Objective First branchial cleft anomalies are rare congenital head and neck lesions. Literature pertaining to classification, work up and surgical treatment of these lesions is limited and, in some instances, contradictory. The goal of this work is to provide refinement of the classification system of these lesions and to provide guidance for clinicians to aid in the comprehensive management of children with first branchial cleft anomalies. Materials and Methods Delphi method survey of expert opinion under the direction of the International Pediatric Otolaryngology Group (IPOG) was conducted to generate recommendations for the definition and management of first branchial cleft anomalies. The recommendations are the result of expert consensus and critical review of the literature. Results Consensus recommendations include evaluation and diagnostic considerations for children with first branchial cleft anomalies as well as recommendations for surgical management. The current Work classification system was reviewed, and modifications were made to it to provide a more cogent categorization of these lesions. Conclusion The mission of the International Pediatric Otolaryngology Group (IPOG) is to develop expertise-based recommendations based on review of the literature for the management of pediatric otolaryngologic disorders. These consensus recommendations are aimed at improving care of children presenting with first branchial cleft anomalies. Here we present a revised classification system based on parotid gland involvement, with a focus on avoiding stratification based on germ layer, in addition to guidelines for management.

Endoscopic posterior cricoid split and costal rib graft placement (EPCSCG) is an important tool in enlarging the glottic and subglottic airway, both of which can be disproportionally affected in the small airways of neonates and early infants. We present a series of 8 patients under the age of one who successfully underwent EPCSCG, with 7/8 patients avoiding tracheostomy entirely. Of these patients, the indication for EPCSCG was isolated bilateral vocal fold immobility (6/8), bilateral vocal fold immobility with subglottic stenosis (1/8), and isolated subglottic stenosis (1/8). EPCSCG can be safely applied to select patients less than one year of age.

OBJECTIVES:To investigate the relationship between social determinants of health and timeliness of management, adherence to follow-up, and outcomes of treatment with interarytenoid injection augmentation (IAIA). METHODS:Retrospective cohort study of all pediatric patients treated with IAIA at a large pediatric institution's multidisciplinary aerodigestive clinic between August 2022 and February 2024. Retrieved demographic factors, dates of referral, consultation, treatment, and follow-up, as well as objective measures of dysphagia and aspiration via videofluoroscopic swallow study (VFSS) reports, using dysphagia outcome and severity scale (DOSS) scores and the greatest unsafe thickness, or 'aspiration score'. These factors were analyzed for correlation with social determinants of health determined through the Area of Deprivation Index (ADI). RESULTS:A total of 120 patients, median age 15 months were included. All underwent IAIA for the indication of persistent pharyngeal dysphagia. The median national ADI score was 45. Patients experienced average improvement in laryngeal penetration and aspiration from an aspiration score of slightly thick preoperatively to thin postoperatively, and improvement in dysphagia from mild-moderate to mild. No correlation was identified between ADI, race and ethnicity, or sex and measures of timeliness of treatment, loss to follow-up, receipt of feeding therapy, or outcome of treatment. CONCLUSION:Addressing persistent dysphagia in pediatric patients with IAIA seems to be equivalently efficacious across a wide population, and outcome did not vary significantly depending on patients' race or socioeconomic contexts. This finding may be due in part to the utilization of a well-organized multidisciplinary center to treat these complex patients. LEVEL OF EVIDENCE:4 Laryngoscope, 135:2164-2170, 2025.

