OBJECTIVE:Sialorrhea commonly affects patients with neurodevelopmental disorders, resulting in aspiration risk and reduced quality of life. This study aims to compare the risk profiles for the surgical management of pediatric sialorrhea. METHODS:A retrospective cohort study was performed using the American College of Surgeons' National Surgical Quality Improvement Program-Pediatric database (2012-2023) of patients undergoing surgery for sialorrhea in the operating room. 30-day outcomes included medical complications, surgical complications, length of stay, unplanned reintubation, reoperation, readmission, and composite morbidity. Clinically relevant, significant variables on univariate analysis were retained for Firth's logistic regression. RESULTS:Among 295 patients, 23% received botulinum injections (Bot-Sal), 56% salivary duct ligation or re-routing (SDL/R), 10% submandibular gland excision alone (SMGE), and 11% combined SMGE + SDL/R. Compared with Bot-Sal, SDL/R was associated with lower odds of pulmonary complications (OR 0.18, 95% CI 0.06-0.56, p = 0.003), medical complications (OR 0.15, 95% CI 0.05-0.45, p = 0.001), and composite morbidity (OR 0.37, 95% CI 0.15-0.90, p = 0.027). Inpatient status (OR 5.04, 95% CI 1.87-13.62, p = 0.001) and CNS abnormalities (OR 2.70, 95% CI 1.07-6.79, p = 0.035) were independently associated with increased risk of pulmonary complications. There were no significant differences in surgical complications by procedure. CONCLUSION:Botulinum injections to the salivary glands in the operating room were associated with increased medical complications, specifically pulmonary, in this dataset, likely reflecting a combination of patient selection, clinical context, and procedural factors. Short-term complication rates may help guide families regarding options for drooling procedures in the OR. LEVEL OF EVIDENCE: 3:

BACKGROUND:Pediatric septoplasty and functional septorhinoplasty remain controversial due to concerns for the effect of surgery on the developing nose. We aimed to assess practice patterns among pediatric otolaryngologists who perform pediatric septoplasty and septorhinoplasty. METHODS:A cross-sectional survey was distributed to members of the American Society of Pediatric Otolaryngology (ASPO). Descriptive statistics were employed to summarize the typical indications and the most common techniques used in pediatric septoplasty and septorhinoplasty. RESULTS:Eighteen percent (105/577) of ASPO members completed the survey. Of respondents, 91 (87.0%) performed septoplasty, while 29 (27.9%) performed septorhinoplasty. Those who did not perform septorhinoplasty most commonly referred to Facial Plastics and Reconstructive Surgery (74.7%). Impacts on patient-reported quality of life were the most common criterion for both septoplasty and septorhinoplasty (82.2% and 76.4%, respectively). The NOSE was the most common patient-reported outcome instrument utilized. Among respondents, 38.9% did not use a strict age cutoff to perform septoplasty and 24.1% for septorhinoplasty. The most common techniques reported were columellar strut grafts for caudal septal deviation (66.7%), spreader grafts for internal nasal valve collapse (86.7%), alar batten grafts for external nasal valve collapse (55.2%), and lateral osteotomies for external bony deviations (85.2%). Spreader grafts only are used more than spreader flaps only to treat internal nasal valve collapse (62.1% vs 3.4%), while lateral osteotomies are used more than transverse osteotomies for bony deformity (85.7 vs 0%). CONCLUSION:Diminished patient-reported quality of life was the most common indication for pediatric septoplasty and functional septorhinoplasty among respondents. Columellar strut grafts, spreader grafts, alar batten grafts, and lateral osteotomies were common techniques used. Further work is needed to develop guidelines on septoplasty and functional septorhinoplasty in children and adolescents.

