Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

Otitis Media Practice During the COVID-19 Pandemic.

The global coronavirus disease-2019 (COVID-19) pandemic has changed the prevalence and management of many pediatric infectious diseases, including acute otitis media (AOM). Coronaviruses are a group of RNA viruses that cause respiratory tract infections in humans. Before the COVID-19 pandemic, coronavirus serotypes OC43, 229E, HKU1, and NL63 were infrequently detected in middle ear fluid (MEF) specimens and nasopharyngeal aspirates in children with AOM during the 1990s and 2000s and were associated with a mild course of the disease. At times when CoV was detected in OM cases, the overall viral load was relatively low. The new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative pathogen responsible for the eruption of the COVID-19 global pandemic. Following the pandemic declaration in many countries and by the World Health Organization in March 2020, preventive proactive measures were imposed to limit COVID-19. These included social distancing; lockdowns; closure of workplaces; kindergartens and schools; increased hygiene; use of antiseptics and alcohol-based gels; frequent temperature measurements and wearing masks. These measures were not the only ones taken, as hospitals and clinics tried to minimize treating non-urgent medical referrals such as OM, and elective surgical procedures were canceled, such as ventilating tube insertion (VTI). These changes and regulations altered the way OM is practiced during the COVID-19 pandemic. Advents in technology allowed a vast use of telemedicine technologies for OM, however, the accuracy of AOM diagnosis in those encounters was in doubt, and antibiotic prescription rates were still reported to be high. There was an overall decrease in AOM episodes and admissions rates and with high spontaneous resolution rates of MEF in children, and a reduction in VTI surgeries. Despite an initial fear regarding viral shedding during myringotomy, the procedure was shown to be safe. Special draping techniques for otologic surgery were suggested. Other aspects of OM practice included the presentation of adult patients with AOM who tested positive for SARS-2-CoV and its detection in MEF samples in living patients and in the mucosa of the middle ear and mastoid in post-mortem specimens.

Acute pediatric tracheitis: Distinguishing the disease by tracheostomy status.

OBJECTIVES: Tracheitis is an upper airway infection that often presents in patients with tracheostomies and can potentially cause airway obstruction. This study aims to use a nationwide database to identify a large cohort of pediatric patients admitted with tracheitis to elucidate the management and resource utilization associated with the disease both with and without tracheostomies. METHODS: The Kids' Inpatient Database (KID) 2012 was used to identify 2394 weighted discharges with acute tracheitis, with or without obstruction, as the primary diagnosis. Data on prior tracheostomy status, demographics, hospital characteristics, management, and resource utilization were obtained. Two groups of interest, based on presence of prior tracheostomy, were studied. Linear regression was performed to determine independent predictors of total charges. RESULTS: The mean age was 5.52 years (SD: 5.54), mean length of stay (LOS) was 6.37 days (SD: 10.18), and mean total charges were $60,996.61 (SD: 107,798.41). Patients with prior tracheostomy had lower rates of endoscopy and endotracheal intubation than patients without (p < 0.0005). There was no significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups based on prior tracheostomy status. CONCLUSION: Pediatric tracheitis should be differentiated on the basis of tracheostomy status. We propose that tracheitis diagnosis codes should be distinguished by the presence of tracheostomy as "open" and the absence of tracheostomy as "closed."

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric tracheotomy. STUDY DESIGN: Blinded, modified, Delphi consensus process. METHODS: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items. RESULTS: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus. CONCLUSIONS: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:2700-2707, 2020.

General anesthesia risk across pediatric surgical specialties: Low in otolaryngology.