Objective. The objective of this study was to assess the efficacy and complication rates of interarytenoid injection augmentation (IAIA) for the treatment of dysphagia in patients 1 year of age and under and to determine if concurrent feeding therapy (FT) affects outcome. Study Design. Retrospective case series. Setting. Tertiary pediatric hospital. Methods. Retrospective review of patients 13 months of age and younger with dysphagia treated by IAIA over a 4-year period. The efficacy of IAIA was determined by comparing perioperative videofluoroscopic swallow studies (VFSS) and Dysphagia Outcome and Severity Scale (DOSS) scores. Complication rates and utilization of concomitant FT were determined by evaluating postoperative admission and follow-up records. Results. Sixty-five patients met inclusion criteria (median age 8 months, interquartile range [IQR]: 7-11). Sixty-seven percent of patients improved on postoperative VFSS scores (median improvement in aspiration of 2 thickness levels, IQR 0-3, P < .0001), and 56% improved in DOSS scores (median increase of 1, IQR: 0-1.5, P < .0001). Ninety-two percent of patients were discharged home on the day of surgery. The 30-day relevant readmission rate was 5%. No patients had intraoperative complications or severe complications at follow-up. No statistical difference in aspiration or DOSS was noted in the concomitant FT cohort due to a lack of sample size. Conclusion. This study demonstrates that IAIA in children under 13 months old shows comparable rates of success and complications to older patients reported in the literature. No patients had long-term complications and most were discharged home on the day of surgery. More studies are needed to determine the effect of concomitant FT on IAIA.

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.

Actinomycosis is a filamentous anaerobic bacillus most classically presenting as a mandibular infection following dental trauma.1 More rarely, it can cause infection throughout the larynx and pharynx among patients who are immunosuppressed.2 Laryngeal actinomycosis has been reported to mimic other diagnoses, such as laryngeal carcinoma or foreign body of the lower airway.3 We describe an episode of chicken bone aspiration, followed by the development of pharyngitis and intermittent acute respiratory distress due to actinomycosis of the larynx in an immunocompromised host. This study was deemed exempt by the Mayo Clinic Institutional Review Board. A 23-year-old man with a history of trisomy 21, acute lymphoblastic leukemia, and chimeric antigen receptor T-cell therapy presented with acute onset of intermittent severe respiratory distress, consisting of transient stridor, difficulty tolerating secretions, tripoding, and oxygen desaturation, which occurred every few hours without identifiable trigger. Treatment consisting of medication, oxygen, and nasal intermittent positive pressure ventilation did not alter the course of these episodes, and the patient would spontaneously improve and return to baseline. He was admitted to the pediatric intensive care unit, and the otorhinolaryngology department was consulted. His caregiver reported an episode of choking while eating bone-in chicken approximately 2 weeks prior to presentation. The patient endorsed mild pharyngitis until the day of admission, when he developed acute onset of stridor with respiratory distress refractory to medical therapy. At the time of bedside examination, the patient was resting comfortably on room air with moderate inspiratory stridor and no acute distress. Flexible laryngoscopy showed an erythematous larynx with a ball-valving, solid-appearing white lesion at the level of the left laryngeal ventricle (Figure 1). The patient was urgently transferred to the operating room for rigid bronchoscopy and removal of foreign body. In the operating room, the mass required significant traction to extricate. On gross examination, it appeared to be consistent with possible chicken cartilage aspiration (Figure 2). Pathology demonstrated hyaline cartilage rimmed with bacterial colonies consistent with actinomycosis, but the origin of the specimen could not be verified as human tissue or poultry. Given that significant traction was required to remove the specimen, it was suspected that the “foreign body” may represent autologous cartilage. Three-dimensional computed tomography was performed and demonstrated a possible defect of a small inferior portion of the calcified thyroid cartilage on the left. The patient’s respiratory distress was instantly alleviated following his procedure, and his pharyngitis improved with prolonged penicillin treatment. At 11 months postoperatively, flexible nasopharyngoscopy demonstrated resolution of the initial findings without airway obstruction. Inflamed supraglottis and glottis. Actinomycosis is a commensal organism of the human alimentary tract that most commonly effects the cervicofacial region among patients who are chronically ill. Laryngeal actinomycosis has been reported to mimic other diagnoses, such as laryngeal carcinoma or foreign body.1 We report an episode of potential chicken bone aspiration, followed by pharyngitis and intermittent acute respiratory distress due to actinomycosis of the larynx in an immunocompromised host. Foreign body specimen. An association between aspiration and actinomycosis of the airway has previously been demonstrated. The most commonly documented aspirated foreign bodies that cause endobronchial actinomycosis are fish and chicken bones.4, 5 There are yet other reports of laryngeal actinomycosis that was suspected to be secondary to aspirated corn.2 In this case, the patient presented with smoldering pharyngitis that evolved into acute respiratory distress and stridor. The most common symptoms of actinomycosis of the larynx include dysphonia, dysphagia, pharyngitis, and weight loss with symptoms ranging from days to months, including a rare case lasting for greater than a year.2, 4 It is rare for laryngeal actinomycosis to present with respiratory distress requiring emergent airway management.3 However, it is important to maintain actinomycosis on the differential when evaluating chronic infection, foreign body, or mass of the airway. In most reported cases, patients have been treated with prolonged penicillin to good effect.2 After reviewing the relevant literature alongside the course and outcome in our patient, we concluded that the patient’s “foreign body” was most likely autologous cartilage from the inferior aspect of the ipsilateral thyroid cartilage, which had been eroded by laryngeal actinomycosis that had been seeded by his initial aspiration event. Over the intervening 2 weeks, the infection spread to the adjacent soft tissues and cartilage, resulting in exposure and malformation of the cartilage and then sudden-onset dynamic airway obstruction. Most important, the patient’s symptoms improved with retrieval of the obstruction and prolonged penicillin treatment. Brian A. Walker, acquisition of data, literature review, manuscript preparation, editing, final approval; Mark E. Gerber, concept, photographs, critical revision of the manuscript, final approval Competing interests: None. Sponsorships: None. Funding source: None. Brian A. Walker https://orcid.org/0000-0002-5734-4889

