ABSTRACT Objectives Chronic rhinosinusitis (CRS) results from complex host‐environment interactions with microbiome dysbiosis and viral infections postulated to drive inflammation and anatomic remodeling. This study investigates the impact of viral presence on pediatric sinonasal disease and clinical outcomes. Methods A prospective, case–control study with retrospective data collection was conducted at a single‐institution tertiary children's hospital. Pediatric patients undergoing sinus surgery for CRS (cystic fibrosis [CF] and non‐CF CRS groups) and a control group undergoing structural septoplasty were enrolled from 2018–2022. Sinus swabs were collected intraoperatively and during up to 3 years of follow‐up. A 14‐virus panel was run. 16S and custom amplicon sequencing and quantitative PCR assessed microbial profiles. Clinical and endoscopic data were recorded. Results Sinonasal swabs were collected from 15 CF‐CRS, 21 non‐CF CRS, and 32 control patients during initial sinus surgery. At least one virus was detected in 30.9% of samples (n = 21/68): 18.8% (n = 6/32) in controls, 33.3% (n = 7/21) in non‐CF, and 53.3% (n = 8/15) in CF. Human rhinovirus (HRV) was most common, comprising 45.8% (n = 11/24) of viral detections. Across study duration, viral‐positive CRS individuals were 3.49 times more likely to report nasal drainage (95% CI: 1.59–9.25, p = 0.005) and 4.23 times more likely to exhibit discharge on endoscopy (95% CI: 1.40–12.81, p = 0.011) than viral‐negative individuals. HRV‐positive samples had decreased Corynebacterium prevalence (p = 0.025), increased Haemophilus prevalence (p = 0.052), and increased Pseudomonas relative abundance (p = 0.076) versus viral‐negative samples. Conclusion Viral infections can exacerbate pediatric CRS by increasing nasal drainage and endoscopic discharge while promoting chronic inflammation and persistent disease. Level of Evidence 4

Vagus nerve stimulation (VNS) is a well-established FDA-approved option for drug-resistant epilepsy. Injury to the vagus nerve can result in vocal cord immobility, which can lead to significant dysphagia and communication deficits. We hypothesized that neurosurgery–otolaryngology collaboration for revision VNS implantation would reduce postoperative complications compared to neurosurgery-only revision. A retrospective chart review was conducted on all consecutive patients who underwent VNS at a tertiary care children’s hospital from 2005 to 2023. Details of the cases were collected, including the reason for surgery, composition of the surgical team, patient outcomes, and pre- and postoperative flexible laryngoscopy findings. Postoperative completion of laryngoscopy and prevalence of symptoms were compared using Fisher’s exact test, α = 0.05. A total of 104 patients underwent VNS placement during the study period; 49/104 (47.1

Importance Tonsillectomy is among the most painful otolaryngologic procedures. It is unclear whether a postoperative course of oral steroids reduces pediatric tonsillectomy pain and morbidity. Objective To determine whether a postoperative course of oral dexamethasone reduces postadenotonsillectomy pain in children. Design, Setting, and Participants This was a parallel-design quadruple-blinded randomized clinical trial conducted at a single tertiary academic center that enrolled pediatric patients (3-17 years of age) undergoing adenotonsillectomy from August 2021 to May 2023, with 14 days of follow-up for pain and 5 to 9 weeks for adverse events. Data were analyzed from October 2023 to May 2026. Intervention Oral dexamethasone (0.5 mg/kg; maximum dose, 20 mg) or placebo on postoperative days 2, 4, and 6. Main Outcome and Measure Mean (SD) pain score before medication administered during days 2 to 8 postoperatively. Results Of 763 children screened, 209 participants (median [IQR] age, 7.1 [5.8] years; 99 females [47.4%] and 110 males [52.6%]) were included (104 to the steroid arm and 105 to placebo) in analyses of adverse events and health care utilization. Of these, 131 (61 steroid arm and 70 placebo) completed pain diaries and were included in primary outcome (pain) analysis. Mean (SD) pain before acetaminophen or ibuprofen on days 2 to 8 was 0.72 (95% CI, 0-1.44) points lower in the dexamethasone group (4.12 [2.00]) than placebo (4.84 [2.15]), but wide 95% CIs and differences in pain prior to taking the study medication prevented making definitive conclusions. The dexamethasone group had less pre- and postanalgesic pain on postoperative days 12 and 13 (mean difference, 0.96-2.37 points) and a considerable decrease in odds of receiving an opioid prescription (odds ratio [OR], 0.23; 95% CI, 0.06-0.84) or having an emergency department visit for pain (OR, 0.12; 95% CI, 0.003-0.91). However, the precision of these estimates limits interpretability. Differences in readmissions, nursing telephone calls, posttonsillectomy hemorrhage, and return to normal diet between groups were small and clinically meaningless. Conclusions and Relevance In this randomized clinical trial, postoperative oral dexamethasone was associated with a modest reduction in pain after pediatric adenotonsillectomy, a considerable reduction in opioid prescriptions, and no increase in complications, supporting its use as an analgesic adjunct. Trial Registration ClinicalTrials.gov Identifier: NCT04879823