PURPOSE: To determine the relevance of the Food and Drug Administration (FDA) warning regarding general anesthesia (GA) in children under 3 years of age for procedures lasting longer than 3 h, by surgical specialty and for otolaryngology specifically. METHODS: A one-year retrospective review was conducted at a tertiary-care medical center for all children younger than 3 years undergoing surgical procedures with durations greater than 3 h. De-identified data related to age, surgical service, procedure types, American Society of Anesthesiologists (ASA) physical status classification, and general anesthesia time were collected and examined. RESULTS: During 2017, 430 of 11,757 patients (3.7%) met the age and duration of anesthesia criteria. Procedures performed by the cardiothoracic surgery service were mostly likely to result in duration of surgery greater than 3 h (46.6%), followed by neurosurgery (12.9%), cardiology (9.3%), plastic surgery (7.1%), general surgery (6.6%), and urology (5.1%). Less than 2% of patients undergoing ophthalmology (1.9%), orthopedic surgery (1.7%), and otolaryngology (0.5%) procedures required anesthesia greater than 3 h. CONCLUSION: Less than 4% of patients younger than 3 years undergoing surgery required general anesthesia for longer than 3 h. The theoretical risks of general anesthesia per the FDA warning are discussed and must be balanced against the known functional and neurodevelopmental consequences of not performing critical and time-sensitive surgery on children in this age group. A strategy for addressing parental and provider concerns is discussed.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Post-transplant lymphoproliferative disease of the larynx.

Laryngeal post-transplant lymphoproliferative disease (PTLD) is rare. Here, we describe two pediatric cases. The first, a 15-month-old who underwent liver transplantation at 5 weeks, presented with airway distress. Airway evaluation identified epiglottic and arytenoid infiltrate, and biopsy was consistent with polymorphic PTLD. The second, a 23-month-old who underwent liver transplantation at 13 months, presented with progressive stridor. Airway evaluation revealed sub-mucosal infiltrate of the epiglottis, arytenoids, post-cricoid region, and uvula. Biopsy was consistent with monomorphic PTLD. Airway findings and symptoms resolved for both after immunosuppression reduction. PTLD diagnosis requires a high index of suspicion in post-transplant patients with airway obstruction.

Dyskeratosis Congenita and Oral Cavity Squamous Cell Carcinoma: Report of a Case and Literature Review.

Dyskeratosis congenita is a rare genetic condition of telomerase dysfunction in which patients are at an increased risk of squamous cell carcinoma (SCCa) of the oral cavity. We present here the youngest patient in the literature with a diagnosis of SCCa. We discuss the literature and management of this advanced presentation of SCCa in a child, stressing the importance of palliative care involvement in facilitating medical decision making.

Palliation in pediatric otorhinolaryngology.

Palliation in pediatric otorhinolaryngology is a rarely discussed but important aspect of care. This review encapsulates current thinking on pediatric palliative care (PC) and demonstrates, through one case, the impact of integrating PC into clinical care. We encourage early consideration of pediatric palliative care approaches for children with complex otorhinolaryngologic disorders.

Risk factor analysis for mortality among infants requiring tracheostomy.

INTRODUCTION: An increasing number of tracheostomies are performed in infants with complex comorbidities including bronchopulmonary dysplasia (BPD) and congenital heart disease (CHD). With this shift in indications, there is an urgent need to characterize outcomes in this population. METHODS: This 5-year retrospective chart review assessed rates of 12-month mortality in infants who were ≤12 months of age at the time of tracheostomy at a tertiary care pediatric hospital and risk factors associated with death. Patient characteristics evaluated included chronologic age and post-menstrual age at tracheostomy placement, gestational age and weight, sex, ethnicity, indication for tracheostomy, and comorbidities including BPD, CHD, subglottic stenosis (SGS), craniofacial syndromes, and chromosomal trisomy syndromes. Subgroup analysis was performed in infants with CHD. RESULTS: One hundred thirty-two tracheostomies were performed during the study period with an overall 12-month mortality of 14.4% (19/132). Mortality was increased in patients with CHD (35%) and decreased in patients with SGS (3.7%). No other patient characteristics were associated with differences in mortality. There was a trend towards improved mortality outcomes among patients born at earlier gestational ages. CONCLUSIONS: Among infants with tracheostomy in this cohort, overall mortality rates were relatively low but not insignificant. CHD was associated with increased mortality; however, children with SGS showed more favorable outcomes. Other patient characteristics were not associated with differences in mortality. These data clarify outcomes in a group of infants with tracheostomy.

