Purpose: To assess the effectiveness, surgical techniques, and safety outcomes of lingual frenum release in infants with feeding difficulties. Methods: The protocol was registered with PROSPERO (CRD42024482618). Ovid MEDLINE, CINAHL, Embase, and Cochrane Library databases were searched from 1946 to May 2025 for studies meeting inclusion criteria. The population included mother-infant dyads with feeding difficulties where infants with restrictive frenum underwent surgical release. The primary outcome measured included feeding difficulties, technique comparison, post-care, and adverse events. Fourteen reviewers screened studies, performed data extraction, and assessed risk of bias (ROB). A Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach determined the quality of evidence. Results: Forty-seven studies qualified for analysis, including 8 randomized controlled trials and 39 observational studies. Maternal nipple pain reduction showed large standardized mean differences sustained from immediate through long-term follow-up. Maternal perception of breastfeeding showed improvement over time. Latch, audible swallowing, type of nipple, comfort, and hold (LATCH) scores showed large improvements in single-arm studies but minimal differences compared to controls in randomized clinical trials. Scissors and lasers appeared comparably effective based on limited evidence. The pooled adverse event frequency was 4%, with bleeding being most common. Conclusion: Very low certainty evidence supports frenotomy for documented functional impairment in carefully selected cases where conservative management has failed, emphasizing multidisciplinary evaluation and individualized decision-making with comprehensive informed consent.

Purpose: To provide evidence-based recommendations for managing infants with restrictive lingual frenum and breastfeeding difficulties. Methods: Recommendations were informed by 2 recent systematic reviews regarding outcomes such as the diagnostic criteria for ankyloglossia, association of ankyloglossia with feeding difficulties, and evidence for surgical release of the lingual frenum. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach guided consensus on problem prioritization, certainty of evidence, benefit-risk balance, patient values, acceptability, and feasibility. Results: Twelve conditional recommendations were developed addressing the diagnosis and management of symptomatic ankyloglossia. Both anatomical and functional assessments were advised for a comprehensive assessment of the tongue. Evidence suggested an association between restrictive lingual frenum and feeding difficulties and potential benefits of frenotomy on feeding in carefully selected cases. This document provides guidance on preferred surgical techniques, postoperative care, and counseling regarding possible adverse events, aiming to support clinical decision making for dental professionals. Conclusions: All recommendations were conditional and grounded in very low-certainty evidence, underscoring the need for high-quality research. Clinicians should engage in multidisciplinary, shared decision making with parents to determine the most appropriate intervention from available options, incorporating the family's values and preferences.

OBJECTIVES:Prospective observational cohort study at a tertiary care academic center to evaluate the post-operative use of oxycodone in pediatric tonsillectomy patients and caregiver knowledge of opioid disposal. METHODS:Pediatric patients 6-18 years old undergoing tonsillectomy were enrolled. Patients were excluded if they required prolonged inpatient care, had a history of organ transplantation, chronic pain or narcotic use, congenital or chromosomal disorders, inability to take acetaminophen or ibuprofen, and other significant medical diagnoses that could potentially alter postoperative pain management. All patients were prescribed a standard amount of oxycodone to be used for breakthrough pain in addition to ibuprofen and acetaminophen. Data on patient demographics, details of their tonsillectomy, pain ratings, and caregiver understanding of opioid use and disposal were collected and analyzed. RESULTS:A total of 46 patients were enrolled with data collected on 38 patients and a mean age of 14.2 years. There were 32 patients (70%, [32/46]) that were opioid naïve. Oxycodone provided excellent pain control in 70% of patients, and 10% of patients returned to the hospital for further pain-associated issues. Near-significant increased opioid consumption was seen in patients with tonsillitis (p = 0.02, α = 0.0167), and significant increase in non-Hispanic patients (p = 0.001, α = 0.0167). 61% of caregivers lacked plans for opioid disposal after the postoperative period was complete. CONCLUSION:Ibuprofen and acetaminophen with oxycodone for breakthrough pain achieved effective pain relief. Increased opioid use was observed in non-Hispanic patients. Notably, families were broadly unaware of safe disposal methods for leftover opioids. Our study highlights need for more comprehensive counseling on opioid usage in children post-tonsillectomy.