Importance:Tonsillectomy is among the most painful otolaryngologic procedures. It is unclear whether a postoperative course of oral steroids reduces pediatric tonsillectomy pain and morbidity. Objective:To determine whether a postoperative course of oral dexamethasone reduces postadenotonsillectomy pain in children. Design, Setting, and Participants:This was a parallel-design quadruple-blinded randomized clinical trial conducted at a single tertiary academic center that enrolled pediatric patients (3-17 years of age) undergoing adenotonsillectomy from August 2021 to May 2023, with 14 days of follow-up for pain and 5 to 9 weeks for adverse events. Data were analyzed from October 2023 to May 2026. Intervention:Oral dexamethasone (0.5 mg/kg; maximum dose, 20 mg) or placebo on postoperative days 2, 4, and 6. Main Outcome and Measure:Mean (SD) pain score before medication administered during days 2 to 8 postoperatively. Results:Of 763 children screened, 209 participants (median [IQR] age, 7.1 [5.8] years; 99 females [47.4%] and 110 males [52.6%]) were included (104 to the steroid arm and 105 to placebo) in analyses of adverse events and health care utilization. Of these, 131 (61 steroid arm and 70 placebo) completed pain diaries and were included in primary outcome (pain) analysis. Mean (SD) pain before acetaminophen or ibuprofen on days 2 to 8 was 0.72 (95% CI, 0-1.44) points lower in the dexamethasone group (4.12 [2.00]) than placebo (4.84 [2.15]), but wide 95% CIs and differences in pain prior to taking the study medication prevented making definitive conclusions. The dexamethasone group had less pre- and postanalgesic pain on postoperative days 12 and 13 (mean difference, 0.96-2.37 points) and a considerable decrease in odds of receiving an opioid prescription (odds ratio [OR], 0.23; 95% CI, 0.06-0.84) or having an emergency department visit for pain (OR, 0.12; 95% CI, 0.003-0.91). However, the precision of these estimates limits interpretability. Differences in readmissions, nursing telephone calls, posttonsillectomy hemorrhage, and return to normal diet between groups were small and clinically meaningless. Conclusions and Relevance:In this randomized clinical trial, postoperative oral dexamethasone was associated with a modest reduction in pain after pediatric adenotonsillectomy, a considerable reduction in opioid prescriptions, and no increase in complications, supporting its use as an analgesic adjunct. Trial Registration:ClinicalTrials.gov Identifier: NCT04879823.

