Objective(s)The first‐line treatment for pediatric obstructive sleep apnea (OSA) is adenotonsillectomy. Post‐operative weight gain is a well‐documented phenomenon. We hypothesized that higher peri‐adenotonsillectomy delta weight correlates with lower rates of OSA resolution in pediatric patients.MethodsThis was a retrospective cohort study consisting of 250 patients from 2 to 17 years of age at a tertiary academic medical center between January 2021 and December 2022. Polysomnography results and body mass index (BMI) changes were collected through the electronic health record. Univariate and multivariate logistical regression analyses were performed, adjusting for confounding factors.ResultsPerioperative delta weight and pre‐operative baseline AHI values were significant predictors of residual OSA. For every 1‐kilogram gain in weight, the odds of residual OSA (AHI >5) increase by 6.0% (OR = 1.06, 95% CI = 1.02–1.10, p < 0.002), and the odds of residual severe OSA (AHI > 10) increase by 8% (OR = 1.08, 95% CI = 1.04–1.12, p < 0.001). Increased AHI, Black/African American race, and male sex were also factors associated with incomplete OSA resolution.ConclusionsIncreased peri‐adenotonsillectomy delta weight is associated with higher rates of residual OSA in children. Patients and families should be counseled about appropriate weight loss and control methods before adenotonsillectomy.Level of EvidenceIV Laryngoscope, 134:4141–4147, 2024

Objective Pediatric inferior turbinate hypertrophy (PedTH) is a frequent and often overlooked cause or associated cause of nasal breathing difficulties. This clinical consensus statement (CCS) aims to provide a diagnosis and management framework covering the lack of specific guidelines for this condition and addressing the existing controversies. Methods A clinical consensus statement (CCS) was developed by a panel of 20 contributors from 7 different European and North American countries using the modified Delphi method. The aim of the CCS was to offer a multidisciplinary reference framework for the management of PedTH on the basis of shared clinical experience and analysis of the strongest evidence currently available. Results A systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) criteria was performed. From the initial 96 items identified, 7 articles were selected based on higher‐evidence items such as randomized‐controlled trials, guidelines, and systematic reviews. A 34‐statement survey was developed, and after three rounds of voting, 2 items reached strong consensus, 17 reached consensus or near consensus, and 15 had no consensus. Conclusions Until further prospective data are available, our CCS should provide a useful reference for PedTH management. PedTH should be considered a nasal obstructive disease not necessarily related to an adult condition but frequently associated with other nasal or craniofacial disorders. Diagnosis requires clinical examination and endoscopy, whereas rhinomanometry, nasal cytology, and questionnaires have little clinical role. Treatment choice should consider the specific indications and features of the available options, with a preference for less invasive procedures. Level of Evidence 5 Laryngoscope , 134:1437–1444, 2024

The incidence of serious complications from acute rhinosinusitis has been estimated to be 1:12,000 in children and 1:32,000 in adults. Orbital complications are more common than intracranial complications and most commonly occur in male children. Most orbital complications occur from an infected ethmoid sinus. Subperiosteal abscess (SPA) of the orbit most commonly affects the medial wall but can also involve the inferior and superior orbital walls. The initial workup includes a full ophthalmologic evaluation. If there is concern for an orbital complication beyond preseptal cellulitis, computed tomography of the sinuses, preferably with contrast, is the investigation of choice. Management of SPA with endonasal endoscopic techniques has decreased the morbidity of surgery. Younger patients with smaller abscesses may be treated initially with medical therapy and close observation, but any patient whose condition does not improve after 48 to 72 hours requires operative drainage. Surgeons should be prepared for increased blood loss and inflamed mucosa that can make the approach challenging. Management of SPAs requires a multidisciplinary team.