Purpose: To assess the diagnostic criteria for restrictive lingual frenum and the association with feeding difficulties in mother-infant dyads. Methods: The protocol was registered with PROSPERO (CRD42024482618). Ovid MEDLINE, CINAHL, Embase, and Cochrane Library databases were searched from 1946 to May 2025 for studies meeting inclusion criteria. The population included mother-infant dyads with or without feeding difficulties, where infants had a restrictive frenum. Outcomes measured included diagnostic accuracy of tools assessing ankyloglossia and the association of ankyloglossia with feeding difficulties. Fourteen reviewers screened studies, performed data extraction, and assessed risk of bias using risk of bias and Office of Health Assessment and Translation tools. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach determined the quality of evidence. Results: Fourteen out of 20 included studies qualified for analysis, examining 5 ankyloglossia-specific diagnostic tools. For diagnosing ankyloglossia, the Bristol Tongue Assessment Tool/Tongue-tie and Breastfed Babies Assessment Tool (BTAT/TABBY) demonstrated high discriminative accuracy (AUC ROC=0.95, >2000 clinical cases), acceptable internal consistency (α=0.708) and strong correlation with the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF, r=0.89). Ten of the included studies examining feeding difficulties showed a trend favoring association with restrictive lingual frenum. Infants with ankyloglossia had a higher odds of maternally reported feeding difficulties (pooled OR= 5.57, 95% CI 0.44-70.02), though the effect did not reach statistical significance (P=0.18) and heterogeneity was substantial (I 2=96%). Conclusion: Very-low certainty evidence supports the use of standardized anatomical and functional (tongue mobility) assessments for restrictive lingual frenum. A consistent direction of association between restrictive lingual frenum and feeding difficulties was observed across studies, though pooled estimates did not reach statistical significance.

Introduction Early and accurate diagnosis of middle ear effusion in primary care settings enables timely intervention, improving long-term patient outcomes while preventing overtreatment with antibiotics. Diagnosis requires assessment of tympanic membrane mobility, but this is hampered by access to and inexperience with pneumatic otoscopy or tympanometry. This research aims to train an artificial intelligence algorithm, using tympanic membrane images captured with consumer-grade otoscopes, to accurately predict the presence or absence of pediatric middle ear effusions. Methods Using an over-the-counter digital otoscope, tympanic membrane images were obtained from patients aged 6 months to 6 years old undergoing tympanostomy tube placement at 4 different institutions. The images were labeled according to the middle ear findings identified by pediatric otolaryngologists during myringotomy. A deep learning neural network was trained to classify tympanic membrane images as “Effusion” or “No Effusion”. Results From 219 patients, 537 tympanic membrane images were obtained. Serous, mucoid or purulent effusion were represented in 263 images and 273 images demonstrated no effusion. The trained model achieved a classification accuracy of 92.1%, a sensitivity of 90.3%, and specificity of 93.8%. Discussion This model has a balanced sensitivity and specificity comparable to or surpassing pneumatic otoscopy (94% sensitivity, 80% specificity) and tympanometry (90-94% sensitivity, 50-75% specificity). With current barriers to using the diagnostic tools recommended in clinical guidelines, it is evident that an inexpensive, objective diagnostic aid is needed for the primary care setting. This model’s performance demonstrates the first step toward an accessible tool for primary care providers.

BACKGROUND:Pre-emptive analgesia may be of benefit in reducing total opioid use and improving the pain experience perioperatively. However, there is conflicting evidence as to the benefits of pre-emptive analgesia, with limited evidence in children. The aim of this study was to examine the association between preoperative use of hydrocodone with acetaminophen and total opioid consumption in children undergoing adenotonsillectomy. METHODS:This was a retrospective cohort study of the children undergoing adenotonsillectomy surgery at Texas Children's Hospital between 11/2017 and 12/2018. Preoperative use of hydrocodone with acetaminophen was the exposure of interest. The primary outcome was total perioperative opioid consumption calculated as oral morphine equivalents (OME). Secondary outcomes of interest included: post-anesthesia care unit (PACU) pain experience and time to discharge. We used multivariable linear regression to estimate the association of hydrocodone with acetaminophen on the outcomes. RESULTS:A total of 1082 patients met inclusion criteria, 366 (33.8%) received pre-operative hydrocodone with acetaminophen. There was no difference in the total intraoperative and postoperative OME between groups, mean OME of 0.49 mg/kg (±0.23) in the HA group versus 0.50 mg/kg (±0.27) in the control group; p = 0.56. For PACU discharge, the median [IQR] for PACU discharge time was longer in the patients who did not receive preoperative HA, at 39.0 [25.0-58.0] versus 30.0 [20.0-46.0] min for the preoperative HA group. Use of preoperative HA was associated with a 61% likelihood of having a PACU discharge time exceeding 30 min, with an odds ratio (OR) of 0.39 (95% CI, 0.28, 0.54; p < 0.001). Use of preoperative HA resulted in a greater likelihood of exhibiting a maximal pain score of 0-3 in PACU, with an OR of 2.16 (95% CI, 1.56-2.99; p < 0.001), as well as an increased likelihood of a having a maximum recorded pain score of zero, with an OR of 1.85 (95% CI, 1.34-2.56; p < 0.001). CONCLUSIONS:Pre-operative hydrocodone with acetaminophen was associated with improved outcomes with respect to PACU pain experience and time to discharge. The total OME increase was limited to the pre-operative HA dose.

