Jeremy D. Prager

Clinical Consensus Statement: Pediatric Chronic Rhinosinusitis

Objective To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS). Methods A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Multidisciplinary care of children with repaired esophageal atresia and tracheoesophageal fistula.

Children with congenital esophageal atresia with tracheoesophageal fistula (TEF) require complex medical and surgical care, but few guidelines exist to guide the long term care of this population. The purpose of this study is to describe the findings and initial management of a comprehensive aerodigestive team in order to understand the ongoing needs of children with repaired TEF.

Standardized letter of recommendation for otolaryngology residency selection

Develop a standardized letter of recommendation (SLOR) for otolaryngology residency application that investigates the qualities desired in residents and the letter writers experience. Compare this SLOR to narrative letters of recommendation (NLORs).

Oropharyngeal Stenosis: A Complication of Multilevel, Single-Stage Upper Airway Surgery in Children

OBJECTIVES To describe oropharyngeal stenosis (OPS), a potential complication of multilevel, single-stage upper airway surgery involving lingual tonsillectomy in children, and to discuss the manner in which OPS may be managed successfully. DESIGN Case series with an average follow-up of 12 months. SETTING Tertiary care childrens hospital. PATIENTS Medical charts were reviewed for 104 patients who underwent lingual tonsillectomy over a 30-month period from January 1, 2007, to June 30, 2009. INTERVENTION Multilevel, single-stage upper airway surgery, including lingual tonsillectomy. MAIN OUTCOME MEASURE Development of OPS noted during office or intraoperative examination. RESULTS Forty-nine of 104 patients underwent multilevel, single-stage upper airway procedures that included lingual tonsillectomy. Four of these 49 patients developed OPS, for a complication rate of 8.2%. Three patients required pharyngoplasty (scar release, debulking of fibrotic tissue, and reorientation of the scar) and triamcinolone injections in the operating room. A fourth patient underwent simple scar release in the operating room. No patient who underwent lingual tonsillectomy alone or in combination with an additional procedure at the same level of the upper airway developed OPS. CONCLUSIONS Oropharyngeal stenosis is a potential complication of multilevel, single-stage upper airway surgery involving lingual tonsillectomy in children. Although there is pressure to perform multilevel procedures that address each site of upper airway obstruction in 1 sitting, this case series suggests the need for a more conservative, staged approach if lingual tonsillectomy is planned.

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.

Inhaled Cidofovir as an Adjuvant Therapy for Recurrent Respiratory Papillomatosis

A previously healthy, full-term, 4-month-old boy presented with progressively weakening cry, hoarseness, and increased work of breathing. Flexible fiberoptic laryngoscopy revealed glottic papillomas, which were endoscopically removed with a microdebrider in the operating room (Derkay score 23). The patient was diagnosed with recurrent respiratory papillomatosis that disseminated throughout his airway. Despite biweekly serial microdebridements, intralesional cidofovir, and systemic interferon-α, the patient’s health declined substantially (Derkay score 40), culminating in a 47-day hospitalization due to complications of his disease. Inhaled cidofovir was initiated after all conventional treatments had failed. Within 6 weeks of therapy (40 mg daily per treatment, 12 days on and 2 days off), the papillomatous disease improved substantially (Derkay score 23). While inhaled cidofovir appeared to significantly reduce papillomatous disease burden in this patient, further investigation into its long-term effectiveness and safety profile is necessary.

Improving Methods of Resident Selection

Applying the concept of the ACGME general competencies, it is possible to define the essential job objectives and competencies of a junior otolaryngology resident. The objective of this study is to incorporate commercially available tools of business in the identification of competencies specific to the junior otolaryngology resident and develop behavioral‐based interview questions and techniques designed to identify these qualities in candidates for residency.

