Short-term quality of life outcomes following pediatric septoplasty

CONCLUSIONS

Pediatric septoplasty may be associated with short-term symptomatic benefit. This benefit may be greater in female patients and equally achievable in young patients and using less invasive surgical approaches.

OBJECTIVE

To determine the short-term effect of pediatric septoplasty, which is not routinely performed, on sinus and nasal-specific quality-of-life.

METHODS

This study is a retrospective case series of 28 pediatric patients that underwent septoplasty. Pre- and post-septoplasty SN-5 overall (mean of all five items, range = 1-7) and visual analog scale (VAS; range = 0-10) scores were obtained and compared using a Wilcoxon signed-rank test. Comparisons of pre- to post-septoplasty changes by sex (female vs male), age (<13 vs ≥13 years), and surgical approach (open vs closed) were performed using a Mann-Whitney U-test. Median and interquartile range are reported.

RESULTS

Overall and VAS scores significantly improved from pre- to post-septoplasty (3.5 [2.8, 4.3] to 2.0 [1.4, 2.8], p < .001; 5.0 [4.0, 6.3] to 8.0 [8.0, 10.0], p < .001). Females reported significantly greater overall and VAS score improvements compared to males (-1.8 [-2.6, -1.6] compared to -1.0 [-1.6, -0.2], p = .01; 5.0 [4.0, 5.0] compared to 3.0 [1.5, 4.0], p = .007). Comparisons of changes by age and surgical approach were not significantly different.

Clinically small tonsils are typically not obstructive in children during drug-induced sleep endoscopy

OBJECTIVE

To determine whether the degree of lateral pharyngeal wall (LPW) obstruction on pediatric drug-induced sleep endoscopy (DISE) correlates with preprocedure tonsillar hypertrophy score on physical examination, and to determine if clinically small tonsils are obstructive.

METHODS

Retrospective review of 154 patients who underwent DISE at a single pediatric tertiary care center over a 4-year period. Inclusion criteria were documentation of Brodsky tonsil score on preoperative physical examination. Exclusion criteria were previous tonsillectomy, adenoidectomy, or adenotonsillectomy. Lateral pharyngeal wall obstruction was graded for each patient from 0 (no obstruction) to 3 (severe obstruction) using a validated pediatric DISE scoring system known as the Chan-Parikh scoring system (C-P). Data were analyzed using multivariate linear regression controlling for age at time of DISE and presence of comorbid conditions.

RESULTS

One hundred fifteen patients met criteria for analysis. Median age at DISE was 5.1 years. A moderate positive correlation was calculated between Brodsky score and DISE score, Spearman correlation coefficient 0.55, P = < 0.001. Linear regression modeling determined that for every 1-point increase in tonsil score, there was a 0.7-point increase in C-P LPW score (95% confidence interval [0.45, 0.92]). Sensitivity analysis did not detect a difference in correlation between children with comorbid conditions and children who were otherwise in good health. Of the 65 children with a pre-DISE Brodsky tonsil score of 1, 39 (60%) had a LPW score of 0 (no obstruction); nine (14%) had a score of 1 (< 50% obstruction); 11 (17%) had a score of 2 (> 50% obstruction); and six (9%) had a score of 3 (100% obstruction).

CONCLUSION

There is a positive correlation between Brodsky Score and DISE LPW score. The majority of children with sleep-disordered breathing with a Brodsky score of 1 did not demonstrate LPW obstruction. These children may benefit from DISE for identification of alternative sites of upper airway obstruction.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1943-1949, 2017.

Surgical outcomes and sleep endoscopy for children with sleep-disordered breathing and hypotonia

OBJECTIVE

To study the efficacy of surgical management for obstructive sleep apnea (OSA) syndrome in children with hypotonia, and to identify common anatomic sites of airway obstruction.