Objective: Non-surgical management of chronic rhinosinusitis (CRS) in children with cystic fibrosis (CF) has been increasing over the last decade. This study examines inpatient children with pulmonary exacerbation of CF who were also diagnosed with CRS and underwent endoscopic sinus surgery (ESS). Study design: We used the 2003 to 2016 Kids Inpatient Database to perform a cross-sectional analysis of inpatients (ages 0-21 years) diagnosed with CF and CRS in the United States from 2003 to 2016. Demographics and CF associated comorbidities were recorded and rates of CRS and ESS in children with CF were examined. Results: 49,110 children were included in the study. A total of 9334 (19%) were diagnosed with CRS. The average age was 13 (SD 5.9) years; the majority were female (56%), and White (67%). The prevalence of CRS increased from 2003 to 2016 (14%-23%, p < 0.001) while the rate of ESS decreased (20%-11%, p < .001). Patients with CRS that underwent ESS more commonly had CF-associated comorbidities including GI manifestations (15%- 25%, p < .001) and liver disease (15%-30%, p < .001). Conclusion: The diagnosis of CRS in children with CF hospitalized for pulmonary exacerbation has increased while ESS has decreased in the last decade. Patients with CRS that underwent ESS more commonly had CF associated comorbidities. Studies to determine whether children with CF-associated comorbidities are more likely to benefit from ESS are needed.

OBJECTIVES:Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of neonatal respiratory distress that is difficult to treat. The primary objective of this study was to identify factors that predict the need for initial and revision surgery for CNAPS. The secondary objective is to identify risk factors in maternal history associated with the development of CNPAS. METHODS:Infants with CNPAS between 2010 and 2017 were identified by ICD- 9 and 10 codes. Demographics, maternal history, anatomic features on imaging and medical and/or surgical management were reviewed. Frequencies, means and standard deviations were calculated. A p-value <.05 was considered significant. RESULTS:Twenty infants were included. All underwent flexible nasal endoscopy with inability to pass the scope in either nostril in 65% of infants. Nineteen had a CT scan and 13 had a MRI with midline defects in 76.3% and 53.8%, respectively. Solitary central mega-incisor was present in 65%. Half underwent surgical intervention at a mean age of 74.8 days, with 90% requiring revision surgery. There was no difference in pyriform aperture distance in the surgical and non-surgical patient subgroups (5.4 mm and 5.2 mm, p = .6 respectively). No specific variables were predictive of need for initial or revision surgery. Maternal diabetes mellitus (MDM) was found in 55% of mothers of infants with CNPAS. CONCLUSION:Pyriform aperture distance was not a predictor of surgical intervention. MRI should be considered in all infants with CNPAS as the rate of intracranial complications is high. MDM may be a risk factor for CNPAS.

Objective: To study the role of endoscopic sinus surgery (ESS) in the management of intracranial complications of children with acute rhinosinusitis Methods: Retrospective chart review at a tertiary care pediatric hospital Main outcomes: Demographics, intracranial complications, length of hospital stay (LOS), neurological sequelae, ESS, neurosurgical procedures Results: Twenty-four children with a mean age (SD) of 12.9 years (+/-3.2) with an intracranial complication(s) of acute rhinosinusitis were identified between 2005-2016. A total of 22 were included and 15 (68%) of these were males. The most common complications were: subdural abscess (n =10), epidural abscess (n =10), meningitis (n = 5), intraparenchymal abscess (n = 5), and cavernous sinus thrombosis (n = 2). Neurologic symptoms included headache (n = 12), hemiparesis (n = 5) and aphasia (n = 3). Average length of stay was 16 (+/- 9.2) days. Average follow up was 7 (+/-5.6) months. One patient had residual seizures and 1 had recurrent rhinosinusitis. Aphasia and hemiparesis resolved in all patients within 1 year. Nineteen (86%) patients had ESS within 4 days of admission. Fourteen patients (63%) had a neurosurgical procedure, 6 (27%) required more than 1 neurosurgical procedure. Six patients (27%) had concurrent neurosurgical drainage and ESS. Four patients (17%) had neurosurgical procedure followed by ESS and 3 patients (13%) were treated only by a neurosurgical procedure. Patients who underwent ESS prior to a neurosurgical procedure had significantly less risk of needing a neurosurgical intervention (OR = .02, p < .01). There was a significantly higher proportion of neurosurgical patients with positive Strep anginosus cultures compared to the ESS only group (85.7% vs 37.5%, p = .02). Studies with larger patient populations are needed to determine the role of ESS in the management of intracranial complications of children with acute rhinosinusitis. Discussion: Early ESS may be associated with less need for neurosurgical procedures.