BACKGROUND:Chronic rhinosinusitis (CRS) and olfactory dysfunction (OD) are highly prevalent among people with cystic fibrosis (PwCF) and negatively impact quality of life. The 40-item Smell Identification Test (SIT) is widely used to assess psychophysical olfaction, but a CF-specific minimal clinically important difference (MCID) has not been established. This study aimed to determine the SIT MCID in PwCF treated with elexacaftor/tezacaftor/ivacaftor (ETI) and/or endoscopic sinus surgery (ESS). METHODS:Data from three prospective, multi-institutional observational studies were pooled. Participants were ≥12 years old with confirmed CF and CRS who completed SIT at baseline and ≥1 follow-up (3, 6, 9, 12, or 24 months). Distribution-based MCIDs were calculated using four methods: standard error of measurement (SEM), minimal detectable change (MDC = 1.96 × SEM), 0.5 × baseline standard deviation (SD), and 0.5 × SD of change scores (ΔSD). RESULTS:A total of 122 participants were enrolled (mean age 32.9 years, 54% female). Of these, 99 contributed follow-up SIT scores (79 ETI, 20 ESS). SIT scores remained stable with ETI, with a small but statistically significant decline at 6 months (-1.4, p = 0.02). ESS was associated with mean gains of 3.1-4.5 points at early follow-up, though these did not reach significance. Pooled distribution-based MCID estimates ranged from 2 to 4 points, with an overall threshold of 3.1 (95% CI: 2.1-4.1). CONCLUSIONS:This CF-specific SIT threshold provides a clinically interpretable cut-off for assessing olfaction. These findings establish a foundation for future work and highlight the importance of developing disease-specific MCIDs to guide clinical care and research.

OBJECTIVE:To characterize the postoperative respiratory complications in children < 3 years old who underwent tonsillectomy. METHODS:Retrospective chart review of patients < 3 years old at time of tonsillectomy. Demographics, comorbidities, polysomnography results, intraoperative factors, and postoperative respiratory complications (desaturations (< 88%) and airway interventions) were collected. Postoperative respiratory complications in all and otherwise healthy patients (without significant comorbidities or perioperative illness) were analyzed using Wilcoxon rank-sum and multivariable logistic regression. RESULTS:498 patients included. Demographics revealed male (56.4%), white (82.9%), severe sleep apnea (30.0%), prematurity (12.9%), and genetic disorders (12.7%). Prematurity (p = 0.04), bronchopulmonary dysplasia/chronic lung disease (p = 0.02), pre-operative AHI (p = 0.006), OAHI (p = 0.01), % total sleep time < 90% O2 (p = 0.001) and O2 nadir (p = 0.001), and intraoperative laryngospasm (p = 0.03) were associated with receiving postoperative supplemental oxygen. With the exception of some pre-op PSG parameters, no characteristics or intraoperative complications were associated with desaturations > 4 h postoperatively. Pre-operative AHI (p = 0.003), OAHI (p = 0.049), O2 nadir (p = 0.006), and % total sleep time < 90% O2 (p = 0.008) were associated with desaturations > 4 h postoperatively. Those with desaturations > 4 h postoperatively received supplemental oxygen (p < 0.001) and had a hospital stay > 24 h (p = 0.006). Of otherwise healthy patients, 10/291 (3.4%) had a desaturation postoperatively, with 7 receiving supplemental oxygen, and only one having had a desaturation > 4 h postoperatively (transient to 87%). CONCLUSION:Otherwise healthy children < 3 years old who underwent tonsillectomy had a low risk of critical postoperative respiratory complications. Children < 3 years old without significant comorbidities or perioperative illness may not require mandatory overnight hospitalization following tonsillectomy. LEVEL OF EVIDENCE: 3:

ObjectiveTo delineate the impact of breast milk feeding (BMF) on the middle ear (ME) and nasopharyngeal (NP) microbiota of children with and without cleft palate with or without cleft lip (CP ± L); to define differences in ME and NP bacterial composition.DesignProspective cohort.SettingTertiary children's hospital.ParticipantsChildren aged <24 months undergoing first bilateral myringotomy and tubes (BMTs). Groups included CP ± L with BMF ≥3 months (n = 6), CP ± L with no BMF (n = 5), controls with BMF ≥3 months (n = 14), and controls with no BMF (n = 14). Exclusions were immunodeficiency, genetic disorders, and antibiotic treatment ≤14 days prior.Main Outcome MeasuresME effusions (MEEs) and NP swabs were collected. Bacterial 16S rRNA gene sequencing was performed. Main outcome measures were abundance (additive-log ratio transformed), β-diversity (permutational multivariate analysis of variance), and α-diversity.ResultsBMF was associated with increased Acinetobacter (β = 1.46) in MEE. In the NP, BMF was associated with increased Haemophilus (β = 2.40), Neisseria (β = 2.39), Granulicatella (β = 1.53), Gemella (β = 1.86), and Prevotella (β = 1.83), and decreased Staphylococcus (β = -1.88). CP ± L was associated with greater α-diversity (Tail β = 1.58; Shannon β = 1.30) and increased Gemella (β = 2.13), Acinetobacter (β = 1.81), and Pseudomonas (β = 2.90) in MEE. In the NP, CP ± L was associated with an increased abundance of Veillonella (β = 3.48), Streptococcus (β = 2.15), and Staphylococcus (β = 1.74) and a decreased abundance of Afipia (β = -1.58). Paired differences revealed more Staphylococcus in MEE relative to the NP (β = -5.98) and a significant difference in β-diversity between the NP and MEE (β = 1.27). All p < .05.ConclusionsBMF and CP ± L may alter ME and NP microbiota. This represents a first step in the identification of factors that could improve ME health in this population.