METHODS

Retrospective chart review of polysomnographic parameters and quality of life instrument scores for seventy eight children with hypotonia who underwent surgical intervention for sleep-disordered breathing at two tertiary children's hospitals, and analysis of drug-induced sleep endoscopy data using a previously validated scoring system.

RESULTS

Children undergoing surgical intervention had baseline severe OSA with a statistically significant improvement in apnea-hypopnea index from 23.6 to 11.1 after surgery, but persistent severe OSA. OSA-18 sleep-related quality of life measurement and overall quality of life score showed statistically and clinically significant improvements, from 72.0 to 43.4 and from 5.3 to 7.6 respectively. Sleep endoscopy showed an average obstructive score of 7.2/15 (n = 39), with multi-level obstruction in 49% of children. Greater than 50% obstruction was observed at the tongue base in 64% of patients, velum in 46%, lateral pharyngeal wall in 38%, supraglottis in 38%, and adenoid in 23%.

CONCLUSION

OSA syndrome is challenging to treat in hypotonic children. Severe residual OSA is common after surgical intervention, but improvement in quality of life is clinically and statistically significant. The tongue base is the most common site of persistent airway obstruction. Drug-induced sleep endoscopy can identify sites of airway obstruction and may aid in surgical planning for high-risk patients.

Factors Associated With Mortality in Pediatric vs Adult Nasopharyngeal Carcinoma

IMPORTANCE

Nasopharyngeal carcinoma (NPC) is endemic in some Asian regions but is uncommon in the United States. Little is known about the racial, demographic, and biological characteristics of the disease in pediatric patients.

OBJECTIVES

To improve understanding of the differences between pediatric and adult NPC and to determine whether race conferred a survival difference among pediatric patients with NPC.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included all 17 317 patients with a primary diagnosis of NCP in the National Cancer Data Base from January 1, 1998, to December 31, 2011. Of these, 699 patients were 21 years or younger (pediatric); 16 618 patients, older than 21 years (adult). Data were analyzed after data collection.

EXPOSURE

Pediatric age at diagnosis of NPC.

MAIN OUTCOMES AND MEASURES

Demographic, tumor, and treatment characteristics of pediatric patients with NPC were compared with those of adults using the χ2 test for categorical variables. An adjusted Cox proportional hazards regression model was used to examine survival differences in pediatric patients relative to adult patients. In addition, the risk for pediatric mortality by race was estimated.

RESULTS

Of the 17 317 patients, a total of 699 pediatric and 16 618 adult patients were identified with a primary diagnosis of NPC (female, 239 pediatric patients [34.2%] and 5153 adult patients [32.4%]). Pediatric patients were most commonly black (299 of 686 [43.6%]), whereas adults were most likely to be non-Hispanic white (9839 of 16 504 [60.0%]; P < .001). Pediatric patients were less likely to be Asian (39 of 686 [5.7%]) than were adults (3226 of 16 405 [19.7%]; P < .001). Pediatric patients were more likely to have regional nodal evaluation and to present with stage IV disease (227 of 643 [35.3%] and 330 of 565 [58.4%], respectively) than were adult patients (3748 of 15 631 [24.0%] and 6553 of 13 721 [47.8%], respectively; P < .001 for both comparisons). Pediatric patients had a lower risk for mortality relative to adults (hazard ratio, 0.37; 95% CI, 0.25-0.56). No difference in mortality by racial group was found among pediatric patients (hazard ratio, 1.10; 95% CI, 0.82-1.40).

CONCLUSIONS AND RELEVANCE

Pediatric patients with NPC were more commonly black and presented more frequently with stage IV disease. Pediatric patients had a decreased mortality risk relative to adults, even after adjusting for covariables. Asian race was not associated with increased mortality in pediatric patients with NPC. Racial differences are not associated with an increased risk for mortality among pediatric patients.