Pediatric Obstructive Sleep Apnea (OSA) is a chronic disorder characterized by the disruption in sleep due to involuntary and temporary cessation of breathing. Definitive diagnosis of OSA requires an intrusive and expensive approach based on polysomnography where the children spend a night in the hospital under the supervision of a sleep technician. The prevalence of OSA is increasing, making the traditional diagnostic approach prohibitively expensive. There has been increasing interest in designing inexpensive approaches to screen children such as the use of questionnaires. In this paper, we study the efficacy of five widely used and representative questionnaires on their ability to diagnose and stratify OSA. Our experiments show that the diagnostic ability of each of these questionnaires is insufficient for widespread clinical use. Using techniques from data mining, we identify the most informative questions and propose a new questionnaire. We show that machine learning models trained based on the answers to our questionnaire can stratify OSA with higher accuracy.

Abstract Background Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB), is a bacterial pathogen that infects roughly one-third of the worldÕs population and causes 1–2 million deaths per year. The current paradigm is that phagocytosis of Mtb by patrolling alveolar macrophages initiates Mtb infection. While this model can account for pulmonary TB, it does not adequately explain the occurrence of extrapulmonary forms of TB that manifest in the absence of obvious lung involvement, such as tuberculous cervical lymphadenitis, also known as scrofula. We hypothesized that specialized epithelial cells called microfold cells (M cells) may be an alternate portal of entry for Mtb. Previously we demonstrated that Mtb is able to transcytose across an epithelial barrier in an M cell dependent manner and that M cell mediated transcytosis is vital for Mtb pathogenesis in a mouse model of tuberculosis. Methods We used an in vitro M-cell mediated translocation assay and a Mtb mutant lacking a key virulence factor, ESAT6. We used biochemistry and genetics to identify a novel receptor for ESAT6. We also developed a novel explanted human adenoid Mtb infection model to study mucosal immunity. Results We now demonstrate that the Mtb virulence factor ESAT6 is necessary and sufficient to mediate binding and transcytosis by M cells in vitro and in vivo, and that uptake of Mtb by M cells requires a unique cell surface ESAT6 receptor. We developed a novel explanted human adenoid model of M cell biology and demonstrate rapid Mtb transcytosis by primary human tissue within 60–120 minutes. Using flow cytometry we find that Mtb is first ingested by M cells and then after transcytosis, by tissue resident antigen-presenting cells. Explanted adenoids from 10 independent donors display a wide range of Mtb uptake. Conclusion We conclude that Mtb ESAT6 is necessary for Mtb uptake by M-cells and that binding and transcytosis require a host receptor. Because explanted adenoids display a wide range of Mtb uptake, M cell mediated transcytosis may confer differential susceptibility to scrofula and disseminated disease. These findings are significant as M cells could potentially serve as the basis for novel therapeutic targets against primary Mtb infection. Disclosures All authors: No reported disclosures.

Objectives/Hypothesis: To evaluate the prevalence of nocturnal enuresis in children diagnosed with sleep disordered breathing (SDB) and the effect of adenotonsillectomy (T&A) on nocturnal enuresis. Study Design: Systematic review of the literature. Methods: Systematic review of the literature was performed using PubMed and Ovid. A systematic analysis of the literature was performed from 1980 to 2010 to identify children who had SDB and enuresis. A subset of children with enuresis who underwent T&A for SDB were also studied. Results: A total of 14 studies were reviewed. A total of 3,550 children had SDB, of which one-third (n = 1,113) had a diagnosis of enuresis. Age range was 18 months to 19 years. Seven studies (n =1,360) had data on patients who underwent T&A for SDB with follow-up data on enuresis. The mean sample size was 194, with a median follow-up of 6 months and age range of 2 to 18 years. Preoperative prevalence of enuresis was 31% (426/1,360). A total of 587 children were followed after T&A. The postoperative prevalence of enuresis was 16% (95/587; P < .0002, two-tailed). Most studies did not make a distinction between primary and secondary enuresis. The age range of the subjects (18 months to 19 years) likely included some patients with developmentally acceptable enuresis. Conclusions: SDB in children is associated with nocturnal enuresis. T&A is associated with a significant improvement in enuresis in children with SDB. There is a need for randomized controlled trials to look at the role of T&A in children with SDB and enuresis. Laryngoscope, 2012

