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Objectives: In patients with mandibular hypoplasia, mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction. Drug-induced sleep endoscopy (DISE) provides a dynamic assessment of the upper airway and visualizes anatomical site and cause of airway obstruction. The aim of this study was to evaluate the effect of MDO on tongue-based airway obstruction found by DISE within a non-isolated patient population with severe upper airway obstruction (UAO). Furthermore, we aimed to assess the additional value of DISE in clinical decision making by correlating DISE findings to functional airway outcomes after MDO., Methods: Findings on DISE in children who underwent MDO were retrospectively gathered and evaluated. According to DISE findings, severity of tongue-based obstruction was scored using a 4-step classification similar to the one that is used by Bravo et al.. Intubation conditions were scored according to the Cormack Lehane score (CLS). Pre-and postoperative DISE findings were compared and correlated with functional airway outcomes following MDO., Results: In 19 out of 28 MDO procedures, both a pre-and postoperative DISE was available. Tongue-based obstruction scores improved in 13 procedures, which correlated to a functional improvement in seven. Postoperative tongue-based obstruction differed significantly between patients with successful MDO and patients treated unsuccessfully (2.00 ((Interquartile range (IQR) 1.00-2.00) vs. 3.00 (IQR 2.00-4.00), p = 0.028), whereas this difference was not significant for the CLS (1.00 (IQR 1.00-1.50) vs. 2.00 (IQR 1.00-4.00), p = 0.066). If no improvement of tongue-based obstruction was seen, MDO is very unlikely to be successful on the functional airway., Conclusions: DISE provides information on the site and nature of airway obstruction and can visualize the effect of MDO on the severity of tongue-based airway obstruction. Therefore, it can be of additional value in understanding the differences in functional airway outcomes after MDO and aids in deciding appropriate and targeted treatment. Hence, standardized use of DISE, in addition to the clinical assessment of mandibular position and a polysomnography, during MDO management is highly recommended., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: The effectiveness of adenotonsillectomy for obstructive sleep disorder breathing (OSDB) in children under age 2 years is unclear. The present study aimed to identify the perioperative symptoms and clinical outcomes of adenoidectomy and tonsillectomy in very young children., Patients and Methods: The present, single-center, retrospective cohort study, conducted from January 2010 to April 2020, enrolled patients under age 2 years with moderate to severe upper airway obstruction who underwent an adenoidectomy or tonsillectomy. The patients were divided according to The Brodsky grading scale into group 1 (Grade 0 to 1 tonsils) or group 2 (Grade 2 or higher tonsils), who received only an adenoidectomy. Group 3 comprised patients with a concomitant adenoidectomy and tonsillectomy. Perioperative symptoms among the groups and the cumulative revision-free status and recurrence-free status rates in groups 1 and 2 were analyzed., Results: Fifty-three patients were enrolled. The median standard deviation score (SDS) for height and weight was -0.79 and -0.31, respectively. No postoperative complications, such as bleeding, were observed. However, two patients underwent intubation preoperatively due to severe obstruction. Seven patients underwent revision surgery. The cumulative revision-free and recurrence-free rates at week 60 were 81% and 100% for Group 1 and 42% and 48.5% for Group 2, respectively. The cumulative revision-free rate and cumulative recurrence-free rate were significantly higher in Group 1 (P < 0.0001; HR: 47.9; 95% CI: 1.12-2050 and P < 0.007; HR: 4.62; 95% CI: 1.37-15.6, respectively). None of the patients in Group 3 had revision surgery or symptom recurrence., Conclusion: Simple adenoidectomy in children with large tonsils carries a high risk of revision surgery. However, given the high risk of severe obstruction in very young children with OSDB, timely surgery is recommended., Level of Evidence: 3., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery., Methods: Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses., Results: Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure., Conclusions: Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: Despite new therapeutic perspectives, the presence of central airways occlusion (CAO) in patients with locally advanced non-small cell lung cancer (NSCLC) is associated with poor survival. There is no clear evidence on the clinical impact of interventional bronchoscopy as a part of an integrated treatment to cure these patients., Materials and Methods: This retrospective cohort study was conducted in two teaching hospitals over a 10 years period (January 2010-January 2020) comparing patients with NSCLC at stage IIIB and CAO at disease onset treated with chemotherapy/radiotherapy (standard therapy-ST) with those