Airway Obstruction during Drug-Induced Sleep Endoscopy Correlates with Apnea-Hypopnea Index and Oxygen Nadir in Children

Objective

To determine if standardized intraoperative scoring of anatomic obstruction in children with obstructive sleep apnea correlates with the apnea-hypopnea index (AHI) and lowest oxygen saturation on preprocedural polysomnogram (PSG). A secondary objective was to determine if age, presence of a syndrome, or previous adenotonsillectomy affect this correlation.

Study Design

Case series with chart review.

Setting

Two tertiary care children’s hospitals.

Subjects

Patients with a preprocedural PSG who underwent drug-induced sleep endoscopy (DISE) over a 4-year period.

Methods

All DISEs were graded in a systematic manner with the Chan-Parikh (C-P) scoring system. AHI and nadir oxygen saturations were extracted from preprocedural PSG. Data were analyzed with a multivariate linear regression model that controlled for age at time of sleep endoscopy, syndrome diagnosis, and previous adenotonsillectomy.

Results

A total of 127 children underwent PSG prior to DISE: 56 were syndromic, and 21 had a previous adenotonsillectomy. Mean AHI was 13.6 ± 19.6 (± SD), and mean oxygen nadir was 85.4% ± 9.4%. Mean C-P score was 5.9 ± 2.7. DISE score positively correlated with preoperative AHI ( r = 0.36, P < .0001) and negatively correlated with oxygen nadir ( r = −0.26, P = .004). The multivariate linear regression models estimated that for every 1-point increase in C-P score, there is a 2.6-point increase in AHI (95% confidence interval: 1.4-3.8, P < .001) and a 1.1% decrease in the lowest oxygen saturation (95% confidence interval: –1.7 to −0.6, P < .001).

Conclusion

The C-P scoring system for pediatric DISE correlates with both AHI and lowest oxygen saturation on preprocedural PSG.

Bilateral Congenital Vocal Cord Paralysis: A 16-Year Institutional Review

Objective:

To review the management and outcome of bilateral congenital true vocal cord paralysis in 22 patients treated over a 16-year period and to review the role of tracheostomy in these patients.

Design:

Retrospective chart review.

Setting:

Pediatric tertiary hospital.

Patients:

Twenty-two pediatric patients diagnosed with bilateral congenital true vocal cord paralysis.

Interventions:

Flexible or rigid diagnostic evaluation, tracheostomy, and vocal cord lateralization procedures.

Main Outcomes Measures:

Vocal cord recovery and decannulation.

Results:

With a mean follow up of 50 months, 15 of 22 patients (68%) with bilateral vocal cord paralysis required tracheostomy for airway securement. Of the 15 tracheotomized patients, 10 were successfully decannulated (8 had spontaneous recovery, whereas 2 required lateralization procedures). Eleven of these patients with tracheostomy had comorbid factors, including neurologic abnormalities (midbrain/brainstem dysgenesis, Arnold-Chiari malformation, global hypotonia, and developmental delay). Of the 7 patients not requiring tracheostomy, 6 recovered vocal cord function (86%).

Conclusion:

In our series of 22 patients with bilateral vocal cord paralysis, 14 had spontaneous recovery of function. Patients managed with tracheostomy were noted to have a high incidence of comorbid factors. In this series, recovery rates were found to be higher in nontracheostomized patients than in tracheostomized patients. Patients can be carefully selected for observation versus tracheostomy at the time of diagnosis based on underlying medical conditions.

Validation of a new grading system for endoscopic examination of adenoid hypertrophy

Objective

To propose and validate a new subjective grading system of adenoid size with flexible fiberoptic evaluation.

Study Design and Setting

Digital video clips of 24 flexible fiberoptic nasopharyngeal exams were presented to 24 examiners (otolaryngology resident and consultant physicians) at a tertiary care institution. Examiners were asked to use the proposed grading system to rate adenoid hypertrophy. Kappa statistical analysis was used to evaluate the degree of intergrader agreement or disagreement.