OBJECTIVE:Pediatric sialolithiasis can be managed effectively through both intraoral approaches, including sialoendoscopy, and extraoral approaches, such as gland removal. This study assesses factors in the evaluation and management of salivary stones in children. METHODS:A descriptive retrospective study of patients diagnosed with sialolithiasis and treated with sialoendoscopy at a tertiary care pediatric hospital from October 2008 to August 2022 was conducted. Presenting symptoms at the time of diagnosis, the distribution of stone locations, size, and the method of stone removal based on stone location were evaluated. RESULTS:Seventeen patients were included in the final review. All patients had salivary gland stones diagnosed through imaging or visualized intraoperatively. The most common presenting complaint of sialolithiasis was facial swelling (82 %). Eighty-eight percent had submandibular duct stones, and 11 % had parotid duct stones. 50 % of stones were proximal, 22 % were distal, 6 % were at the hilum, and 11 % intraglandular. Forty-seven percent of patients underwent stone removal via sialoendoscopy and intraoral incision, 35 % through sialoendoscopy alone, and 18 % required gland removal. Chi-square testing was performed to evaluate differences in removal rates based on the location of the stone. Among patients with submandibular gland stones, distal stones (100 %) were more likely to be removed via sialoendoscopy with or without an intraoral incision compared to proximal (75 %), hilar (0 %), and intraglandular stones (0 %) (p = 0.005). Proximal (25 %), hilar (100 %), and intraglandular (100 %) submandibular stones were more likely to require gland removal than distal stones (0 %) (p = 0.026). CONCLUSION:The findings in this review suggest that distal stones in the submandibular gland are more likely to be removed via sialoendoscopy with an intraoral incision as opposed to proximal, hilar, and glandular stones, which were more likely to necessitate gland excision.

Gastroesophageal reflux (GER) involves retrograde transit of gastric contents into the esophagus, a physiologic, transient, and typically benign process in infants. By contrast, GER disease arises when reflux causes troublesome symptoms or complications. Laryngopharyngeal reflux (LPR)-a subset of extraesophageal reflux-occurs when gastric contents flow proximally to affect the larynx and pharynx. LPR in the pediatric population presents unique challenges due to incomplete understanding of its pathophysiology and overlapping signs and symptoms with other conditions. Multidisciplinary evaluation is crucial for accurate diagnosis and optimal treatment.

AbstractChildren post‐tracheoesophageal fistula (TEF) repair may present with chronic respiratory and gastrointestinal symptoms that can affect quality of life.ObjectiveTo identify factors associated with positive findings on triple endoscopy following neonatal TEF repair.Study DesignCase series with retrospective review of patients.SettingTertiary care center aerodigestive program.MethodsChildren with neonatally repaired congenital TEF who had a triple endoscopy between 2011 and 2022 were reviewed. The presence of chronic cough, recurrent pulmonary infections, lipid‐laden macrophages (LLM), and airway and esophageal anomalies were among the variables analyzed. Chi‐square and Kruskal‐Wallis univariate analysis was performed.ResultsThe mean age was 4.28 ± 4.65 years old, and the most common type of TEF repaired was type C (78%). Within our cohort, 87% of patients had GERD, 60% of patients had prior esophageal dilations, and 84% of patients had tracheomalacia. Thirty‐one (46.3%) patients had laryngeal cleft, of which 77.4% had a history of prior esophageal dilations (P = .01). Twenty‐one (33.9%) patients had tracheal diverticulum on bronchoscopy, which was associated with chronic cough, stridor, and coughing with feeds. Patients with positive LLM on BAL were associated with presentation of chronic cough and stridor (P = .03). Recurrent TEF was associated with chronic cough. Subglottic stenosis was associated with a history of prolonged intubation (P < .05).ConclusionChronic cough was frequently reported and associated with tracheal diverticulum, recurrent TEF, and positive LLM findings on triple endoscopy in patients after congenital TEF repair. Patients presenting with chronic cough and stridor following congenital TEF repair may benefit from a multidisciplinary evaluation.