receiving interventional bronchoscopy plus ST (integrated treatment-IT). Primary outcome was 1-year survival. The onset of respiratory events, symptoms-free interval, hospitalization, need for palliation, and overall mortality served as secondary outcomes., Results: A total of 100 patients were included, 60 in the IT and 40 in the ST group. Unadjusted Kaplan-Meier estimates showed greater effect of IT compared to ST on 1-year survival (HR = 2.1 95%CI[1.1-4.8], p = 0.003). IT showed a significantly higher survival gain over ST in those patients showing KRAS mutation (7.6 VS 0.8 months,<0.0001), a lumen occlusion >65% (6.6 VS 2.9 months,<0.001), and lacking the involvement of left bronchus (7 VS 2.3 months,<0.0001). Compared to ST, IT also showed a favorable difference in terms of new hospitalizations (p = 0.03), symptom-free interval (p = 0.02), and onset of atelectasis (p = 0.01)., Conclusions: In patients with NSCLC stage IIIB and CAO, additional interventional bronchoscopy might impact on 1-year survival. Genetic and anatomic phenotyping might allow identifying those patients who may gain life expectancy from the endoscopic intervention., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To provide recommendations for the comprehensive management of airway obstruction in patients with Robin Sequence., Methods: Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG)., Results: The consensus statement provides recommendations for medical specialists who manage infants with Robin Sequence including: evaluation and treatment considerations for commonly debated issues in post-natal airway obstruction, assessment of antenatal obstruction and perinatal airway management., Conclusion: Consensus recommendations are aimed at improving management of airway obstruction in patients with Robin Sequence., Competing Interests: Declaration of competing interest Dr Balakrishnan declares Royalties from Springer, Inc; Research funding from Rosivo, Inc. Other authors don't have any conflict of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To compare glottic and supraglottic movements in healthy adolescents and adolescents experiencing dyspnoea during strenuous exercise., Methods: Using the continuous laryngoscopy exercise (CLE)-test laryngeal movements during exercise were analysed in healthy controls (n = 28) and compared to subjects with exercise induced bronchoconstriction (EIB) (n = 10), exercise induced laryngeal obstruction (EILO) (n = 10) and subjects experiencing exercise-induced dyspnoea without having any of these diagnoses (n = 31). Images from the video recordings were assessed regarding glottic angle, glottic area and supraglottic area using the software measuring tool EILOMEA., Results: No significant differences were detected between controls, the dyspnoea group without a diagnosis of EIB or EILO and the EIB group regarding glottis angle, glottis area or supraglottic area at maximum effort. All three parameters differed significantly in the EILO group compared to the other groups (p=<0.001). In the group with EILO all but one had supraglottic obstruction (corresponding to a CLE-test score ≥2). Movement of the laryngeal structures, corresponding to a CLE-test score of 1, at glottic and/or supraglottic level was seen in 26 of 35 (74%) of controls, 34 out of 41 (83%) of patients in the dyspnoea group, and in 25 of 38 (66%) of EIB-subjects., Conclusion: Minor movements at both glottic and supraglottic level are equally common in healthy controls as among adolescents with exercise induced dyspnoea without EIB or EILO and adolescents with EIB. Adolescents with EILO had a statistically significant more pronounced supraglottic obstruction than the other groups., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Exercise-induced laryngeal obstruction (EILO) affects 2-3% of the general population and 5.1% of elite athletes. Symptoms arise during high-intensity exercise and resolve at rest. EILO is often misdiagnosed as exercise-induced asthma as both conditions can present with dyspnea, chest tightness and cough. The purpose of this quality initiative was to identify patient characteristics that predict a higher likelihood of EILO, streamline referrals for exercise-endoscopy testing and avoid unnecessary medications., Methods: A retrospective chart review included patients referred to a pediatric tertiary center between 2013 and 2018 for suspected EILO requesting exercise endoscopy. Data was collected from the patient chart and referral letters included age, sex, physical activity, medications, symptoms, and results of pulmonary and cardiac function tests., Results: Between 2013 and 2018, 35 patients (9 males and 26 females, aged 5-18 years) were referred. Only 18 patients developed symptoms during an exercise endoscopy test. The majority were female (15/18), older than 10 years (18/18) and were involved in competitive sports (16/18). Stridor was the most common complaint among all patients referred (24/35) and many reported anxiety and high stress (15/35). The majority (63%) were previously treated with asthma medication. Pulmonary and cardiac function testing was not