Karthik Balakrishnan

Objective: This systematic review and meta‐analysis compare the outcomes of primary laryngotracheal reconstruction (LTR) and partial cricotracheal resection (PCTR) in managing moderate‐grade pediatric subglottic stenosis (severe Grade II and Grade III). While both surgical approaches are widely used, no clear consensus exists on the superior technique.Methods: A systematic literature search was conducted across PubMed, Embase, and Scopus following PRISMA guidelines. Studies reporting outcomes of LTR and PCTR in pediatric patients (< 18 years) with severe Grade II (> 60%) or Grade III subglottic stenosis were included. The primary outcome was successful extubation or decannulation. Statistical analysis, including pooled prevalence estimates and heterogeneity assessment, was performed using STATA software.Results: A total of 24 studies were included, comprising 193 patients in the LTR group and 88 in the PCTR group. Successful decannulation was achieved in 83.93% of LTR cases and 96.59% of PCTR cases. However, the difference was not statistically significant (p = 0.47). Failed decannulation in both groups was associated with factors such as neurological disorders, severe airway scarring, and coexisting airway anomalies. PCTR demonstrated slightly better functional outcomes in voice and swallowing, whereas LTR was associated with a higher risk of restenosis and revision surgeries.Conclusion: Both LTR and PCTR are viable options for moderate‐grade pediatric subglottic stenosis, with comparable decannulation success rates. PCTR may offer advantages in functional outcomes, but further research with standardized reporting is necessary to establish an optimal surgical approach.Level of Evidence: II

Tracheomalacia and bronchomalacia are challenging problems with several treatment options including endoscopic and open surgical approaches. Laser tracheobronchoplasty is a novel technique for managing this entity in adults. This case report is the first to describe the technique in a pediatric patient.

Objectives: To investigate potential demographic bias in artificial intelligence (AI)‐based simulations of otolaryngology, residency selection committee (RSC) members tasked with selecting one applicant among candidates with varied racial, gender, and sexual orientations.Methods: This study employed random sampling of simulated RSC member decisions using a novel Application Programming Interface (API) to virtually connect to OpenAI's Generative Pre‐Trained Transformers (GPT‐4 and GPT‐4o). Simulated RSC members with diverse demographics were tasked with ranking to match 1 applicant among 10 with varied racial, gender, and sexual orientations. All applicants had identical qualifications; only demographics of the applicants and RSC members were varied for each simulation. Each RSC simulation ran 1000 times. Chi‐square tests analyzed differences across categorical variables. GPT‐4o simulations additionally requested a rationale for each decision.Results: Simulated RSCs consistently showed racial, gender, and sexual orientation bias. Most applicant pairwise comparisons showed statistical significance (p < 0.05). White and Black RSCs exhibited greatest preference for applicants sharing their own demographic characteristics, favoring White and Black female applicants, respectively, over others (all pairwise p < 0.001). Asian male applicants consistently received lowest selection rates. Male RSCs favored White male and female applicants, while female RSCs preferred LGBTQIA+, White and Black female applicants (all p < 0.05). High socioeconomic status (SES) RSCs favored White female and LGBTQIA+ applicants, while low SES RSCs favored Black female and LGBTQIA+ applicants over others (all p < 0.001). Results from the newest iteration of the LLM, ChatGPT‐4o, indicated evolved selection preferences favoring Black female and LGBTQIA+ applicants across all RSCs, with the rationale of prioritizing inclusivity given in >95% of such decisions.Conclusion: Utilizing publicly available LLMs to aid in otolaryngology residency selection may introduce significant racial, gender, and sexual orientation bias. Potential for significant and evolving LLM bias should be appreciated and minimized to promote a diverse and representative field of future otolaryngologists in alignment with current workforce data.Level of Evidence: N/A Laryngoscope, 2024