Implementation of a Web-Based Provider Care Team System at the VA North Texas Health Care System.

Concern that our Department of Veterans Affairs (VA) suffers low relational coordination led us to seek a system that might improve domains of relational coordination. The lack of an accurate system to identify the physician caring for a patient at any given time was a ready target. We conducted forward effect analysis, a novel methodology we adapted from our shared experience in software development and entrepreneurship. This study sought to implement a Web-based patient care team system in the critical care units at the VA North Texas Health System. Surveys were distributed to nurses before and after the intervention. Nursing confidence in the system improved from a median of 40% to 70%, and median satisfaction improved from 20% to 80%. Forty percent of nurses believed the old paging system resulted in harm to patients, compared with none with the new paging system. This study demonstrates technical and organizational implementation of a paging system as a two-sided platform with the ability to improve relational coordination between these sides.

Stomal maturation does not increase the rate of tracheocutaneous fistulas.

OBJECTIVES/HYPOTHESIS: To determine the rate of persistent tracheocutaneous fistula (TCF) in pediatric patients managed with stomal maturation at the time of the tracheostomy. STUDY DESIGN: Retrospective chart analysis of all cases of tracheostomy performed at a tertiary pediatric care center between 2001 and 2011. METHODS: The use of stomal maturation, number of decannulations, number of persistent TCFs, timing of TCF repair, and the overall mortality were assessed. RESULTS: A total of 264 patients received tracheostomy between 2001 and 2011. Of the total, 173 (66%) underwent stomal maturation. Of those 173 patients, 89 patients (51% of maturation group) underwent planned decannulation. Forty seven (53%) of the 89 decannulated were found to have a persistent TCF in the stomal maturation group. These were diagnosed an average of 1.3 years (range, 4-43 months) after decannulation. Of the 91 patients (34% of the total) who did not undergo stomal maturation, 44 (48% of nonmaturation group) underwent planned decannulation. Twenty of the 44 patients decannulated (45%) were diagnosed with a residual TCF 8 to 28 months later. Both groups achieved similar rates of decannulation (51% maturation vs. 48% non-maturation [P = .80]) and TCF (27% maturation vs. 22% non-maturation [P = .44]). Overall, mortality rates were (32/173) 18% (matured) versus (26/91) 29% (nonmatured). No mortalities were tracheostomy related. The mean (standard deviation) time from operation to TCF closure among those with TCF was 4.0 (1.9) years. CONCLUSIONS: Comparable rates of persistent TCF with stomal maturation (27%) and without maturation (22%) were found in this single institution's 10-year experience. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2395-2398, 2016.

Complications Following Pediatric Tracheotomy.

IMPORTANCE: Pediatric tracheotomy is a complex procedure with significant postoperative complications. Wound-related complications are increasingly reported and can have considerable impact on clinical course and health care costs to tracheotomy-dependent children. OBJECTIVE: The primary objective of this study was to identify the type and rate of complications arising from pediatric tracheotomy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of medical records of 302 children who underwent tracheotomy between December 1, 2000, and February 28, 2014, at a tertiary care pediatric referral center. Records were reviewed for preoperative diagnoses, gestational age, age at tracheotomy, tracheotomy technique, and incidence of complication. MAIN OUTCOMES AND MEASURES: Main outcome measures included incidence, type, and timing of complications. Secondary measures included medical diagnoses and surgical technique. RESULTS: Of the 302 children who underwent tracheotomy, the median (SD) age at time of tracheotomy was 5 months (64 months) and the range was birth to 21 years. The most frequent diagnosis associated with performance of a tracheotomy was ventilator-associated respiratory failure (61.9%), followed by airway anomaly or underdevelopment (25.2%), such as subglottic or tracheal stenosis, laryngotracheomalacia, or bronchopulmonary dysplasia. The remaining indications for tracheotomy included airway obstruction (11.6% [35 of 302]) and vocal fold dysfunction (1.3% [4 of 302]). No statistical significance was found associated with diagnosis and incidence of complications. Sixty children (19.9%) had a tracheotomy-related complication. Major complications, such as accidental decannulation (1.0% [3 of 302]). There were no deaths associated with tracheotomy. Minor complications, such as peristomal wound breakdown or granuloma (12.9% [39 of 302]) and bleeding from stoma (1.7% [5 of 302]), were more common. Of all complications, 70% (42 of 60) occurred early (≤7 days postoperatively) and 20% (12 of 60) were late (>7 days postoperatively). CONCLUSIONS AND RELEVANCE: Pediatric tracheotomy at our institution is associated with an overall 19.9% incidence of complications. Although the rate of major complications such as accidental decannulation or death is low, rates of peristomal skin breakdown and development of granuloma are more frequently reported and can occur at any point following tracheotomy. Further work is necessary to understand and mitigate wound care issues in post-tracheotomy care.