Background The 22-item sinonasal outcome test (SNOT-22) is widely used to evaluate quality of life (QOL) in cystic fibrosis chronic rhinosinusitis (CF-CRS) but lacks formal validation in people with CF (PwCF). This study explores the psychometric properties of the SNOT-22 following elexacaftor/tezacaftor/ivacaftor (ETI) administration. Methods Data from three prospective observational cohort studies investigating the impact of ETI on CF-CRS were pooled across four U.S. centers and used for validity assessments. SNOT-22 scores, Lund-Mackay (LM) computed tomography (CT) sinus scores, and Cystic Fibrosis Questionnaire-Revised (CFQ-R) scores were used to assess test-retest reliability, construct validity, and responsiveness to clinical change in SNOT-22 scores. Results Strong test-retest reliability was observed for the SNOT-22 during the first 6 months post-ETI (N = 53, all r ≥ 0.80, p < 0.001). SNOT-22 intraclass correlation coefficients were strong (0.883) at 3 and 6 months after ETI was initiated and moderate (0.693) across all time points. Mean individual scores in 20 SNOT-22 items decreased from baseline to post-ETI (90.1%, p < 0.05). Moderate convergent validity was observed between pre-treatment SNOT-22 scores and LM scores (r = -0.42, p = 0.002) and CFQ-R respiratory domain scores (r = -0.35, p = 0.025). Conclusions The SNOT-22 is a valid, reliable, and responsive instrument for evaluating CRS-specific QOL in adults with CF, and functions effectively as a unidimensional construct across most of its 22 items.

Objective Academic meetings provide opportunities for collaboration and career advancement in the national spotlight. We sought to explore sponsorship opportunities by gender by investigating committee leadership, keynote speakership, and panelist-moderator ratios from prior American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and Combined Otolaryngology Sections Meeting (COSM) conferences.Study Design Cross-sectional review of publicly available program conferencing.Setting Literature review.Methods Gender breakdowns of committee leadership and keynote speakerships were recorded from official AAO-HNS conference programming from 2013 to 2021. Panelist-moderator gender ratios were calculated for the AAO-HNS conferences from 2023 to 2024. Society leadership representation and panelist-moderator gender ratios were also investigated from recent COSM conferences between 2018 and 2024 via official programming.Results Between 2013 and 2021, analyses of the AAO-HNS national conferences determined that women comprised on average of 29.6% of annual directorship roles (range 12.5-37.55), 35.6% of board member positions (26.3%-47.4%), and 25.2% of keynote speaker appointments (0%-40%). Between 2019 and 2023, in COSM, women held on average 23.3% of available society chair/secretary positions and 19.0% of society president roles. The ratio of female:total panelist was positively correlated with female moderators.Conclusion Female representation in AAO-HNS and COSM leadership and keynote speakerships has improved over time in recent years, and appears to be on par with academic otolaryngology workforce composition. However, male moderators presenting panels at both conferences had significantly fewer female panelists versus female moderators. This difference in national panel participation opportunities may impact career advancement and national reputation for female otolaryngologists.