Excessive weight gain after tonsillectomy has been described by a handful of studies since as early as 1988 and, in recent years, mostly with variable study design, methods, and baseline weight of the subjects. Although most otolaryngologists have likely been asked whether tonsillectomy may lead to weight gain by parents and caretakers, there has been very limited research on this issue, and certainly no causal effect has been established by existing research. Awareness and counseling based on what has been described are relevant as a part of preoperative counseling. However, it is critical that our national epidemic of excessive weight gain in children and adolescents not be simply reduced to a matter of tonsillectomy but be understood as a multifactorial and complex issue. To study this topic well requires commitment to well-designed studies assessing caloric intake and expenditure, metabolic changes, and prospective growth measurements. Mechanisms for weight gain, even if excessive during the 12 months after tonsillectomy surgery, are far from being elucidated.

Objective. Tonsillectomy is the most common major surgical procedure performed in children. There is evidence that tonsillectomy is associated with weight increase and may contribute to pediatric obesity. The study aimed to review the evidence that tonsillectomy with or without adenoidectomy is a risk factor for future obesity. Data Sources. Systematic literature search was performed using PubMed and Ovid. Review Methods. Systematic analysis of the literature from 1970 to 2009 on patients who underwent adenotonsillectomy (T&A) with preoperative and postoperative weight-based measurements. Results. Nine studies satisfied inclusion criteria. A total of 795 children were included. Preoperative weight ranged from normal to morbid obesity. In total, 656 children had demographic information recorded, and 53.35% of the children were male. Indication for surgery was not recorded in 336 patients. In 47.7% patients, the indication recorded was sleep-disordered breathing. The first group included 3 studies involving 127 children, and body mass index (BMI) increased by 5.5% to 8.2%. The second group included 3 studies involving 419 patients; the standardized weight scores increased in 46% to 100% of patients. The third group included 3 studies with 249 patients; the corrected weight increased postoperatively in 50% to 75% of patients. Morbidly obese patients (weight 130%-260% vs peers) remained unchanged postoperatively. Limitations. Each study was designed with different definitions of overweight and a range of follow-up periods. Demographic information was limited. Conclusions. A large population of normal and overweight children undergoing T&A gained a greater than expected amount of weight postoperatively, which suggests an association between T&A and weight gain. A significant need exists for a large study with consistent outcomes measured.

Otolaryngology–Head and Neck SurgeryVolume 143, Issue S2 p. P110-P110 Oral Presentation Adenotonsillectomy: A Risk Factor for Obesity? Anita Jeyakumar MD, Anita Jeyakumar MD presenterSearch for more papers by this authorNicholas Fettman MD, Nicholas Fettman MDSearch for more papers by this authorRon Mitchell MD, Ron Mitchell MDSearch for more papers by this author Anita Jeyakumar MD, Anita Jeyakumar MD presenterSearch for more papers by this authorNicholas Fettman MD, Nicholas Fettman MDSearch for more papers by this authorRon Mitchell MD, Ron Mitchell MDSearch for more papers by this author First published: 20 June 2017 https://doi.org/10.1016/j.otohns.2010.06.196Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume143, IssueS2August 2010Pages P110-P110 RelatedInformation

To review the history of pediatric laryngotracheal reconstruction and to highlight those who made major contributions in the field.