Endoscopic cricoid expansion and reduction are newer approaches to the management of pediatric bilateral vocal fold immobility and postlaryngotracheal reconstruction glottic insufficiency, respectively. These procedures offer a less invasive, endoscopic alternative to procedures that typically required open management with a more prolonged recovery. These technically demanding procedures are currently performed only in select centers, and there is no currently described training model for practicing them. We present a modification to a laryngeal dissection station that allows for simulation of endoscopic cricoid reduction and expansion with excised larynges. The model allows trainees to practice endoscopic posterior cricoid exposure, incision of the cricoid cartilage, placement of a simulated costal cartilage graft for expansion, and endoscopic suturing for reduction. Development of simulators for procedures that are infrequently performed have the potential to help trainees reach surgical competency faster and more safely.

Objective: To review a cohort of over 2500 patients and investigate the short and long-term outcomes of intracapsular as compared to extracapsular tonsillectomy, and show if the complication rates are comparable between methods. Study design: A multicenter, retrospective chart review was conducted, evaluating pediatric tonsillectomies performed from 2004 to 2014. The electronic medical record was reviewed through December 2018, providing up to 14 years of follow-up data. Setting: Two tertiary care, academic medical centers. Subjects and methods: A retrospective chart review was conducted to identify children undergoing tonsillectomy and adenotonsillectomy. A chart review was first performed of patients by a single surgeon (MEG) and then the analysis was repeated using enterprise data warehouse (EDW) to search for complications and interventions using International Classification of Diseases, ninth revision, (ICD-9) and Current Procedural Terminology (CPT) codes. The second surgeon's patients (JLC) patients were added to increase the cohort. Patients were excluded from the review of long-term outcomes if there was less than two-year follow-up. Short-term outcomes examined included rate of post-tonsillectomy hemorrhage and re-presentation for dehydration, while long-term outcomes included rates of peritonsillar abscess and tonsillar regrowth requiring revision tonsillectomy. Results: A total of 2508 pediatric patients were identified who had undergone tonsillectomy or adenotonsillectomy. In 1456 (58.1%) of these patients, the intracapsular technique was used and in 1052 (41.9%) patients, the extracapsular technique was used. The mean documented follow-up time was 8.2 years. Thirty-five patients (1.4%) were identified with post-tonsillectomy hemorrhage, 2 of these patients (5.7%) with primary hemorrhage and 33 patients (94.3%) with secondary hemorrhage. 11 underwent intracapsular tonsillectomy and 24 underwent extracapsular tonsillectomy (p = 0.0042). The rate of post-tonsillectomy hemorrhage with intracapsular tonsillectomy was 0.76%, compared to 2.3% in the extracapsular group. Three patients (0.12%) undergoing intracapsular tonsillectomy required revision tonsillectomy; no patients in the extracapsular group required revision surgery. Three patients (0.12%) developed peritonsillar abscess postoperatively, two following intracapsular tonsillectomy and one following extracapsular tonsillectomy. Conclusion: This retrospective review comparing the intracapsular and extracapsular techniques for tonsillectomy provides further evidence of the benefits of this technique. It is worthwhile to continue offering intracapsular tonsillectomy to patients and their families during pre-operative discussions.

