing the clinical implications of this relationship, the authors discuss hypothesized mechanisms involving changes in the prefrontal cortex, dopamine regulation, and the circadian system that may mediate the link between sleep disturbances and symptoms of inattention and hyperactivity. An important article in NSS further explores the relationship of short sleep duration and teacher ratings of inattention and cognition.4 This study demonstrates that shorter sleep duration is significantly associated with worse ratings in the inattention/cognitive problems domain of the Conners’ Teacher Rating Scale but not with the hyperactivity/impulsivity domain.4 Another article provided preliminary data that in pediatric ADHD patients, better sleep hygiene before bed (eg, fewer caffeinated drinks, consistency of bedtime routine) predicts increased time in bed with improved sleep quality. In addition, observations that disrupted sleep is associated with weight and bedtime sleepiness, and that food consumption patterns are associated with morning sleepiness provide indirect evidence of a link between sleepiness, sleep quality, and eating behaviors in children with ADHD.5 Assessments of pediatric sleep have traditionally relied on either parental report of sleep history or objective measures such as polysomnography, considered the gold standard for diagnosis of a variety of sleep disorders. Several articles in NSS have used actigraphy as an alternative measure of sleep–wake patterns.4–6 Actigraphy uses a watch-like device that contains an accelerometer to measure physical activity. Estimates of sleep–wake states are then made based on algorithms using different thresholds of baseline activity to judge wakefulness. One recent study reported 86% sensitivity and 85% specificity of actigraphy in measuring sleep–wake states among infants when compared to polysomnography.7 When actigraphy was used as a gold standard to assess the accuracy of parental report of child sleep patterns among healthy children, subjective reports were judged to be acceptable for assessments of sleep start and end times but inadequate for total durations of sleep and nocturnal wakefulness.8 To assess whether this relationship holds true among children who are habitual snorers or suffer from insomnia, Dayyat et al6 compared sleep logs and actigraphy in children who were nonsnorers, habitual snorers, or had insomnia. All three groups showed a similar pattern of overestimated sleep duration of approximately 1 hour per night and an average error of 30 minutes in estimating sleep onset. It appears that actigraphy may provide more reliable objective data than parental report alone with respect to sleep–wake states and have a complementary role in assessing pediatric sleep habits at home. While actigraphy provides a complementary objective measure of child sleep patterns, a subjective instrument allowing self-report among children aged 5–10 years is called the children’s sleep comic.9 This approach was adapted from an unpublished German questionnaire named the “Freiburger Children’s Sleep Comic” and utilizes cartoons to depict activities and scenarios related to sleep hygiene, sleep quality, and bedtime routines. This instrument was shown to have moderate correlations with other validated pediatric sleep questionnaires but has the advantage of being applicable to young children who do not yet read or write. Thus, this technique holds promise as an instrument that allows self-reported sleep symptoms even among very young children. Further prospective studies with longer follow-up are needed to establish its validity and potential utility in diagnosing pediatric sleep disorders. An example of such a prospective study was also published in NSS. This 5-year longitudinal study was based on self-report on the sleep–wake habits of teenagers aged 15–19 years.10 Ikeda and Hayashi10 demonstrated that only 5% of students in this age-group consistently self-awakened (awakening without the need for an external stimulus) over the entire study period, while 56% consistently required forced awakening. In general, students who consistently self-awakened went to bed earlier, got up from bed earlier, slept for a longer time, and had less change in their sleep patterns over time. This longitudinal study with excellent long-term follow-up helped to confirm similar findings in previous cross-sectional studies. Amid the growth of research in pediatric sleep, the first 100 articles published in NSS have covered a broad range of topics that are relevant to the diagnosis and management of pediatric sleep disorders. Whether these are review articles describing what is known about neurocognitive and behavior outcomes after treatment for SDB or reports on new diagnostic methods of characterizing pediatric sleep disorders, these articles illustrate the increasing depth and variety of research in this area. They also serve to highlight the need for further study in a field that presents unique challenges in the diagnosis and management of sleep disorders in different age ranges, and where new avenues of inquiry and opportunities for research abound.