Hamdy El-Hakim

Objective: (1) Compare proportions of collapse, obstruction, or mixed instances on drug‐induced sleep endoscopy findings of obese and nonobese children with obstructive sleep disordered breathing. (2) Determine the frequency of collapse in general between both groups.Study Design: Retrospective case‐control study.Setting: Tertiary pediatric center.Methods: Obese (body mass index >95 percentile) children presenting with obstructive sleep disordered breathing (>33 on the pediatric sleep questionnaire) were identified from a prospectively kept surgical database. Only those who had undergone drug‐induced sleep endoscopy were eligible. Age and sex pair‐matched nonobese children were identified. Only nonsyndromic, neurologically normal, surgically naïve patients were included. The frequency of obstructive, collapse, and mixed pharyngeal patterns was documented in both groups. A comparison of proportions was then undertaken (χ² test).Results: Over a 5‐year period, 73 consecutive children with obesity were identified (40 males; mean of 8.5 ± 3.0 years, 2.8‐13.1). They were matched with 73 nonobese children (8.4 ± 3.0 years, 2.6‐14.1). The obese group exhibited significantly more pharyngeal collapses (62:47) (p = .0021 odds ratio [OR] 3.358, 95% confidence interval [CI] 1.52‐7.42). The proportion of pharyngeal findings on drug‐induced sleep endoscopy was significantly different (p = .000129) between the 2 groups; obese (61 mixed: 3 obstruction: 9 collapse) and nonobese (48 mixed: 22 obstruction: 4 collapse).Conclusion: The predominance of hypopharyngeal collapse in children with obesity may explain the likelihood of failure of surgery directed at obstructive findings. This may also strengthen the case for drug‐induced sleep endoscopy in this group at the initial surgery to guide it rather than after the failure of adenotonsillectomy.

Objective: The literature on the entity of the anterior larynx (AL) is restricted to little evidence on the difficulty encountered in exposing the larynx for intubation, perioperative morbidity and mortality, and scant reports on its prevalence in general adults and children. Here, we describe the prevalence of AL in a series of children presenting with aerodigestive symptoms and explore its association with functional abnormalities, congenital and structural anomalies or conditions.Setting: Tertiary paediatric centre.Methods: We conducted a retrospective case–control study. Using a prospectively collected surgical database, we identified patients diagnosed with AL (Grades IIb‐III‐IV Modified Cormack‐Lehane scale) and sex and age‐matched controls who had undergone full airway endoscopy for aerodigestive symptoms. We collected the demographics, presentations, associated diagnoses and investigations. We compared the proportion of patients with large airway abnormalities and dysmorphism and estimated the prevalence of AL.Results: Over a 5.5‐year period, 58 children with AL (28 females, mean age 0.38 years) were matched with 58 controls (mean age 0.42 years). Although both groups presented with permutations of stridor, respiratory failure, cyanotic spells, swallowing and feeding difficulties and SDB, AL presented much more with swallowing and feeding problems (33 vs. 20, p < .05). There were significantly more children with dysmorphism in the AL group (29 vs. 9, p < .05). The prevalence of AL was 4.9% (SE 0.0063).Conclusions: AL was detected in 4.9% of a sample of children who had undergone airway examination for aerodigestive symptoms. It is significantly associated with dysmorphism, and swallowing difficulties that warrant instrumental evaluation.

Objectives Swallowing dysfunction (SwD) is under-reported in otherwise healthy infants and toddlers (OHITs). The identification of parental perceptions of factors that may hinder the diagnosis could help clinicians manage these children in a more expeditious manner. This study investigated the barriers to diagnosing SwD, as reported by the families. Design Grounded theory study. Setting This study was performed in a tertiary care paediatric centre in Canada. Participants Parents of OHITs were recruited using purposeful sampling. Intervention We used detailed, semistructured, in-person interviews and the audiotapes and transcriptions were thematically analysed. From the parental insights, we built a framework composed of three themes of barriers. Result Ten parents of OHITs with SwD were interviewed. The children presented with recurrent coughing, choking, cold-like symptoms, recurring/consistent illnesses and feeding difficulties. They were managed with multiple rounds of antibiotics and diagnosed with allergies, asthma or recurrent viral infections before considering SwD. The three emerging themes are false beliefs about SwD among parents and some physicians, parent-related barriers and physician-related barriers. These barriers had severely impacted the parents, impairing work productivity and leading to work-related reprimands and changes in the family dynamics. Conclusion This study suggests that there are several barriers that face the parents of OHITs when seeking a diagnosis of SwD and initiating appropriate management. These barriers likely interact with one another and amplify their effects on the family and the child. A common denominator is a lack of education regarding SwD, its clinical manifestations and the available expertise to manage this condition.