OBJECTIVE: The purpose of this study was to determine the effectivenes of adenotonsillectomy (T&A) for treating obstructive sleep apnea (OSA) in obese children.DATA SOURCES: PubMed and Ovid databases.REVIEW METHODS: A meta-analysis of studies that reported sleep parameters in obese children with OSA before and after T&A. Data were analyzed using the random effects model. Statistical significance was P <= 0.05.RESULTS: Data from four Studies that included 110 children were analyzed. The mean sample size was 27.5 (range, 18-33). The mean body mass index 7 score was 2.81. The mean pre- and postoperative apnea-hypopnea index (AHI) was 29.4 (range, 22.2-34.3) and 10.3 (range. 6.0-12.2). respectively. The weighted mean difference between pre- an(] postoperative AHI was a signifiant reduction of 18.3 events per hour (95% confidence interval [Cl]. 11.2-25.5). The mean pre- and postoperative oxygen saturation nadir was 78.4 percent (range. 73.9%-81.1%) and 85.7 percent (range 83.6%-89.9%). respectively. The weighted mean difference was a significant increase of the oxygen saturation nadir of 63 percent (95% Cl. 3.9-8.7). Forty-nine percent of children had a postoperative AHI <5. 25 percent of children had a postoperative AHI <2, and 12 percent of children had a postoperative AHI <1.CONCLUSIONS: T&A improves but does not resolve OSA in the majority of obese children. The efficacy and role of additional therapeutic Options require more study. The high incidence of obesity in children makes this a public health priority.

Objective: Describe the pharmacokinetics of ciprofloxacin and dexamethasone after administration of CIPRODEX (R) Otic Suspension (CIP/DEX) into the middle ears of children.Design: Open-label, single-dose, pharmacokinetic studies, administering four drops of CIP/DEX instilled into each middle ear through the tympanostomy tubes immediatety following tube placement. Blood was collected for 6 h and analyzed for ciprofloxacin and dexamethasone concentrations using a validated liquid chromatography and tandem mass spectrometry (LC/MS/MS) method.Setting: The study was conducted through a referral pediatric ototaryngology practice with actual surgical procedures performed in an ambulatory care center.Patients: Twenty-five randomly selected patients, 1-14 years of age (mean age, 5 years), receiving tympanostomy tubes.Results: Peak ciprofloxacin plasma levels were observed at about 1 h, with a mean C-max of 1.33 +/- 0.96 ng/mL (range <0.5-3.45 ng/mL) and an estimated half-life of 3.0 +/- 1.2 h. Peak dexamethasone plasma levels were observed within 2 h with a mean C-max of 0.90 +/- 1.04 ng/mL (range <0.05-5.10 ng/mL) and an estimated half-life of 3.9 +/- 2.9 h.Conclusion: These results demonstrated low systemic exposure of ciprofloxacin and dexamethasone following topical otic administration in pediatric patients. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

The workup and treatment of rhinosinusitis in children is usually multidisciplinary. Recent advances in endoscopy and imaging techniques and in pharmacotherapy continue to improve the overall well-being of children with sinus disease. Research to date has focused mostly on antimicrobial therapy, criteria for disease classification, and improved techniques in operative management in adults. Sinus disease in children differs significantly from that seen in adults. Children with sinus disease have multiple factors that influence the presentation and the progression of the disease and these factors may be congenital, immunologic, or environmental. In addition, the initial symptoms, clinical findings, and radiological manifestations are quite different in children than in adults.

Rhinosinusitis is a disease state that affects the nasal passages and the paranasal sinuses. During the initial 7 to 10 days of the disease process, acute rhinosinusitis is difficult to distinguish from a simple upper respiratory infection. Acute rhinosinusitis becomes evident when the signs and symptoms persist beyond 10 days. Chronic rhinosinusitis is a disease state that persists for longer than 12 weeks. Chronic rhinosinusitis may be exacerbated by acute rhinosinusitis (1). Rhinosinusitis can be further divided into a subacute form with duration of symptoms intermediate between acute and chronic disease (2). Clinically, rhinosinusitis is indistinguishable from rhinitis. Although isolated rhinitis may occur, isolated sinusitis is rare (1,3).

Orbital complications of pediatric rhinosinusitis are usually unilateral at presentation. We describe 3 children with bilateral orbital cellulitis that occurred as a complication of rhinosinusitis. The children ranged in age from 11 to 14 years, had prolonged hospital stays that ranged from 10 to 19 days, and underwent multiple surgical procedures to drain subperiosteal and intraorbital abscesses. They appeared to have direct spread of disease from the ethmoid sinuses to both orbits, without intracranial spread of infection. Therefore, the presence of bilateral orbital complications of rhinosinusitis does not necessarily imply spread of disease to the cavernous sinus. Children who present with bilateral orbital complications of rhinosinusitis should be treated aggressively from the outset, since they suffer from a more widespread form of the disease.