OBJECTIVE:To evaluate the impact of social determinants of health (SDoH) on clinical characteristics and surgical outcomes in pediatric patients with sleep-disordered breathing (SDB) and allergic rhinitis (AR) undergoing adenotonsillectomy (T&A) with or without inferior turbinate reduction (ITR). STUDY DESIGN:Retrospective cohort study. SETTING:UPMC Children's Hospital of Pittsburgh. METHODS:Pediatric patients with SDB and AR who underwent T&A with or without ITR from 2007 to 2017 were included. SDoH variables were race, insurance status, sex, and neighborhood-level measures such as Area Deprivation Index (ADI), Child Opportunity Index (COI), distance to hospital, and environmental pollutant exposure. Statistical analysis was performed using logistic regression, Spearman's rank correlation, and Wilcoxon rank-sum tests (α = 0.05). RESULTS:Asthma (41.4% vs 15.7%, p = 0.003) and eye symptoms (10.3% vs 0.9%, p = 0.03) were more common in non-White patients. Patients with allergic dermatitis lived in less deprived neighborhoods (median 23.5 vs 72, p = 0.02). Public insurance was associated with persistent AR symptoms (OR: 2.69, p = 0.02) and post-operative sneezing (OR: 6.66, p = 0.02). Greater distance to hospital correlated with younger age at surgery and higher post-operative apnea-hypopnea index (AHI). Increased industrial pollution was associated with reduced adenoid obstruction. Females had lower pre-operative AHI and higher oxygen nadir. CONCLUSIONS:Socioeconomic, environmental, and demographic factors significantly influence disease characteristics and outcomes in pediatric SDB and AR. Addressing these factors is necessary for promoting health equity in pediatric otolaryngologic care.

INTRODUCTION:Tympanostomy tubes (TTs) are a common otolaryngologic procedure. Historically, tubes placed in the anterior inferior (AI) quadrant were thought to last longer, reduce ossicular damage, and minimize hearing loss. However, perforation risk remains at 2-16 %. AI perforations may require more complicated repair compared to PI perforations. This study aims at comparing early hearing outcomes between AI and PI TT placement after 3 months. METHODS:Randomized controlled trial was conducted at a tertiary pediatric hospital. Children (6 months-14 years) undergoing initial TT placement were randomized to receive a tube in AI in one ear and a tube in the PI quadrant in the opposite ear. Exclusion criteria included non-RAOM indications, tube type other than Armstrong, anatomical abnormalities, or genetic conditions. Audiometry and caregiver questionnaires at 3-month follow-up were analyzed using McNemar's Chi-squared test. RESULTS:Of 386 enrolled, 118 completed audiometry (73 with ear-specific data). Only one patient had mild hearing loss (30 dB PTA at 500 Hz) in the PI ear. Tympanometry in 41 participants showed similar rates of flattened admittance: 9.8 % in PI vs. 7.3 % in AI (OR: 1.00). Caregivers of 303 participants reported tube blockage in 5.6 % (PI) vs. 5.9 % (AI) and otorrhea in 25.7 % (PI) vs. 24.4 % (AI). Provider forms for 86 patients showed similar occlusion rates. Tube patency could not be assessed in 41.9 % of PI vs. 3.5 % of AI tubes due to visualization limitations. CONCLUSION:No significant differences in hearing, tube extrusion, or function were observed between AI and PI TT placement at first follow-up.