Pediatric foreign body aspiration: A nidus for Aspergillus colonization.

We describe an immunocompetent child with bronchial fungus following foreign body aspiration. A two-year-old male presented with cough. Workup revealed air trapping and bronchoscopy showed aspirated foreign material in the right mainstem bronchus. Histopathology revealed fungal organisms suggestive of Aspergillus within an ulcer of the adjacent bronchial mucosa. Foreign body aspiration has been posited as a nidus for aspergilloma formation but is not yet described in the available English-language pediatric literature. Here, the foreign body provided a site for fungal growth in the bronchus of an otherwise healthy child. This case suggests that bronchial foreign body may pose risk of fungal colonization even in immunocompetent children.

Tracheotomy after laryngotracheoplasty: risk factors over 10 years. [Corrected].

BACKGROUND: Subglottic stenosis (SGS) is the most common congenital and/or acquired laryngotracheal anomaly requiring tracheotomy in infants. We sought to determine factors associated with a greater likelihood of tracheotomy in symptomatic infants with SGS who underwent laryngotracheoplasty (LTP). METHODS: Retrospective case series with chart review of patients undergoing single-stage LTP for SGS over a 10-year period (2001-2010) in a tertiary-care pediatric hospital. RESULTS: Twenty-two children (15 boys, 7 girls), with a mean gestational age of 32.5weeks, underwent LTP with and without interpositional grafting, at a median age of 89days. Ten patients (43%) required postoperative tracheotomy. Of patients weighing <2.5kg, 7 of 8 eventually required tracheotomy, while none weighing >5kg needed tracheotomy (p=0.003). The average length of stay for patients with a tracheotomy was 125days, while those without tracheotomy required only 58days (p=0.011). The grade of SGS (p=0.809), gender (p=0.968), age at surgery (p=0.178), and gestational age (p=0.117) were not significantly associated with the need for tracheotomy. Weight at surgery was significantly correlated with the likelihood of needing tracheotomy (p=0.003). CONCLUSIONS: Patients who weighed less than 2.5kg at the time of LTP procedures were more likely to require a postoperative tracheotomy. Children who required tracheotomy had longer lengths of hospital stay.

Risk factors associated with postoperative tympanostomy tube obstruction.