Objectives/HypothesisTo compare treatment outcomes in pediatric patients with chronic rhinosinusitis (CRS) using adenoidectomy and maxillary sinus irrigation with or without balloon catheter sinuplasty (BCS).MethodsProspective, randomized, and blinded. Patients between 2 and 12 years who met clinical and computed tomography criteria for CRS unresponsive to maximal medical therapy and no prior sinus‐ or adenoid‐related procedures were eligible. Twenty‐five patients were randomized, had surgery, and completed the follow‐up. The control group underwent adenoidectomy with maxillary sinus irrigation alone; the treatment group underwent the same, with the addition of maxillary BCS for the maxillary sinus irrigation. Patients and parents were blinded to group assignment throughout the follow‐up time frame. A validated questionnaire, the Sinus and Nasal Quality of Life Survey (SN‐5), was used to measure health status changes and quality of life (QOL) at baseline, 6 months, and 12 months postintervention. Data was analyzed using t tests and multivariate linear regression.ResultsThere were 12 patients in the BCS group and 13 in the control group. Other than a higher atopic history in the control group (P = 0.047), there were no significant differences (P = 0.07) in the two groups (demographics and baseline SN‐5 scores). Following surgery, both groups demonstrated similar improvement in QOL scores and median SN‐5 scores in all domains (number of sinus infections, nasal obstruction, allergy symptoms, emotional distress, and activity limitations).ConclusionThe addition of BCS to adenoidectomy/maxillary sinus irrigation did not provide additional QOL and sinonasal symptom improvement in the surgical treatment of pediatric CRS.Level of Evidence1b Laryngoscope, 128:2893–2897, 2018

Objectives: To determine the characteristics of laser-protected endotracheal tubes (LPETs) valued by otolaryngologists performing transoral laser surgery in the head and neck and to measure LPET stiffness. Methods: An online questionnaire was completed by American Broncho-Esophagological Association (ABEA) and American Head and Neck Society (AHNS) members. LPET distal end compliance was measured in a biomechanics laboratory. Results: A total of 228 out of 2109 combined ABEA and AHNS members completed the survey. The following LPET characteristics, which were properties of the Medtronic Laser-Shield II tube (MLST), were highly valued: softness and flexibility, surface smoothness, and a tight-to-shaft balloon (all P < .01). Prior to industry-driven discontinuation of the MLST, 52% of surgeons (78% of fellowship-trained laryngologists [FTLs]) reported using it; afterward, 58% reported using the stainless steel, Mallinckrodt Laser-Flex tube (MLFT). Forty-six percent of all respondents (69% of FTLs) did not consider cost being a factor in LPET choice. Biomechanical testing revealed the distal end of the MLST to be 3.45 times more compliant than the MLFT (P < .01). Conclusion: Members of the ABEA and AHNS, particularly FTLs, highly value distinguishing properties of the now discontinued MLST. Manufacturers should consider this in the design of new LPETs.