INTRODUCTION: Pediatric meningoencephalocele is herniation of brain and meningeal tissue through a skull base defect. Meningoencephaloceles of the ventral skull base are readily treated via endoscopic endonasal surgery (EES). METHODS: Retrospective review of pediatric patients treated with EES for meningoencephalocele from 2000-2022. RESULTS: Eighteen patients with a median age of 6.1 years (range 2.4 to 17.1) and a male predominance (n=12, 66.67%) underwent EES. One (5.56%) had recurrent pathology. Median clinical follow-up was 20.5 months (range 0-216) and median radiographic follow up was 10 months (range 0-154). Meningoencephaloceles were most often located in the anterior cranial fossa (n=14, 78%), middle and infratemporal fossae (n=3, 17%), and sella (n=1, 6%). Most cases were spontaneous (n=13, 72%) while some were associated with trauma (n=5, 28%). Almost all were repaired with EES alone (n=17, 94%). One patient required additional bicoronal craniotomy and pericranial flap for repair of two defects in the orbital roof and ethmoid (n=1, 6%). Eight patients underwent perioperative lumbar or ventricular drain (44%) and two required long-term CSF diversion (n=2, 12%). Reconstruction included free mucosal graft in 8 patients (44%) and nasoseptal flap in 7 (39%). Median length of stay was 2 days (1-10). Three patients (18%) had postoperative CSF leak requiring repair (1 early- < 30 days; 2 delayed). At the time of last follow-up, one patient had chronic rhinitis (n=1, 12.5%) and two had frequent bouts of sinusitis (25%). No patient suffered a decline in vision, cranial neuropathy, or hormone dysfunction. CONCLUSIONS: This single-center case series demonstrates the safety and effectiveness of EES for treating pediatric meningoencephalocele with favorable neurological outcomes. These findings underscore the utility of EES as a viable treatment option in pediatric patients with meningoencephalocele.

INTRODUCTION: Advanced juvenile nasopharyngeal angiofibroma (JNA) has historically been resected via open transfacial and transcranial approaches. Recently, endoscopic endonasal/transmaxillary surgery (EETS) has emerged as a safe and effective alternative. METHODS: Retrospective review of patients treated with EETS for JNA between 2009-2022. RESULTS: Thirty-seven patients were included. All were male with a median age of 14.2 years (range 7.5-17.8). Twenty-one (57%) were UPMC stage V (intracranial extension with residual post-embolization vascularity). Median tumor volume was 42 cm 3 (range 1.3-209). Despite many tumors with significant extension to the intracranial compartment (n=21,57%), infratemporal fossa (n=24.65%), cavernous sinus (n=19.51%), and orbit (n=16.43%), all were successfully resected primarily with EETS. The anterior transmaxillary corridor was used for lateral extension (n=19.51%). Two cases (6%) required lateral orbitotomy and one subtemporal craniotomy (3%) for complete resection of medial sphenoid wing tumor. The rate of gross total resection was 86% (n=30). Preoperative embolization was performed routinely (n=35.95%), but advanced stage tumors (n=26.70%) suffered significant blood loss (median 1.9 L, range 750 ml-16L). Six patients (16%) required staged resection due to blood loss. Most tumors (n=28.80%) had residual vascular supply from the internal carotid (ICA) (n=23) and ophthalmic arteries (n=3). Postoperative complications included an embolization-related stroke (n=1.3%), complete monocular blindness due to central retinal artery occlusion (n=1.3%), and ICA injury requiring vessel sacrifice (n=1.3%) without consequence. Eight patients (22%) suffered recurrence at a median of 8.5 months postoperatively (range 5-33). Five recurrences were completely resected via EETS, but three in the medial sphenoid wing (38%) required addition of lateral orbitotomy. CONCLUSIONS: EETS is safe and effective for resection of all JNAs in children. It offers excellent exposure even in large tumors with lateral or intracranial extension. In rare cases of disease with sphenoid wing extension, addition of lateral orbitotomy can facilitate complete resection.

BACKGROUND:Severe chronic rhinosinusitis (CRS) is a near universal manifestation of cystic fibrosis. Elexacaftor/tezacaftor/ivacaftor (ETI) is an oral, small molecule, highly effective Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) corrector-potentiator drug. In people with cystic fibrosis age > 12 years, ETI improves sinonasal symptoms, endoscopy findings, polyp size, and radiologic findings. This study evaluates changes in CRS in children ages 6-12 years newly started on ETI. METHODS:This was a prospective, three center, pre-post study of 11 children age 6-11 years newly started on ETI. Study endpoints included the SN-5 sinonasal health survey, Sniffin' Kids olfaction test, a sinus computerized tomography (CT) scan, and nasal endoscopy with mucus sampling for full-length 16S rRNA sequencing microbiome analysis. Study visits were conducted before ETI and at a median of 9 months after treatment initiation. RESULTS:ETI lead to improvement in symptoms, endoscopy scores and radiologic findings of CRS. Olfaction was below normal at baseline and did not improve. The sinonasal microbiome was dominated by typically commensal organisms before and after treatment for most participants. Additionally, Staphylococcus aureus was found in five participants at baseline and six participants on treatment. CONCLUSIONS:ETI improves sinonasal symptoms and endoscopy findings in children 6-11 years of age. Olfaction did not improve with ETI treatment in this age group, suggesting that olfactory dysfunction associated with CF is established early in life. This younger cohort of pediatric patients presented with abundant Staphylococcus aureus and only very rare Pseudomonas aeruginosa at baseline or after treatment.