IMPORTANCE: Myringotomy and tympanostomy tube placement for chronic otitis media with effusion is the most common reason for a child to undergo anesthesia in the United States. Postoperative tube obstruction occurs in 1.4% to 36.0% of cases and remains a challenge in achieving middle ear ventilation. OBJECTIVE: To identify risk factors associated with tube obstruction. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 248 patients, mean age 2.54 years, seen between March 2007 and June 2011 in a tertiary care pediatric hospital. INTERVENTIONS: Tympanostomy tube placement and postoperative otic drop therapy. MAIN OUTCOMES AND MEASURES: Tube patency at postoperative visit, number of tube removals and revisions, age, sex, body mass index (BMI), middle ear fluid type at time of surgery, and time between surgery and first postoperative visit were examined. Type of surgery (tympanostomy tube placement alone, adenoidectomy + tympanostomy tube placement, tympanostomy tube placement + adenoidectomy + tonsillectomy) and its effect on tube patency were also reviewed. RESULTS: At first follow-up, 10.6% of patients had occlusion of one or both tubes. No significant association was found between tube patency and a patient's BMI percentile, sex, or procedure type. Patients with no middle ear fluid were more likely to have patent tubes than those who had serous fluid (odds ratio [OR], 3.5; 95% CI, 1.2-10.6; P = .02). A significant inverse correlation was found between patency and time between surgery and follow-up in that patients who had longer follow-up after surgery were less likely to have patent tubes (OR per day of follow-up delay, 0.990; 95% CI, 0.981-0.999; P = .01). CONCLUSIONS AND RELEVANCE: Tympanostomy tube obstruction was seen in 10.6% of patients. Serous fluid and increased time to postoperative visit were statistically significant indicators for tube occlusion.

Resource analysis of tonsillectomy in children.

OBJECTIVES/HYPOTHESIS: To analyze variables that affect time and cost parameters of pediatric adenotonsillectomy. STUDY DESIGN: Longitudinal 7-month retrospective review of sequential tonsil and adenoid surgery at a university pediatric tertiary care hospital. METHODS: All children aged 2 to 12 years who underwent adenotonsillectomy from May 2008 to October 2008 had charts and billing records analyzed for variations in charges and times of adenotonsillectomy according to patient age, body mass index for age (BMIFA), American Society of Anesthesiologists (ASA) status, surgical indication, technology used, and teaching status of case. A total of 214 children had records reviewed. RESULTS: Statistically significant variations were observed for all measured parameters except for indications for surgery. Children 3 years and younger had shorter procedures (P = .005) and total operating room times (P = .037). Charges for supplies were lower for ASA 1 patients than for ASA 2 patients (P = .010). Obese children with elevated BMIFA required longer procedures (P = .039) and more expensive surgery (P = .003). Procedure times were shorter for Coblation (ArthroCare, Austin, TX) compared with electrocautery (P = .27) and for microdebrider compared with electrocautery (P < .001). Charges for Coblation were substantially higher (P < .001). Teaching cases took longer (P < .001). CONCLUSIONS: Charges and times for adenotonsillectomy surgery varied by patient age, BMIFA, ASA status, tonsillectomy technique, and teaching case status. Clinically salient differences were noted for ASA status, BMIFA, and surgical technique. This method of cost analysis provides useful information for resource management in tonsillectomy.

Castleman disease in the pediatric neck: a literature review.

OBJECTIVE: To investigate the common features of cervical pediatric Castleman disease. DATA SOURCES: Literature review of pediatric patients with cervical Castleman disease. REVIEW METHODS: Online medical journal databases were searched for patients aged 18 years or younger. Eighteen published studies were found, comprising 29 patients. CONCLUSIONS: An asymptomatic or slowly enlarging neck mass was the most common presentation. No sex differences were noted. Magnetic resonance imaging demonstrates a homogeneous, isointense to slightly hyperintense T1-weighted signal and high signal intensity on T2-weighted imaging. Lymphoma was the most common differential diagnosis. All patients were treated with complete surgical excision and diagnosed as hyaline-vascular type on histology, except for 1 patient for whom histologic type was not reported. No reports of multicentric disease, plasma cell, or mixed histology were found. No recurrences were reported. IMPLICATIONS FOR PRACTICE: In this article, we provide the largest known literature review of pediatric patients with cervical Castleman disease. Although Castleman disease is rare, it should be considered on the differential for a pediatric neck mass, particularly when presenting with an asymptomatic posterior neck mass and equivocal workup. Fortunately, our study suggests that if diagnosed as Castleman disease, the most likely diagnosis is hyaline-vascular type, for which the long-term prognosis is good. Surgical excision is both diagnostic and therapeutic.