Christopher J. Hartnick

Introduction: Mortality among intubated children in public pediatric intensive care units (PICUs) in lowand middle-income countries remains high, driven in part by gaps in workforce training, team coordination, and standardized processes. We evaluated a low-cost, multidisciplinary digital education and team-based quality-improvement (QI) intervention—a multilingual online curriculum, telesimulationbased team training, standardized airway and handoff workflow tools, and on-site visits—in the PICU of a public pediatric hospital in Cartagena, Colombia. Methods: In this single-center pre–post QI study, we included all intubated patients (<18 years) admitted to the PICU of Casa del Niño during a baseline period (1 October 2023–30 April 2024), a washout period of near-complete nursing turnover (1 April–30 June 2025), and a post-intervention period (1 July–22 October 2025). The primary outcome, 30-day all-cause mortality, was analyzed by multivariable logistic regression adjusted for age, sex, and the logit of Pediatric Index of Mortality 3 (PIM3)-predicted mortality, calculated without diagnosis-risk terms for all patients because these were not recorded for later patients, supplemented by additional case-mix adjustment, an interrupted time-series analysis of all 272 intubated patients admitted between October 2023 and October 2025 (with the implementation period also modeled as a separate transition segment), and sensitivity analyses. Cost-effectiveness was explored as incremental cost per death and per disability-adjusted life-year (DALY) averted. Results: Of 144 patients analyzed (95 pre-intervention; 49 post-intervention), age, sex, and median PIM3 were similar between periods, but mean PIM3-predicted mortality was twice as high before the intervention (10.7% versus 5.3%), reflecting 10 pre-intervention patients with bilaterally fixed pupils (none after). All-cause mortality was 28.4% before and 10.2% after the intervention (risk difference −18.2 percentage points, 95% confidence interval [CI] −29.6 to −4.1; relative risk 0.36, 95% CI 0.15–0.87; adjusted odds ratio 0.26, 95% CI 0.09–0.77). PIM3 under-predicted mortality in both periods (standardized mortality ratio 2.68 and 1.94, respectively). Findings were consistent in case-mix-adjusted analyses and in interrupted time-series analysis with implementation modeled as a separate transition segment (level-change odds ratio 0.24, 95% CI 0.07–0.82). Mortality was higher during implementation (35.9%) than at baseline (27.6%), which was not explained by measured severity of illness. Under the most conservative assumptions (the entire 5-year program cost attributed to the approximately two deaths averted when expected deaths were estimated with PIM3, with 3% discounting), the intervention cost up to approximately US$4,800 per DALY averted, below Colombia’s gross domestic product per capita but above half of it; less conservative scenarios gave lower estimates. Discussion: Implementation of this program was associated with lower mortality among intubated children in one public Colombian PICU. Given the single-center, non-randomized design, small sample, and imperfect severity adjustment, these findings require confirmation in controlled multisite evaluations, for which we provide an implementation protocol.

Objective: To report institutional outcomes in pediatric suprastomal collapse and to describe a structured, phenotype‐directed diagnostic and surgical management framework grounded in dynamic airway assessment and morphology‐based operative selection. ^7,19 Study Design: Retrospective cohort study. Setting: Tertiary pediatric airway reconstruction center. Methods: Consecutive pediatric patients undergoing operative correction of suprastomal collapse between December 2020 and July 2024 were reviewed. All patients underwent rigid bronchoscopy followed by dynamic flexible bronchoscopy after tracheostomy tube removal. Collapse was classified as anterior, posterior, lateral, or combined according to dynamic behavior, segment length, and cartilage integrity. Operative intervention was selected based on phenotype and structural characteristics. The primary outcome was successful decannulation. Results: Twenty‐five patients underwent 28 procedures. Mean age at first intervention was 6.3 years (range 0.8‐21.2 years). Anterior or combined collapse was present in 18 patients and treated with primary anterior closure (n = 5), anterior external bioresorbable stent reinforcement (n = 4), tracheal resection and reconstruction (n = 7), or slide tracheoplasty (n = 2); all were successfully decannulated. Posterior collapse (n = 4) treated with posterior external stent tracheopexy achieved 75% decannulation. Lateral collapse (n = 3) treated with vertical external stenting achieved 100% decannulation. Overall decannulation success was 92%. Conclusion: Suprastomal collapse represents a heterogeneous spectrum of localized airway instability rather than a uniform pathologic entity. Phenotype‐directed operative selection based on dynamic bronchoscopic classification is associated with favorable decannulation outcomes and offers a reproducible framework for surgical decision‐making.

We present the case of a 2-year-old male with persistent oropharyngeal dysphagia and recurrent aspiration. Feeding difficulties began in the neonatal period, characterized by coughing, wet cry, choking, and cyanosis during feeds. Multiple hospitalizations followed, and flexible endoscopic evaluation of swallowing (FEES) showed mobile vocal folds and pharyngeal pooling and silent aspiration with various consistencies, alongside absent swallow initiation. Videofluoroscopic swallowing studies (VFSS) demonstrated ongoing penetration and aspiration, with contrast coating both, anterior and posterior tracheal wall during pharyngeal phase, leading to gastrostomy placement. What mechanisms might explain persistent severe dysphagia in this child, and what therapeutic strategies could be considered?