Objective Understanding of maxillary sinus hypoplasia (MSH) and associated sinonasal variants is paramount to the diagnostic and therapeutic success of maxillary sinus and maxillary dental implant surgery. The purpose of this work was to explore the prevalence of MSH, frequency of mucosal thickening, and anatomical variations in the sinonasal complex. Methods Retrospective case-control design based on cone beam CT images of dental patients with MSH and matched for age and gender. MSH type and sinonasal variables were recorded. Results One thousand three hundred seventy cone beam CT scans were analyzed for MSH. MSH prevalence was 6% (n=82), matched with 82 controls= 100 females and 64 males, mean age 37.1±14.1 years. Most MSH were type I, 69.5%, 80.5% unilateral, 65.9% associated with no or mild mucosal thickening. Associated sinonasal anatomical variations were <27% except for deviated/hyperplastic (DH) meatus, 48.8%. Within the MSH group, significant associations were presented between MSH type, mucosal thickening, and DH nasal meatus. MSH group vs controls showed a significant difference in mucosal thickening (OR 5.2, 95% CI 2.0–17.3) and DH meatus (OR 1.6, 95% CI 1.4–2.1). Conclusions A hypoplastic maxillary sinus with abnormal or absent uncinate process is associated with advanced mucosal thickening and may present with altered anatomy of the lateral wall of the nasal cavity causing its approximation to the orbital floor. Clinical relevance Pre-surgical knowledge of altered anatomy in the sinonasal complex is crucial in dental implant or sinus surgery.

Background: To evaluate the clinical management of choanal atresia (CA) in tertiary centers across Canada. Methods: Multi-centre case series involving six tertiary care pediatric hospitals across Canada. Retrospective chart review of patients born between 1980 and 2010 diagnosed with choanal atresia to a participating center. Results: The health charts of 215 patients (59.6% female) with choanal atresia (CA) were reviewed. Mean age of initial surgical repair was 0.8 months for bilateral CA, and 48.6 months for unilateral CA. Approaches of surgical repair consisted of endoscopic transnasal (31.7%), non-endoscopic transnasal (42.6%), and transpalatal (25.2%). Stents were used on 70.7% of patients. Forty-nine percent of patients were brought back to the OR for a planned second look; stent removal being the most common reason (86.4%). Surgical success rate of initial surgeries was 54.1%. Surgical technique was not associated with rate of restenosis [χ² (2) = 1.6, p = .46]. Conclusions: The present study is the first national multi-institutional study exploring the surgical outcomes of CA over a 30-year period. The surgical repair of CA presents a challenge to otolaryngologists, as the rate of surgical failure is high. The optimal surgical approach, age at surgical repair, use of stents, surgical adjuncts, and need for planned second look warrant further investigation. Graphical

Background: To evaluate the clinical presentation of choanal atresia (CA) in tertiary centers across Canada. Methods: Multi-centre case series involving six tertiary care pediatric hospitals across Canada. Retrospective chart review of patients born between 1980 and 2010 diagnosed with CA at a participating center. Results: The health charts of 215 patients (59.6% female) with CA were reviewed and included in this study. The mean age of patients at time of CA presentation was 0.4 months (range 0.1 to 7.2 months) for bilateral CA and 37.8 months (range 0.1 to 164.1 months) for unilateral cases. The most common presenting symptoms for bilateral CA in decreasing order were respiratory distress (96.4%), feeding difficulties (68.2%), and rhinorrhea (65.5%), and for unilateral cases in decreasing order were rhinorrhea (92.0%), feeding difficulties (24.7%), and respiratory distress (18.0%). For the majority of patients (73.2%), the obstruction comprised mixed bony and membranous tissue, with only 10.5% presenting with a purely membranous obstruction. Familial history of CA was confirmed in only 3.3% of cases. One half of patients with CA presented with one or more associated anomalies and 30.6% had a syndrome. Conclusions: The present investigation is the first national multi-institutional study evaluating the clinical presentation of CA over three decades. The present cohort of CA patients presented with a breadth of co-morbidities with highly variable presentations, with bilateral cases being more severely affected than unilateral cases. Further investigation into hereditary linkages to CA development is warranted. Graphical

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, 2020