Margaret L. Skinner

Objectives/Hypothesis: Adenotonsillectomy is first‐line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely.Study Design: Retrospective chart review.Methods: We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank‐sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea‐hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest X‐rays (CXRs).Results: Mean age was 5.9 (±3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (±23.8) and 80.7% (±9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7–8.5) or CXR (OR, 3.0; 95% CI, 1.4–6.8) compared to OAHI 10–59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1–320.1) and CXR (OR, 4.1; 95% CI, 1.2–14.4).Conclusions: Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre‐adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre‐adenotonsillectomy evaluation and reduce cost.Level of Evidence: 4Laryngoscope, 131:2361–2368, 2021

Objective: Create and validate an objective structured assessment of technical skills (OSATS) for otolaryngology residents learning how to perform a tonsillectomy.Study Design: Multicenter prospective longitudinal validation study.Methods: A multi‐institutional study at six tertiary academic otolaryngology residency programs from July 2009 to May 2012. Using the modified Delphi technique, a panel of pediatric otolaryngologists created a tonsillectomy task‐based checklist (TBC) for a tonsil OSATS using a 5‐point Likert‐type scale. Residents were assessed by pediatric otolaryngology staff at the time of surgery with the TBC and a global rating scale. Procedure time, patient age, number of previously performed tonsillectomies, and surgical technique were also collected.Results: One hundred sixty‐seven tonsil OSATS were completed for 38 residents, and competency was recorded for 99 (59.2%). Residents scored as competent had performed significantly more previous tonsillectomies than those deemed noncompetent, 44.4 ± 35.6 and 13.5 ± 11.6, respectively (P < .001). The mean overall score on the tonsil TBC was 4.0 ± 0.8 and 2.6 ± 1.0 for competent and noncompetent, respectively (P < .001). Higher number of tonsillectomies performed and mean tonsil TBC score significantly increased the likelihood of competency (P < .001). Each additional tonsillectomy performed increased the likelihood of achieving competency by 6.3% (P = .006, 95% confidence interval (CI): 1.330–1.110), and each 1.0 point increase in mean tonsil TBC score increased the likelihood of competency by a factor of 2.71 (P = .006, 95% CI:1.330–5.513). There is a 95% likelihood of competency at 48 tonsillectomies or a tonsil TBC score of 4.91.Conclusion: The tonsil OSATS is a valid and feasible instrument to assess resident competency with tonsillectomy and provides timely objective feedback.Level of Evidence: 4. Laryngoscope, 131:E359–E366, 2021

Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.

Objectives: (1) Analyze upstream and downstream activity before and after enrollment with the Multidisciplinary Pediatric Aerodigestive Care Team (MPACT). (2) Identify potential demand for MPACT services with ICD‐9 data.Study Design: Retrospective review of financial claims data.Setting: Tertiary care children’s center.Subjects: Pediatric patients (0‐18 years old) enrolled with MPACT (pediatric otolaryngology, gastroenterology, pulmonary, speech‐language pathology).Methods: Case mix data from fiscal years (FYs) 2010‐2013 were analyzed for primary, secondary, and tertiary ICD‐9 codes in 4 aerodigestive diagnostic categories (ADCs): dysphagia, chronic cough, gastroesophageal disease, and chronic pulmonary disease/asthma. Inclusion criteria included patients ICD‐9 data suggest potential demand for MPACT services.