Pediatric Tracheal Reconstruction Using Cadaveric Homograft

OBJECTIVE To examine the indications, risks, and surgical outcomes after tracheal reconstruction using cadaveric homograft in children. DESIGN Retrospective medical record review. SETTING Tertiary referral center. PATIENTS Ten children (4 boys and 6 girls). INTERVENTION Tracheal reconstruction using cadaveric homograft. MAIN OUTCOME MEASURES Cause of stenosis, number and type of procedures before homograft reconstruction, severity of preoperative stenosis, surgical approach, homograft length, duration of stenting, number and type of procedures after reconstruction, and rates of decannulation and survival. RESULTS Ten children (mean [SD] age, 8.4 [5.5] years) underwent 14 tracheal reconstructions using cadaveric homograft. Patients had an average of 7.0 (range, 1-16) procedures before homograft reconstruction, including an average of 2.8 (range, 0-6) major open airway reconstructions. Mean (SD) pretracheoplasty Myer-Cotton grade of stenosis was 3.80 (0.42) (range, 3-4), and all patients were tracheotomy dependent. A cervical approach was used in 12 reconstructions (86%), and 2 (14%) required median sternotomy. Mean (SD) homograft length was 3.9 (1.7) cm (range, 2-8 cm), which was approximately 0.60 times the length of the total recipient trachea. Mean (SD) duration of stenting for all homografts was 0.67 (0.46) years (range, 0.24-1.98 years). The survival rate was 90% after a mean follow-up of 5.47 (1.52) years (range, 3.32-7.55 years). Surviving patients required an average of 7.38 (5.52) procedures (range, 1-19) after homograft transplant, including an average of 1 major open airway reconstruction (range, 0-4). The mean (SD) grade of stenosis after the final homograft placement was 1.89 (1.27) (range, 1-4). Although the operation-specific decannulation rate was only 7% (1 of 14), the overall decannulation rate eventually reached 60%. Statistical bootstrapping methods and a multivariate regression model determined that increasing patient age (odds ratio, 1.21; 95% confidence interval, 1.07-1.36), increasing number of prior procedures (1.26; 1.02-1.57), and increasing homograft length (2.42; 1.60-3.40 [P < .001]) were associated with an increased risk of no decannulation after tracheal homograft reconstruction. CONCLUSIONS Tracheal reconstruction using cadaveric homograft is an option in children who have undergone multiple airway surgical procedures and present with long-segment stenoses that cannot be bridged using conventional methods. These patients must receive close postoperative follow-up. Subsequent procedures are almost always required before decannulation, and eventual decannulation rates are only 60%. Decannulation rates are lower in older patients who have previously undergone many procedures and require a long tracheal homograft.

Comprehensive Airway Management of Neonatal Head and Neck Teratomas

Objectives. To determine the success of initial airway management and to characterize late airway-related complications in patients with airway obstruction due to congenital head and neck teratomas Study Design. Case series with chart review. Setting. Tertiary airway referral institution. Subjects and Methods. Review of consecutive patients with congenital head and neck teratomas from 1988 to 2010. Variables examined include initial airway stabilization at time of birth and perinatal airway management. Outcomes include short- and long-term complications. Results. Fourteen cases were reviewed. In 12 patients, initial airway management was accomplished on placental support with either intubation or tracheotomy. Two vaginal births required subsequent uncomplicated oral intubation within 24 hours. Nine patients required tracheotomy (3 within the delivery suite, 2 during mass excision on day of life 6 and 24, and the remaining 4 occurred at days 29, 32, 92, and 100). Five deaths occurred, 4 within several days of birth due to complications related to the cervical teratomas and 1 on day of life 32 due to an airway-related complication. Follow-up for surviving patients ranged from 1 month to 18 years. Long-term airway complications ranged from vocal cord paralysis to stenosis requiring laryngotracheoplasty. Conclusion. This study demonstrates that a multidisciplinary team and a standardized approach in the operating suite have led to successful initial airway stabilization. Furthermore, this study demonstrates the need for continued airway management after delivery. Reassessment of the airway after delivery and an airway management planning meeting with the multidisciplinary team may help decrease morbidity and mortality.

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.