OBJECTIVE:To assess pediatric patients presenting with acute mastoiditis with and without intracranial complications (ICC) METHODS: A case series with retrospective review was performed on pediatric patients who presented to a pediatric tertiary care center with the diagnosis of mastoiditis from 2012 to 2020. All patients had a documented microbiology culture. The main factors compared among patients were bacteria isolated from cultures, antibiotic resistance, and occurrence of intracranial complications of mastoiditis. RESULTS:298 patients with mastoiditis were included in this study with an average age of 8.6 years (SD = 4.45). 41 of those patients presented with at least one intracranial complication (ICC) with the most common being epidural abscess (51 %). 143 (48 %) of patients had a history of acute otitis media prior to presentation, and thirty-eight patients (13 %) had a history of chronic otitis media prior to presentation. Patients with a history of acute otitis media were less likely to develop ICC compared to patients without a history of otologic infections OR: 0.49 (95 % CI = 0.24-0.99), p = 0.047. Patients with history of chronic otitis media were less likely to develop ICC compared to patients with no history of otologic infections OR: 0.20 (95 % CI = 0.04-0.90), p = 0.036. Patients with antibiotic use were more likely to develop ICC compared to antibiotic naïve patients OR: 2.64 (95 % CI = 1.31-5.32) p = 0.006. There was also no significant effect of patient sex, and ethnicity in the development of ICC. CONCLUSION:The occurrence of intracranial complications from mastoiditis are noted to be higher in patients with no history of otologic infections. Additionally, the occurrence of ICC is noted to be higher among patients with prior antibiotic use. LEVEL OF EVIDENCE:level 4 LEVEL OF EVIDENCE: level 4.

Purpose: To describe the effects of scoliosis severity on the trachea in patients with a tracheostomy tube. Materials and methods: A retrospective chart review of patients 21 years and younger with a tracheostomy and scoliosis between 2001 and 2019 was conducted at a single tertiary pediatric hospital. Patients with spine curvature from C6 - T3 (tracheal limits) were divided into two groups based on curvatures that were either greater than or equal to 30 degrees (Group A) or less than 30 degrees (Group B). Results: Among the 59 patients who met the inclusion criteria, median age at tracheostomy tube placement was 1.45 years, median tracheostomy duration was 10.26 years, and 75 % were ventilator dependent. Group A encompassed 22 patients, and Group B included 37 patients. There were no significant differences in the following outcomes between Groups A and B: obstructed carina view (p = 0.095), tracheal irritation (p = 0.270), tracheal curvature (p = 0.113), inadequate tracheostomy tube fit (p = 0.323), tracheomalacia (p = 0.765), custom tracheostomy tube use (p = 0.113), or ventilator dependence (p = 0.109). Conclusion: Most tracheostomy patients with scoliosis were ventilator dependent. Spine curvatures of 30 degrees or greater from C6 to T3 did not significantly influence view of the carina, tracheal irritation, tracheal curvature, and tracheostomy tube fit. Further work is needed to analyze the effects of scoliosis on tracheal abnormalities with greater power and to determine the best tracheostomy tube fit via in-office tracheoscopy evaluations.

Background:. Salivary gland obstruction can present as unilateral, episodic facial swelling. Vascular malformations as a cause of parotid duct obstruction with associated unilateral cheek swelling and pain are rare. Case description:. We describe the case of a 16-year-old female with a protracted 2-year history of unilateral facial swelling and pain that was misdiagnosed as recurrent parotitis on computed tomography and sialoendoscopy. Eventually, the 16-year-old female was diagnosed by magnetic resonance imaging to have a microcystic lymphatic malformation of the parotid duct as the cause of her cheek swelling and pain. Afterwards, the patient was referred to undergo interstitial bleomycin sclerotherapy. Conclusions:. This case demonstrates a unique microcystic lymphatic malformation producing obstructive symptoms as well as the utility of magnetic resonance imaging for the diagnosis of a patient presenting with recurrent unilateral facial pain and swelling.

OBJECTIVE:The purpose of the study is to compare the incidence of early postoperative tracheotomy stoma wound complications in pediatric patients using a silver-impregnated barrier dressing (Mepilex Ag) versus a standard absorbent foam dressing (standard Mepilex). METHODS:This is a prospective, non-blinded, randomized trial of pediatric patients undergoing tracheotomy at a tertiary care children's hospital. Patients were randomized to receive Mepilex Ag versus standard Mepilex tracheostoma dressings following tracheotomy. All patients received standard postoperative wound care and daily stomal examination. Wound related complications, breakdown, granulation, and infection were recorded for the first 7 days after surgery. A non-inferiority study design was used to test the hypothesis that the Mepilex group had a non-inferior wound complication rate (within 10% margin) compared to the Mepilex Ag group. RESULTS:Eighty-two patients were enrolled; 52 received Mepilex Ag, and 30 received standard Mepilex. There was no difference between the groups with respect to age, sex, race, surgical indication, or postoperative length of stay. Non-inferiority testing demonstrated that the Mepilex standard cohort had no more than 10% greater stomal wound complication rate than that of Mepilex Ag dressing group (p = 0.0108). CONCLUSION:Standard Mepilex was found to be non-inferior to Mepilex Ag in the prevention of tracheotomy stomal wound complications. Standard Mepilex may be used effectively in the postoperative period, potentially reducing costs to caregivers and the institution. Further work is needed to analyze additional factors that could contribute to poor postoperative stoma healing such as bacterial colonization. LEVEL OF EVIDENCE:Randomized Controlled Trial, 2 Laryngoscope, 134:5160-5163, 2024.