Results

Statistical analysis of intergrader agreement demonstrated an overall Kappa score of 0.71 suggesting a “substantial” strength of agreement. The Kappa strength of agreement was found to be 0.83 (almost perfect) among consultant physicians and 0.62 (substantial) among resident physicians.

Conclusions

The proposed adenoid staging system is a reliable and consistent method of staging adenoid tissue size.

Significance

This new validated grading system may be a useful standard for reporting adenoid size in future clinical outcome studies.

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.

Supraglottoplasty for sleep endoscopy diagnosed sleep dependent laryngomalacia

OBJECTIVES

To evaluate the polysomnographic outcomes of supraglottoplasty (SGP) performed for sleep endoscopy diagnosed sleep dependent laryngomalacia as treatment for obstructive sleep apnea syndrome (OSAS).

METHODS

Nine subjects aged 6-55 months underwent supraglottoplasty for sleep dependent laryngomalacia. All subjects underwent both pre- and post-procedural polysomnograms.

RESULTS

Supraglottoplasty for sleep dependent laryngomalacia resulted in improvement of OSAS as measured by collective improvements in 8 different primary polysomnogram parameters: apnea-hypopnea index (AHI), minimum (nadir) and mean oxygen saturation, mean and maximum carbon dioxide, total sleep time, sleep efficiency, arousal index, as well as improvement in weight for length percentiles. Subjects had a significant 80% decrease in percentage change in AHI (p<0.005), with decrease in mean AHI from 23.4 to 4.8 following supraglottoplasty. Seven of 9 subjects demonstrated improvement in nadir saturations, 6 of 9 subjects had improvement in sleep efficiency, and 7 of 8 subjects under 4 years of age had improvement in weight for length percentile.

CONCLUSIONS

Supraglottoplasty for sleep dependent laryngomalacia is an effective treatment of OSAS, and can be readily diagnosed using sleep endoscopy. Further investigation is warranted to increase awareness and outcomes related to sleep dependent laryngomalacia.

Nasoseptal flap reconstruction of pediatric sellar defects: a radiographic feasibility study and case series

OBJECTIVES

In this study, we used computed tomography measurements to investigate the feasibility of nasoseptal flap reconstruction of sellar defects in children, and we reviewed our institutional experience with the procedure.

STUDY DESIGN

Cross-sectional and case series.

SETTING

Pediatric tertiary care facility.

METHODS

We obtained 10 normal maxillofacial scans for each year of age from birth to 18. Computer-assisted nasal and skull-base measurements were performed. Patients with incomplete pneumatization were excluded from analysis. Reconstruction was presumed feasible if the ratio of nasoseptal flap length to associated sellar defect length was greater than 1. Chart review identified surgical patients.

RESULTS

Of 190 scans, 125 had complete pneumatization. Of these, 120 (96%) displayed a ratio of nasoseptal flap length to sellar defect length greater than 1, suggesting that reconstruction would be feasible. Mean ratio of flap length to defect length for all subjects was 1.47 (SD 0.33; 95% CI, 1.41-1.53). Only 5 of 125 patients (4%) had a ratio less than 1; the median age for these patients was 15 years, which is older than the median age of 12 years for subjects with a ratio greater than 1 (P = .02). An inverse relationship was identified between age and ratio of flap length to defect length (r = -0.49, P < .001). Case series identified 6 children, ages 5 to 17; flap length was never described as a limitation.

CONCLUSIONS

Nasoseptal flap length is not a limiting factor for reconstruction of pediatric sellar defects. When compared with older patients, younger patients tend to have greater nasoseptal flap length relative to sellar defect length.

A new scoring system for upper airway pediatric sleep endoscopy

IMPORTANCE

Sleep-associated upper-airway obstruction in children is a significant cause of morbidity. Development of a simple, standardized, quantitative technique to assess anatomic causes of sleep-related breathing disorder is important for surgical planning, clinical communication, and research.

OBJECTIVE

To design, implement, and evaluate a scoring system to quantify airway obstruction in pediatric drug-induced sleep endoscopy.