OBJECTIVES:To assess the utility of 3-dimensional printing for both trainee education in frontal sinus anatomy and preoperative surgical planning in complex sinonasal pathology. METHODS:A quasi-experimental pre/postsurvey study was performed at a tertiary care center pediatric rhinology clinic. Four otolaryngology residents and 1 pediatric attending at an academic otolaryngology program were included. Eleven 3D printed models of the pediatric sinuses were created from CT maxillofacial scans. Six models were used to define the frontal outflow pathway. Five additional 3D models were created for pre-surgical planning. The models were dissected in the lab to facilitate surgical planning, technique, and instrumentation selection. Pre- and post-survey evaluations of the training experience were completed by participants. Cost analysis data was collected from the home institution's 3D printing program. RESULTS:Models were accurate to the actual CT scan that they were created from; however, the consistency of the 3D printed models was more firm than true anatomic specimens. Painting sinonasal pathology and the frontal outflow pathway in a distinct color was extremely helpful in identification. Participant post-simulation survey results showed that 60% of participants found the simulation moderately valuable and 40% found it valuable or very valuable as a training tool. A cost analysis was also performed with an average final production cost of $420.52 ± $239.52 per model. CONCLUSION:3D printed models are a useful tool to study and plan for uncommon sinonasal pathology. They can also serve as a useful trainee tool for learning frontal sinus anatomy. This feasibility study shows that 3D sinus models are affordable and accurate in preserving and identifying important anatomical landmarks. The cost-effectiveness, reusability, and customization of these models support their potential for broader implementation in pediatric surgical training curriculum.

OBJECTIVE:To compare the safety and efficacy of nonopioid versus opioid pain management following adenotonsillectomy (AT) among pediatric patients. STUDY DESIGN:An open-label randomized controlled trial. SETTING:Tertiary care children's hospital. METHODS:Patients aged 3 to 17 years undergoing AT were eligible. Participants were randomly assigned to receive either acetaminophen and ibuprofen (nonopioid group) or acetaminophen, ibuprofen, and oxycodone (opioid group). Pain scores and prevalence of emergency department (ED) visits, hospital readmission, and posttonsillectomy hemorrhage (PTH) were compared between groups. RESULTS:From January 2019 to March 2020, 267 patients were enrolled and randomly assigned; 144 completed a postoperative pain diary. Of the 144, 69 (48%) patients received an opioid prescription, and 75 (52%) did not. Mean pain scores before (opioid: 5.78, 95% CI: 5.29-6.27 vs nonopioid: 5.66, 95% CI: 5.20-6.12) and after (opioid: 2.33, 95% CI: 1.89-2.78 vs nonopioid: 2.24, 95% CI: 1.82-2.66) analgesics were not significantly different between opioid and nonopioid groups. Although 7/75 (9%) from the nonopioid group crossed over and requested opioids, only 43/69 (62%) randomly assigned to receive opioid prescription consumed opioids. The rate of opioid consumption increased with increasing age: 18/71 (25%) patients aged 3 to 7 years, 22/57 (39%) 8 to 12 years, and 10/16 (63%) 13 to 17 years, P = .015. Differences in ED visits, hospital readmissions, and PTH between opioid and nonopioid groups were not significant. CONCLUSION:Many children do not require opioid analgesics following AT, particularly children less than 8 years of age. Postoperative pain scores and outcomes were similar in opioid versus nonopioid groups. Opioid prescriptions should be limited or avoided altogether after pediatric AT. TRIAL REGISTRATION:Title: Nonopioids for analgesia after adenotonsillectomy in children; ID: NCT03618823, Clinicaltrials.gov.