BACKGROUND:Obstructive sleep apnoea (OSA) has been thought to increase the risk of respiratory depression from opioids. The primary aim of this study was to assess whether preoperative hypoxaemia by sleep study pulse oximetry imparts greater opioid sensitivity. METHODS:A multicentre observational cohort study with in-cohort dose randomisation was performed in children 2-8 yr of age with OSA undergoing adenotonsillectomy. Ninety patients were assigned to one of two Spo2 cohorts by preoperative sleep study Spo2 nadir of < or ≥85% to receive fentanyl 1.0 or 1.5 μg kg-1 (maximum 25 μg) after sevoflurane induction. The primary outcome was the extent of opioid-induced central ventilatory depression over time by Spo2 status as defined by the differences in tidal volume, respiratory rate, end-tidal CO2, and minute ventilation for 10 min after fentanyl administration when compared with pre-fentanyl baseline values. Secondary outcomes included assessment of body mass index, fentanyl dose, sex, age, and race on opioid-induced central ventilatory depression. Intention-to-treat and per protocol analysis were performed. RESULTS:Ninety patients underwent in-cohort randomisation (Spo2 <85%; n=47 and Spo2 ≥85%; n=43). Final per protocol analysis included 73 subjects, fentanyl 1.0 μg kg-1 (Spo2 <85%; n=36 and Spo2 ≥85%; n=37) and 15 subjects, fentanyl 1.5 μg kg-1 (Spo2 <85%; n=9 and Spo2 ≥85%; n=6). Multivariable mixed effect model for the primary outcomes (tidal volume, respiratory rate, end-tidal CO2, and minute ventilation) from baseline to 10 min (as % change per minute) were not different between groups by Spo2 nadir (< or ≥85%) and fentanyl dose for the intention-to-treat and per protocol analyses. CONCLUSIONS:Single-dose fentanyl ventilatory effects in paediatric OSA patients during sevoflurane anaesthesia were not associated with preoperative nocturnal hypoxaemia nadir. Fentanyl dosing in children with OSA should not be determined by sleep study Spo2 nadir. CLINICAL TRIAL REGISTRATION:NCT05051189.

Introduction: Non-tuberculous mycobacterial (NTM) infection commonly manifests as subacute or chronic cer-vicofacial lymphadenitis in immunocompetent children. The optimal management of this pathology remains controversial. Objectives: This international consensus guideline aims to understand the practice patterns for NTM cervicofacial lymphadenitis and to address the primary diagnostic and management challenges.Methods: A modified three-iterative Delphi method was used to establish expert recommendations on the diag-nostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature. Setting: Multinational, multi-institutional, tertiary pediatric hospitals. Results: Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation. Conclusion: The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation.

Purpose: To assess changes in outpatient clinic, inpatient consult, and operative volumes among pediatric otolaryngologists in response to the COVID-19 pandemic.Materials and methods: An online questionnaire was distributed to 535 active members of the American Society of Pediatric Otolaryngology from April 21, 2020, to May 4, 2020. The questionnaire assessed operative and clinical volumes during a two-week period between April 6, 2020, to April 20, 2020, while restrictions on elective surgery were in place, as compared to an average two-week period before the start of the COVID-19 pandemic.Results: Both outpatient clinic and inpatient consult visit volume decreased significantly during the Covid-19 period. Academic practitioners typically reported seeing fewer outpatient visits than their private practice counterparts. Operative case volume decreased significantly across all procedures and surgeries common to pediatric otolaryngology. One-third of surveyed surgeons reported no operative cases during the assessed period.Conclusions: Pediatric otolaryngologists reported a severe reduction in operative volume, in-office visits, and inpatient consults during a time period at the peak of the 2020 Covid-19 outbreak. Many respondents saw no patients, nor operated in any capacity. This time period could have lasting effects on practitioner finances and trainee education.

Langerhans cell histiocytosis (LCH) is a rare hematopoietic disorder characterized by granuloma formation in various body systems, with a corresponding variety of presenting symptoms. Head and neck disease accounts for ~60% of pediatric LCH, with temporal bone involvement in 4–16% of cases. Pediatric temporal bone LCH typically presents with a temporal bone mass, otorrhea, and hearing loss. Vestibular symptoms are very rare at presentation and are more often related to central nervous system (CNS) extension or treatment effects. We present a case of isolated ataxia as the presenting symptom for a pediatric patient with temporal bone LCH.