Introduction: Vagal nerve stimulator (VNS) implantation is a vital therapy for epilepsy refractory to other treatments; however, it is associated with a very high rate of voice changes. Relatively few of these patients are evaluated for vocal fold motion impairments. In this series, we evaluate 5 such patients with a novel phenotype of forced abduction with VNS stimulation. Methods: Retrospective case series. Results: Five patients with a VNS implant who underwent operative direct or in-office rigid laryngoscopy and had vocal fold motion impairment associated with VNS activation are included. All 5 patients had vocal fold mobility with VNS off and a fixed with activation. All patients exhibited vocal fold abduction with VNS activation. Patient 2 has since undergone laryngeal reinnervation, which helped her intermittent dysphonia but left a small glottic gap. A type 1 thyroplasty corrected this gap and improved her voice further. Patient 3 has undergone laryngeal reinnervation for which early results show improvement in perceptual and patient reported outcomes. Patients 4 and 5 have both undergone laryngeal reinnervation with improvement in voice. Conclusion: Previous reported cases of stimulated immobility associated with VNS use describe only adduction of the vocal fold. This series expands the previous work showing the VNS activation can also cause stimulated immobility in an abducted position, for which reinnervation and other medialization procedures offer promising treatment.

Objective: To determine the utility of triple endoscopy (combined direct laryngoscopy, bronchoscopy (DLB), flexible bronchoscopy with bronchoalveolar lavage (FB + BAL), and esophagogastroduodenoscopy (EGD)) in the diagnosis and management of patients with recurrent croup (RC), and to identify predictors of endoscopic findings Methods: A retrospective chart review was performed of pediatric patients (age < 18 years) with RC evaluated by triple endoscopy at a tertiary care pediatric hospital from 2010 to 2021. Data including presenting symptoms, airway findings, BAL and EGD with biopsy findings were collected. Results: 42 patients with RC underwent triple endoscopy were included. The mean age was 4.55 +/- 2.84 years old. The most common symptom was chronic cough among 19 (45%) patients, while 23 (55%) patients had gastrointestinal (GI) symptoms. Airway findings included tracheomalacia in 19, laryngeal cleft in 17, and subglottic stenosis in 11 patients. On EGD with biopsy, abnormal gross findings were present in 6 and abnormal microscopic findings in 18 patients, including 6 with histologic findings suggestive of gastroesophageal reflux and 5 with eosinophilic esophagitis. Seventeen (40%) patients had positive culture on BAL. No findings in patient histories significantly predicted presence of lower airway malacia, subglottic stenosis, or abnormal EGD findings. Conclusions: Children with recurrent croup presenting to aerodigestive centers may not have any pertinent presenting symptoms that correlate with significant findings on triple endoscopy. Further work is needed to determine which children with recurrent croup may benefit from aerodigestive evaluation. Level of evidence: Level 3 (c) 2023 Japanese Society of Otorhinolaryngology-Head and Neck Surgery, Inc. Published by Elsevier B.V.

Pediatric dysphagia is a common condition encountered in clinical practice. We review the physiology and development of swallow, presentation, epidemiology, and etiology of dysphagia. Additionally, comorbidities, associated conditions, and medical management of dysphagia are discussed.

Objective: To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration. Methods: Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step. Results: Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children. Conclusion: Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.