OBJECTIVE:To evaluate persistent obstructive and allergic rhinitis (AR) symptoms in pediatric patients with concurrent sleep disordered breathing (SDB) and AR, comparing adenotonsillectomy (T&A) alone to T&A and inferior turbinate reduction (ITR). STUDY DESIGN:This retrospective cohort study examined patients ages 5-18 years who underwent T&A±ITR from 2007 to 2017. Exclusions were no AR (n = 1771), no SDB (n = 170), no otolaryngology clinic note (n = 60), tonsillectomy or adenoidectomy only (n = 53), no follow-up (n = 142), age <5 years (n = 5), syndrome (n = 9), concomitant airway surgery (n = 3), and ITR before T&A (n = 1). SETTING:UPMC Children's Hospital of Pittsburgh. METHODS:Chi-squared, Fisher's exact, Wilcoxon rank-sum, Wilcoxon signed-rank, McNemar's, and Spearman correlation tests were used (α = 0.05). RESULTS:Of the 269 patients, 42 had T&A with ITR, and 227 had T&A only (median age: 12 years, range 5-18 years). Pre-T&A±ITR, common medications were oral antihistamines (112/269, 41.6 %) and nasal corticosteroids (104/269, 38.7 %). In the T&A only group, fewer patients used oral antihistamines post-operatively compared with pre-operatively (χ2 (1) = 30.6, p < 0.001). In both the T&A only (χ2 (1) = 9.28, p = 0.002) and T&A with ITR (χ2 (1) = 14.2, p < 0.001) groups, fewer patients used nasal corticosteroids post-operatively. No significant differences in complications or post-op AR symptoms or sleep abnormalities were observed between groups. Seven T&A-only patients underwent ITR in the following 5 years. CONCLUSIONS:Both T&A with ITR and T&A alone resulted in reduced AR symptoms and improved AHI post-operatively. While no significant differences were observed in complications, post-op AR symptoms, or AHI between the groups, T&A with ITR significantly reduced post-operative nasal corticosteroid use. This study highlights the benefits of appropriate patient selection for T&A vs T&A with ITR in managing patients with SDB and AR.

Objectives: Pediatric epistaxis is a multifactorial disease entity. The objective of this study is to determine the socioeconomic and air-quality contributions to pediatric epistaxis. The study also evaluates the utility of diagnostic lab work as a predictor of bleeding rates and need for operative intervention. Methods: A case series of pediatric patients treated in an outpatient Otolaryngology clinic at a tertiary care children's hospital in 2021 for epistaxis was performed. Patients with nasal bone trauma (n = 8), consult while inpatient (n = 7), and those with nasal masses (n = 2) were excluded; 181 patients met inclusion criteria. Demographic, clinical, socioeconomic, and air quality (tropospheric ozone, particulate matter) data were recorded. Associations with persistent bleeding and operative interventions were evaluated using logistic regression, Wilcoxon rank-sum, and Spearman rank correlation. Results: Of the 181 patients, 75 (41.4%) were female. Forty-six of 181 (25.4%) had associated allergic symptoms. Twenty-six patients had allergy testing; 14/26 (53.8%) of these had positive results. Re-bleeding was more common in those with allergic symptoms (OR: 2.42, 95% CI: 1.22-4.78, p = 0.01). Patients with re-bleeding lived in counties with more days with ozone over the US standard (median 5 days, range 0-32 days) compared with those with no re-bleeding (median 3 days, range 0-32 days, p = 0.007). There was also an association between the number of visits for re-bleed and percent below poverty level (rho = 0.259, p = 0.03) as well as the number of days with particulate matter levels over the US standard (rho = 0.343, p = 0.01). Coagulopathy was present in 9/54 (16.7%) patients, with the majority being Von Willebrand disease (5/54, 9.3%). Easy bruising was not significantly associated with positive lab results. Conclusions: Environmental pollution, living in a zip code with more residents below the poverty level, and allergic rhinitis were positively associated with recurrent epistaxis. Understanding the geographic background of presenting patients may help direct workup and treatment options.