OBJECTIVES:To outline an expert-based consensus of recommendations for the diagnosis and management of pediatric patients with congenital tracheal stenosis.METHODS:Expert opinions were sought from members of the International Pediatric Otolaryngology Group (IPOG) via completion of an 18-item survey utilizing an iterative Delphi method and review of the literature.RESULTS:Forty-three members completed the survey providing recommendations regarding the initial history, clinical evaluation, diagnostic evaluation, temporizing measures, definitive repair, and post-repair care of children with congenital tracheal stenosis.CONCLUSION:These recommendations are intended to be used to support clinical decision-making regarding the evaluation and management of children with congenital tracheal stenosis. Responses highlight the diverse management strategies and the importance of a multidisciplinary approach to care of these patients.

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Objective Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. Purpose The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan. The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. Action Statements The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method. The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

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.

Objective To identify and seek consensus on issues and controversies related to ankyloglossia and upper lip tie in children by using established methodology for American Academy of Otolaryngology-Head and Neck Surgery clinical consensus statements. Methods An expert panel of pediatric otolaryngologists was assembled with nominated representatives of otolaryngology organizations. The target population was children aged 0 to 18 years, including breastfeeding infants. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus, per established methodology published by the American Academy of Otolaryngology-Head and Neck Surgery. Results After 3 iterative Delphi method surveys of 89 total statements, 41 met the predefined criteria for consensus, 17 were near consensus, and 28 did not reach consensus. The clinical statements were grouped into several categories for the purposes of presentation and discussion: ankyloglossia (general), buccal tie, ankyloglossia and sleep apnea, ankyloglossia and breastfeeding, frenotomy indications and informed consent, frenotomy procedure, ankyloglossia in older children, and maxillary labial frenulum. Conclusion This expert panel reached consensus on several statements that clarify the diagnosis, management, and treatment of ankyloglossia in children 0 to 18 years of age. Lack of consensus on other statements likely reflects knowledge gaps and lack of evidence regarding the diagnosis, management, and treatment of ankyloglossia. Expert panel consensus may provide helpful information for otolaryngologists treating patients with ankyloglossia.

Objective The proportion of women in otolaryngology-head and neck surgery (OHNS) has steadily increased in recent years. This study examines gender representation in recognition awards given by OHNS societies between 2009 and 2019. Study Design Retrospective analysis of recognition awards given by 10 OHNS societies between 2009 and 2019. Setting Retrospective review of web-based, public records. Methods Data from 19 awards were analyzed for recipient gender ratio, society, subspecialty, award type (research, achievement, or humanitarian), and change over time. Results Of 184 awards given by societies in otolaryngology-head and neck surgery, 59 (28%) were given to women. Women received 49 (28%) research awards, 9 (31%) humanitarian awards, and 1 (2.8%) achievement award. Women represented 31% of award winners in rhinology/skull base, 30% of award winners in head and neck surgery, 8% in neurotology, and 6% in facial plastic surgery. The American Head and Neck Society Prevention and Early Detection award had the highest representation of women at 43%. Some awards had no female awardees over the past decade. No temporal trends were observed. Conclusion From 2009 to 2019, women received recognition awards at a higher percentage than overall gender representation in OHNS. Comparison of research, humanitarian, and achievement awards revealed the disparity of women receiving fewer achievement awards relative to men. Gender representation of award recipients varied by subspecialty, which may be partially determined by gender distribution within the fields.

INTRODUCTION:Postoperative prescribing of opioids following pediatric adenotonsillectomy can have negative consequences including unnecessary opioid exposure and potential for respiratory depression. While guidelines from The American Academy of Otolaryngology/Head & Neck Surgery recommend treatment of post adenotonsillectomy pain using acetaminophen and ibuprofen, many providers continue to prescribe opioids and may do so, in part with concern for parental dissatisfaction with post-operative analgesia. Our aim was to determine whether a post-operative prescription for opioids affects parental assessment of pain control following pediatric adenotonsillectomy. METHODS:This post-operative survey assessed the parental assessment of pain control in 324 patients, ages 1-17 years undergoing adenotonsillectomy. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 1, 2018 through March 31, 2019. Post-operative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for post-operative analgesia based on the attending surgeons prescribing preferences. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric adenotonsillectomy as poor or inadequate based on the post-operative analgesic regimen including opioids. RESULTS:Of the 798 surveys sent, the response rate was 42% (324/775) of those who received the survey email, and 69% (324/470) for those who opened the email. Between the opioid and non-opioid groups, there was no difference in gender (male; 48% vs. 51.3%; p = 0.58), race/ethnicity (white; 53% vs. 46%; p = 0.35) or insurance status (insured; 62% vs. 50.9%; p = 0.06). The proportion of parents who rated their child's pain as poor or inadequately controlled following adenotonsillectomy was relatively rare: 9% and 5% in the non-opioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following adenotonsillectomy were 58% and 50% in the non-opioids and opioid groups respectively. CONCLUSION:The results of this study indicate that non-opioid analgesic regimens following pediatric adenotonsillectomy were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric adenotonsillectomy is feasible and does not result in worse parental satisfaction with the analgesic plan.