Objective: To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy‐specific steps.Methods: A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as “keep” or “remove”. In the second and third rounds, experts were asked to rate the importance of each item on a 9‐point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments.Results: The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy‐specific steps, team and personnel factors, and equipment respectively.Conclusions: The resultant assessment tool can be used to assess both tracheostomy‐specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives.Level of Evidence: 5 Laryngoscope, 133:3588–3601, 2023

Objective(s): To quantify the effect of laryngeal prominence size on socially perceived attributes relating to gender expression. Chondrolaryngoplasty (“tracheal shave”) is a common procedure performed for transgender women to feminize neck appearance. The extent of thyroid cartilage resection needed to convey socially‐perceived feminine gender expression without destabilizing the voice is incompletely understood.Methods: Cross‐sectional evaluation of a randomized allocation of images of varying laryngeal prominence to a non‐repeated, random sample from November 2021 to December 2021. Photos of laryngeal prominence were isolated against a constant neck baseline with lateral, oblique, and frontal views. The images were embedded into a web‐based survey with visual analog scales to capture perceived scaled gender expression (masculinity, femininity) and social traits (e.g., attractiveness, friendliness, leadership). We performed bivariate and multivariate analyses relating the laryngeal prominence to perceived gender expression and social traits.Results: The analytic sample included 1,026 respondents. Laryngeal grades similar to the demonstrated “grade M” in this study and smaller demonstrated similar perceptions of increased femininity and decreased masculinity. Grades larger than M demonstrate significantly increased perceived masculinity and significantly decreased perceived femininity. The lateral and oblique views of the neck appear to be the most gender‐informative.Conclusion: This crowd‐sourced analysis of external laryngeal anatomy by a large population of observers provides clear, reproducible insights into social perceptions of gender identity and specifically femininity. These data will meaningfully inform patient counseling and surgical planning for gender‐affirming interventions by establishing normative data representing the general public's perceptions.Level of Evidence: NA Laryngoscope, 133:2292–2300, 2023

Objectives/Hypothesis: This study defines essential data elements to be recorded during an aerodigestive “triple endoscopy” to form the foundation of a standardized multicenter registry and to clearly define measurement of each consensus item.Study Design: Modified Delphi process.Methods: Modified Delphi consensus with six survey rounds. Twenty‐four expert pediatric otolaryngology, pulmonology, and gastroenterology aerodigestive clinicians from eight large academic pediatric aerodigestive programs formed the Delphi panel. After achieving consensus through the Delphi process, outside validation was performed at 2019 national Aerodigestive Society conference. Consensus, near‐consensus, or exclusion was obtained for each proposed data element. Concordance was then measured between expert panel conclusions and validation group conclusions.Results: Overall response rate was 94.4%. 73/167 proposed items reached consensus in six domains (flexible bronchoscopy, bronchoalveolar lavage, microdirect laryngoscopy and bronchoscopy, esophagogastroduodenoscopy with biopsies, and esophageal impedance and pH probe). Measurement of all items was defined; classification/grading systems were selected for 11 items. Validation group endorsed importance of 82/167 data items; compared to expert consensus, overall, inclusion, and exclusion concordance rates were 94.5%, 98.7%, and 90.9%.Conclusion: Triple endoscopy is a central component of aerodigestive care. This study identifies and defines data elements to be recorded for all triple endoscopy procedures. The list is of usable length, and clear definitions were created for all items, with explicit classification/grading systems selected for 11 items. Face validity was confirmed with an independent multispecialty sample of aerodigestive providers. This consensus provides the foundation for a triple endoscopy registry but also is immediately applicable to standardize clinical documentation in aerodigestive care.Level of Evidence: 5 Laryngoscope, 132:2251–2258, 2022

Objectives/Hypothesis: The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.Study Design: Delphi method‐based survey series.Methods: A multidisciplinary, multi‐institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work‐up.Results: The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).Conclusion: This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best‐practice applications of systemic bevacizumab for patients with early‐onset or less‐severe disease phenotypes.Level of Evidence: 5 Laryngoscope, 131:E1941–E1949, 2021

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