Objectives: Severe tracheomalacia in children is challenging to manage, and surgical options ranging from tracheostomy to posterior tracheopexy has been performed for treatment of posterior tracheomalacia, with their associated morbidities. The role of posterior external stent tracheopexy (PEXY) has not been established, and we report our experiences in treatment of severe posterior tracheomalacia using PEXY.Methods: A retrospective review of our case series of three pediatric patients with severe posterior tracheomalacia who underwent PEXY.Results: Between August 2024 and December 2024, three patients received PEXY. Using bioresorbable external plates as posterior stents, the posterior tracheal myomembrane was sutured to the external stent instead of the anterior longitudinal spinal ligament, minimizing the risk associated with injury of surrounding structures typically encountered during mobilization for spinal ligament access, such as the thoracic duct and esophagus. There were no reported injuries intra‐operatively to the recurrent laryngeal nerves and esophagus, and all patients were discharged home within a week after their first post‐operative bronchoscopy. All patients reported symptomatic improvement.Conclusion: We describe a novel procedure accessible to the pediatric otolaryngologist in treatment of severe posterior tracheomalacia using easily available bioresorbable plates molded to the airway as external posterior stents to resist airway collapsibility. Further research and longer‐term outcomes are required for the role of PEXY in treatment of posterior tracheomalacia.Level of Evidence: 4 Laryngoscope, 135:2190–2195, 2025

Background: Current assessment techniques for determining whether a patient has normal interarytenoid anatomy, a deep interarytenoid notch, or a minor laryngeal cleft are highly variable. However, differentiating between these three entities is important, given it may distinguish whether a patient should be considered for surgical intervention. The Interarytenoid Assessment Protocol (IAAP) was developed to provide standardization of interarytenoid anatomy evaluations. We aimed to assess the reliability of the IAAP for assessment of interaytenoid mucosal height (IAMH) through a multi‐institutional validation study.Methods: Reliability of the IAAP was assessed by 10 pediatric otolaryngologists all from different academic centers. 30 de‐identified endoscopic videos of interarytenoid assessments were rated at two separate time points, 2 months apart. Intra‐class correlation (ICC) coefficients with two‐way models were used to evaluate inter‐ and intra‐rater reliability.Results: Thirty endoscopic videos were collected for patients with a median (IQR) age of 4.9 years (59 months; range: 1 month to 20 years). On the first video assessment, inter‐rater reliability was 0.74 (95% CI 0.63–0.84), and on the second video assessment, inter‐rater reliability was 0.75 (95% CI 0.63–0.85) indicating strong inter‐rater reliability. Overall intra‐rater test–retest reliability was 0.75 (95% CI 0.69–0.79) indicating strong agreement. In almost half, 14 (46.6%) raters chose IAAP classification levels within 1 level of each other.Conclusions: Multi‐institutional validation of the IAAP demonstrates strong inter‐ and intra‐rater reliability for assessment of IAMH when evaluated through pictorial analysis. Standardization of anatomical evaluations may improve our ability to perform more reliable outcomes studies of pediatric pharyngeal dysphagia in the future.Level of Evidence: NA Laryngoscope, 135:1499–1505, 2025

Objective(s): Hypoglossal nerve stimulation (HGNS) is safe and effective for patients with Down syndrome (DS) and severe persistent obstructive sleep apnea (OSA). Long‐term outcomes for this patient population have not been evaluated.Methods: A prospective single‐group multicenter cohort study with 1‐year follow‐up was conducted between 2015 and 2021 among 42 adolescent patients with DS and severe persistent OSA. Here, we evaluate long‐term outcomes in this patient cohort. Patients were evaluated with polysomnogram (PSG) at three timepoints: pre‐implantation (timepoint 1), 1‐year post‐implantation (timepoint 2), and long‐term follow‐up (timepoint 3).Results: Long‐term follow‐up data were available for 33 of 42 patients. Mean (SD) of timepoint 3 was 4.0 (1.9) years after implantation. Using a therapy response definition of a 50% decrease in Apnea Hypopnea INdez (AHI) from timepoint 1, the response rate was 69.7% (23/33) at timepoint 2 and 87.9% (29/33) at timepoint 3. From timepoint 1, there was a mean (SD) decrease in AHI of 12.7 (13.4) events/h at timepoint 2 and 15.7 (13.1) events/h at timepoint 3. The mean percentage change in AHI between timepoints 1 and 2 was −51.1% (95% CI: −32.8% to −69.3%) and between timepoints 1 and 3 was −59.6% (95% CI: −42.0% to −77.3%).Conclusion: Patients with DS and severe persistent OSA who undergo HGNS implantation may continue to experience improvement in PSG parameters at long‐term follow‐up. Future studies are needed to assess additional long‐term outcomes in this patient population, including neurocognition and quality of life.Level of Evidence: 3 Laryngoscope, 135:1218–1222, 2025

Placement of the sensing lead can be challenging in obese and Down syndrome patients. This article presents an alteration in technique for its placement for these patient populations. Laryngoscope, 2024.