DESIGN, SETTING, AND PARTICIPANTS

This study was a retrospective case series conducted at a tertiary pediatric hospital. The patients were children with sleep-related breathing disorder who underwent polysomnography and drug-induced sleep endoscopy.

INTERVENTIONS

Flexible fiber-optic laryngoscopy was performed. Endoscopic examinations were recorded on video and assessed by 4 independent raters based on a scoring template.

MAIN OUTCOMES AND MEASURES

Five locations in the upper aerodigestive tract (adenoid, velum, lateral pharyngeal wall, tongue base, and supraglottis) were evaluated on a 4-point scale for minimum and maximum obstruction. Internal reliability was assessed by calculating interrater and intrarater intraclass correlation coefficients (ICCs). For external validation, aggregate and site-specific scores were correlated with preoperative polysomnographic indices.

RESULTS

Videos recorded of sleep endoscopies from 23 children (mean age, 2.2 years) were reviewed and rated. Children had an average apnea-hypopnea index of 24.8. Seventy percent of interrater and intrarater ICC values (7 of 10 for each set) were above 0.6, demonstrating substantial agreement. Higher total obstructive scores were associated with lower oxygen saturation nadir (P = .04). The scoring system was also used to quantitatively identify children with multilevel airway obstruction, who were found to have significantly worse polysomnographic indices compared with children with single-level obstruction (P = .02).

CONCLUSIONS AND RELEVANCE

The proposed scoring system, which is designed to be easy to use and allow for subjectivity in evaluating obstruction at multiple levels, nonetheless achieves good internal reliability and external validity. Implementing this system will allow for standardization of reporting for sleep endoscopy outcomes, as well as aid the practicing clinician in the interpretation of sleep endoscopy findings to inform site-directed surgical intervention in cases of complicated obstructive sleep apnea.

New Concepts in Pediatric Otolaryngology: A Video Forum

Program Description:

In this state-of-the-art miniseminar, 7 experts will share video-based examples of new ideas in pediatric otolaryngology. New knowledge, techniques, and outcomes for emerging concepts will be discussed while ample opportunity for audience questions and answers will be provided. Steven L. Goudy: endoscopic-assisted pharyngeal surgery. Christopher J. Hartnick: optical coherence tomography in the operating room; differentiating cysts from nodules. Sanjay R. Parikh: drug-induced sleep endoscopy: technique and findings. Soham Roy: mechanical models of operating room airway fires. Michael J. Rutter: slide tracheoplasty for difficult tracheoesophageal fistula. David R. White: a new understanding of congenital nasal stenosis. Carlton J. Zdanski: transoral robotic surgery: pearls and pitfalls.

Educational Objectives:

(1) Characterize novel ideas for pediatric airway surgery techniques and concepts. (2) Prevent airway fires during surgery. (3) Practice novel techniques for understanding pediatric sleep apnea evaluation.

Nasoseptal Flap Reconstruction of Pediatric Sellar Defects: A Radiographic Feasibility Study

Objectives:

Computed tomography (CT) measurements were used to investigate the feasibility of performing vascularized nasoseptal flap reconstruction of sellar defects in children.

Methods:

Ten CT scans from children of each year of age from birth to 18 were obtained for 190 total subjects. Patients with incomplete pneumatization were excluded from analysis. Measurements of nasoseptal flap and sellar defect length were obtained for each subject using OSIRIX radiology software. Reconstruction was presumed feasible if the ratio of nasoseptal flap length to associated sellar defect length was greater than 1.

Results:

Of the 190 CT studies, 125 displayed complete pneumatization. Of these, 120 (96%) displayed a ratio of nasoseptal flap length to sellar defect length greater than 1, suggesting feasibility of flap reconstruction. Mean ratio of nasoseptal flap length to sellar defect length for all subjects was 1.47 (SD = 0.33) with 95% CI [1.41, 1.53]. Only 5 patients (4%) had inadequate nasoseptal flaps; mean age for these patients was 14.8 years (SD = 2.9), which is older than mean age of 11.6 years (SD = 4) for subjects with adequate measurements. The mean age difference did not meet significance with t-test ( P = .069), likely due to the small number of patients with inadequate flaps. An inverse relationship was identified between age and ratio of nasoseptal flap length to sellar defect length (Pearson correlation coefficient –0.49).