Children with complex respiratory and gastrointestinal symptoms, also known as aerodigestive disorders, can present with a variety of diagnoses, including sleep apnea, asthma, congenital airway or esophageal anomalies, dysphagia, feeding disorders, gastroesophageal reflux, esophagitis, and/or airway malacia. The burden of disease is unknown because no estimates of the prevalence of these complex aerodigestive disorders exist, but these conditions may be more common than previously realized. One common presentation of a pediatric aerodigestive disorder is infant feeding disorder: in 2010 2.6% of sick newborns discharged from short hospital stays in the United States had feeding disorders (International Classification of Diseases, Ninth Revision [ICD-9] code 779.3).¹ These disorders, even as comorbidities, can lead to increased mortality and morbidity; for example, comorbid dysphagia in hospitalized patients has been associated with longer hospital stays and increased mortality.² These children frequently require care from multiple pediatric subspecialists, including gastroenterologists, dietitians and/or nutritionists, otolaryngologists, pulmonologists, respiratory therapists, and speech-language pathologists. Over the past decade, a number of pediatric tertiary care hospitals have established interdisciplinary clinics to coordinate care,^3,4 including at least 35 centers in the United States as of May 2014 (found via systematic web search for pediatric aerodigestive center websites, May 16, 2014).

Objectives/Hypothesis: To describe the reasons for hospitalization and characteristics of children with preexisting tracheostomy and to compare hospital utilization between children with and without tracheostomy.Study Design: Retrospective cohort study.Methods: Children with tracheostomy were selected in the Healthcare Cost and Utilization Project Kids' Inpatient Database 2009 using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared hospital utilization with the children's clinical characteristics (e.g., chronic condition number and type). We also assessed hospitalizations for tracheostomy complications and ambulatory care sensitive conditions (ACSCs) that could be potentially influenced by high‐quality outpatient and community care delivery.Results: In 2009, there were 21,541 hospitalizations for children with tracheostomy totalling $1.4 billion (U.S.). On average, children with tracheostomy had five chronic conditions (standard deviation 1.4). Eighty‐one percent (n = 17,448) had one or more complex chronic conditions (CCCs), and 67.1% (n = 14,379) had a gastrostomy. Among children with one or more CCCs, mean hospital charges were greater for hospitalizations of children with tracheostomy compared to without ($69,999 vs. $64,017, P = 0.008). Twenty‐one percent (n = 4,421) of all hospitalizations of children with tracheostomy were due to an ACSC (14.5%, n = 3,122) or a tracheostomy complication (6.0%, n = 1,299). Bacterial pneumonia (9.6% of all hospitalizations, n = 2,059) was the most common ACSC.Conclusions: Children with tracheostomy are a vulnerable group of children with multiple CCCs who experience lengthy and costly hospitalizations. Many hospitalizations are due to an ambulatory care sensitive condition or a tracheostomy complication. Further investigation is needed to determine whether some of these hospitalizations may be avoidable with improved outpatient and community tracheostomy care.Level of Evidence: 2b. Laryngoscope, 125:462–468, 2015

Objectives/Hypothesis: Laryngeal cleft (LC) associated with tracheoesophageal fistula (TEF) with or without esophageal atresia (EA) has rarely been described. The purpose of this study is to review our experience, clinical features, management, delay in diagnosis, and complications in children with these anomalies.Study Design: Retrospective chart review at pediatric tertiary referral center.Methods: Patients diagnosed with LC alone or LC and TEF over a 10‐year period were included. Data including demographics, type of TEF and LC, comorbidities, symptoms, management, complications and swallowing outcomes were analyzed.Results: There were 161 pediatric patients diagnosed with LC alone and 22 with LC and TEF. In patients with LC and TEF, aspiration was the most common presenting symptom (n = 11, 50%). Seventeen patients (77%, mean age 4 years 7 months) underwent endoscopic repair and five patients (23%) with type I clefts did not require surgery. Two patients required revision surgery. For patients with LC alone, the mean age at repair was 3.70 years (4 months–19.9 years) compared to 4.69 years (8 months–17.83 years) for patients with LC and TEF (P = 0.0187). The postoperative swallowing studies from 15 patients showed no aspiration. Mean follow‐up was 4 years and 6 months.Conclusion: The diagnosis and management of LC in patients with TEF is often delayed. If a child presents with persistent aspiration after TEF repair, a complete airway endoscopy should be performed to evaluate for vocal fold mobility and cleft. Endoscopic repair is the recommended approach for those patients requiring surgical intervention.Level of Evidence: 4. Laryngoscope, 125:469–474, 2015