An adolescent female with a past medical history significant for Crohn's disease presented with fevers, tonsillitis without exudate, and tender posterior cervical lymphadenopathy. Laboratory results showed transaminitis, leukocytosis with a left shift, and atypical lymphocytes on a blood smear. The patient did not respond to supportive care or dexamethasone, necessitating a tonsillectomy and adenoidectomy. Although her presentation was consistent with infectious mononucleosis, diagnosis was not confirmed until Epstein-Barr virus (EBV) polymerase chain reaction (PCR) from tonsillar tissue was positive. False-negative results on the heterophile antibody test are common in pediatric populations and the detection of EBV antibodies is further complicated in immunocompromised patients. Studies indicate PCR is a more sensitive test, although there is no consensus regarding ideal material to use or quantitative levels necessitating intervention.

Objectives: Surgery is the definitive treatment for oral tongue squamous cell carcinoma (OSCC). Studies have described correlates of delayed diagnosis. However, little is known about treatment delays after diagnosis. This study investigates time intervals from diagnosis to surgery for OSCC using the National Cancer Data Base (NCDB). Methods: The NCDB was queried for OSCC patients initially treated with surgery in 1998 through 2009. Patients were dichotomized based on time to surgery relative to the median. Chi‐square and multivariable logistic regression models were used for statistical analyses. Results: A total of 14,270 patients were identified. The median age was 60 years (range, 18‐90 years). For all stages, the median time from diagnosis to surgery was 27 days (SD = 42). Factors that predicted a longer interval to surgery included: advanced stage (28 days), Hispanic ethnicity (29 days), lack of health insurance (29 days), treatment at an academic/research facility (29 days), residence >75 miles from the hospital (31 days), treatment in the Middle (29 days) and South Atlantic (28 days) states, and having a referral to a different treating center (30 days). The strongest predictors of time delay were having a referral (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.83‐2.13, P <. 001) and geographic location (Middle Atlantic: OR 1.83, 95% CI 1.57‐2.14, P <. 001). Conclusions: There is significant variation in the time from diagnosis to surgery for patients with OSCC. Several patient, geographic, and facility factors predict treatment delays. These findings can be used as a benchmark for quality of care and to guide further investigation into whether timing disparities affect outcomes.

Objectives. To review a multi-institutional experience using endoscopic posterior cricoid split and costal cartilage graft (EPCSCG) placement in the management of pediatric bilateral vocal fold immobility (BVFI), posterior glottic stenosis (PGS), and subglottic stenosis (SGS).Design. Case series with chart review.Setting. Tertiary medical centers.Methods. Review of all patients treated between 2004 and 2012 with EPCSCG placement in 3 academic and multispecialty group settings. The main outcomes measured include indications, complications, and outcome (need for additional procedures, decannulation rate).Results. A total of 28 patients underwent EPCSCG. Age range at time of surgery was 1 month to 15 years (mean, 56 months). Overall, 25 of 28 were decannulated or never required tracheostomy, and 24 of 28 had adequate symptom control with mean follow-up of 25 months. Twenty-two patients had resolution of their symptoms without additional procedures. Sixteen patients had SGS in isolation or in combination with cricoarytenoid fixation, glottic stenosis, or vocal fold immobility. Decannulation and/or symptom control was achieved in 14 of 16. Three patients had isolated PGS or cricoarytenoid fixation with all achieving decannulation. Nine patients had isolated BVFI with 7 being able to achieve resolution of their airway symptoms, 5 without additional procedures.Conclusion. This descriptive series shows a consistent outcome in more than double the number of cases previously reported in the previously published series. We believe that EPCSCG is an important option to have in the management of pediatric glottis/subglottic stenosis and bilateral vocal fold immobility.