Conclusions:

Flap length is not a limiting factor in nasoseptal flap reconstruction of sellar defects in children. Younger patients have higher ratios of nasoseptal flap length to sellar defect length than older patients.

Board of Governors’ Hot Topic 2014: Will Fee for Service Survive?

Program Description:

On the hinge of health care reform, the Board of Governors’ (BOG’s) 2014 hot topic is: will fee for service survive? Expert panelists, consisting of American Academy of Otolaryngology—Head and Neck Surgery presidents, BOG chairs, and physician payment and policy workgroup members, will discuss if fee for service will be superseded by payments based on work relative value units, quality measures, hospital employment, and bundled payments. Presentations will be made on current and past payment structures, bundled payments, quality metrics, and the sustainability of private practice. Time for interaction between the audience and panelists will be ensured through a final round table discussion.

Educational Objectives:

(1) Describe the history of fee for service and how it has changed in the past 10 years. (2) Relate the impact of health care reform on current and future payment systems. (3) Recognize the challenges private practice will have with new reimbursement models.

Interarytenoid Sodium Carboxymethylcellulose Gel Injection for Management of Pediatric Aspiration

Objective:

This study aimed to investigate the role of interarytenoid injection laryngoplasty (IL) for the management of pediatric aspiration.

Methods:

Medical records of 30 patients, 9 female, with radiographically confirmed chronic aspiration who underwent intraoperative IL were retrospectively reviewed. Clinical improvement was defined as successful advancement of feeds to thinner consistencies.

Results:

Clinical improvement was observed in 57% of patients. Six children with type 1 posterior laryngeal cleft (PLC-1) were not significantly more likely to show improvement compared to the children without PLC-1. Type 1 posterior laryngeal cleft was associated with older age and higher prevalence of neurodevelopmental risk factors relative to absence of PLC-1. Patients with PLC-1 were more likely than noncleft patients to show recurrence of symptoms after initial improvement with IL. Five patients underwent endoscopic repair. Repair was successful in 3 patients who improved after IL but not in 2 patients who did not improve after IL.

Conclusion:

Chronic aspiration can improve after IL even in patients with normal anatomy. Injection laryngoplasty can be performed to improve selection of PLC-1 patients for definitive endoscopic repair. Further prospective research, with a randomized control group, is needed to understand whether interarytenoid incompetence plays a role in some patients with chronic aspiration, who do not have a PLC-1.

Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children

OBJECTIVES/HYPOTHESIS

To evaluate the risk of post-tonsillectomy hemorrhage associated with perioperative ketorolac use.

STUDY DESIGN

Systematic review and meta-analysis of primary articles reporting individual-level post-tonsillectomy hemorrhage rates in subjects receiving perioperative ketorolac and matched controls. Retrospective and prospective studies were both included.

METHODS

PubMed search was performed for "[ketorolac OR toradol] AND tonsillectomy." Articles fulfilling inclusion criteria were subjected to meta-analysis to determine summary relative risk (RR).

RESULTS

Adults are at five times increased risk for post-tonsillectomy hemorrhage with ketorolac use (RR: 5.64; 95% confidence interval [CI]: 2.08-15.27; P < .001). In contrast, children under 18 are not at statistically significantly increased risk (RR: 1.39; 95% CI: 0.84-2.30; P = .20). Both retrospective and prospective studies yield consistent findings. There is no association of RR with pre- or postoperative administration of ketorolac.

CONCLUSIONS

Ketorolac can be used safely in children, but is associated with a five-fold increased bleeding risk in adults.