OBJECTIVE:The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy. METHODS:This single-center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long-term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long-term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy. RESULTS:One-hundred eighty-three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post-conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44-8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator-dependent 2 years following their tracheostomy. CONCLUSION:Our study provides critical perioperative complications and long-term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy. LEVEL OF EVIDENCE:3 Laryngoscope, 134:1945-1954, 2024.

INTRODUCTION:Sialorrhea or drooling can result in physical and psychosocial complications, such as aspiration and social isolation. Treatment options include botulinum toxin into the salivary glands and 4-duct ligation (i.e., simultaneous ligation of the bilateral parotid and submandibular ducts). This systematic review aimed to compare the efficacy and complication rates of botulinum toxin and 4-duct ligation for the treatment of drooling in children. METHODS:Following PRISMA guidelines, PubMed, Embase, Web of Science, and Cochrane Library were searched from inception through June 17, 2021 for studies examining the efficacy of botulinum toxin or 4-duct ligation for drooling in children. Data were summarized by pooled counts, percentages, and means. Complication rates were compared by a chi-squared test. RESULTS:A total of 22 studies (n = 606) examining botulinum toxin and 5 studies (n = 124) examining 4-duct ligation were included. From 12 botulinum toxin studies (n = 211), mean drooling frequency and severity scores was 7.5 at baseline. Mean difference from baseline was -2.6 (n = 92) at 4 weeks follow-up, -2.1 at 8 weeks (n = 41), -2.1 at 12 weeks (n = 56), and - 2.1 at 16 weeks (n = 58). From 4 4-duct ligation studies (n = 103), mean baseline drooling frequency and severity score was 8.4. Mean difference was -3.7 at mean follow-up of 35.6 months (n = 103). Eighteen botulinum studies (n = 343) recorded 53 (15.5 %) complications, including thickened saliva (n = 9), dysphagia (n = 4), and cheek abscesses (n = 4). Four 4-duct ligation studies (n = 108) recorded 25 (23.1 %) complications, including parotid gland swelling (n = 4), aspiration pneumonia (n = 3), and oxygen desaturation (n = 3). There was no statistically significant difference in complication rates between botulinum toxin and four-duct ligation (p = 0.065). CONCLUSION:Botulinum toxin injection and 4-duct ligation are both effective in improving sialorrhea in children and have comparable complication rates.

OBJECTIVE Children with tracheostomies have complex medical issues that require long-term technology dependence and continuous medical care at home. Parents of tracheostomy-dependent children often assume the majority of their child's home care leading to a shift in family dynamics and a decrease in caregiver quality of life. This systematic review sought to identify instruments to measure caregiver psychosocial outcomes after their child's tracheostomy and report on the findings. DATA SOURCES A systematic review was performed using Medline, CINAHL, and EMBASE. REVIEW METHODS Studies that evaluated psychosocial outcomes in caregivers of tracheostomy-dependent children were included. RESULTS We screened a total of 1286 nonduplicate records to include a total of 12 studies assessing the psychosocial outcomes of parents of tracheostomy-dependent children. Fourteen instruments were identified. Caregivers reported lower quality of life when compared to other chronic caregiver groups. They experienced high degrees of stress, struggled to cope individually and as a family unit, and experienced decision regret and conflict. CONCLUSION Findings from this review suggest a significant impact on caregiver psychosocial well-being, but few quantitative studies investigated this dynamic with measures validated in this caregiver population. This review demonstrates the need for longitudinal studies using validated tools to assess the long-term impacts and outcomes of caregivers of the tracheostomy-dependent child.

Objective: To provide guidance for the comprehensive management of children referred for anterior drooling. The mission of the International Pediatric Otolaryngology Group (IPOG) is to develop expertise-based recom-mendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. Methods: Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The recommendations are derived from current expert consensus and critical review of the literature.Results: Consensus recommendations include initial care and approach recommendations for health care pro-viders who commonly evaluate children with drooling. This includes evaluation and treatment considerations for commonly debated issues in drooling management, initial work-up of children referred for anterior drooling,treatment recommendations, indications and contra-indications for rehabilitation, medical, and surgical man-agement, as well as pros and cons of different surgical procedures in the hands of drooling management experts.Conclusion: Anterior drooling consensus recommendations are aimed at improving patient-centered care in children referred for sialorrhea.