predictive of EILO., Conclusion: EILO is typically present in adolescent females involved in competitive sports. Anxiety and high stress was commonly noted. The majority were treated with asthma medication even though pulmonary function testing was normal. Recognition of this patient profile should improve timely access to appropriate diagnostic assessments, avoid unnecessary medical treatment, and promote a return to optimal athletic performance., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background and Objectives: The main pathologic feature of asthma is episodic airway obstruction. This is usually detected by spirometry and body plethysmography. These tests, however, require a high degree of collaboration and maximal effort on the part of the patient. There is agreement in the literature that there is a demand of research into new technologies to improve non-invasive testing of lung function. The purpose of this study was to develop automatic classifiers to simplify the clinical use and to increase the accuracy of the forced oscillation technique (FOT) in the diagnosis of airway obstruction in patients with asthma., Methods: The data consisted of FOT parameters obtained from 75 volunteers (39 with obstruction and 36 without). Different supervised machine learning (ML) techniques were investigated, including k-nearest neighbors (KNN), random forest (RF), AdaBoost with decision trees (ADAB) and feature-based dissimilarity space classifier (FDSC)., Results: The first part of this study showed that the best FOT parameter was the resonance frequency (AUC = 0.81), which indicates moderate accuracy (0.70-0.90). In the second part of this study, the use of the cited ML techniques was investigated. All the classifiers improved the diagnostic accuracy. Notably, ADAB and KNN were very close to achieving high accuracy (AUC = 0.88 and 0.89, respectively). Experiments including the cross products of the FOT parameters showed that all the classifiers improved the diagnosis accuracy and KNN was able to reach a higher accuracy range (AUC = 0.91)., Conclusions: Machine learning classifiers can help in the diagnosis of airway obstruction in asthma patients, and they can assist clinicians in airway obstruction identification., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: The role of airway fluoroscopy in the diagnosis of laryngotracheal anomalies in infants is controversial. We aimed to (i) compare airway fluoroscopic characteristics with endoscopic findings in infants presenting for evaluation of upper airway obstruction and (ii) assess the as low as is reasonably achievable (ALARA) status for airway fluoroscopy as an initial diagnostic test in suspected laryngotracheal anomalies., Materials and Methods: We performed a retrospective review of children who underwent fluoroscopy and endoscopic evaluation of the airway in the operating room for suspected laryngotracheal anatomic abnormalities. Thirty-four infants who underwent both procedures at a tertiary level university-based children's hospital from January 1, 2008 to December 1, 2013 were included. Infants with suspected foreign bodies or an existing tracheostomy were excluded. Intraoperative findings from endoscopy and radiologic interpretation from fluoroscopy were compared using standard tools for validation of a diagnostic test. These metrics were compared with historic data that suggested good correlation between radiologic and endoscopic findings in older children., Results: The median age was 3.6 months (range 1-8 months). The sensitivity of airway fluoroscopy for determining laryngotracheal pathology was 18%. Specificity, positive predictive value and negative predictive value were 83%, 67% and 35%, respectively. Although each fluoroscopic exposure was optimized for pediatric patients, the median cumulative exposure to ionizing radiation was 19 mR (range 10-34 mR)., Conclusions: Airway fluoroscopy yields metrics that are overall poor to be considered a valid and accurate universal radiologic diagnostic test in infants evaluated for laryngotracheal pathology. The cumulative exposure to ionizing radiation from use of a fluoroscope cannot be justified by the sensitivity of the test and may not conform to ALARA standards for imaging in this population., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Severe malignant airway obstruction (SMAO) is a life-threatening form of non-small cell lung carcinoma (NSCLC)., Objectives: To determine the efficacy and safety of para-toluenesulfonamide (PTS) intratumoral injection in NSCLC-SMAO., Methods: Ninety patients with NSCLC-SAO received repeated courses of PTS intratumoral injection until tumor sizes had reduced by 50% or greater. Primary endpoint was objective alleviation rate, assessed by chest computed tomography (CT) and bronchoscopy, at day 7 and 30 following final dosing. Secondary endpoints included airway obstruction, spirometry, quality-of-life and survival time., Results: In full-analysis set (N=88), using RECIST criteria, PTS treatment resulted in a significant objective alleviation rate [chest CT: 59.1% (95%CI: 48.1%-69.5%), bronchoscopy: 48.9% (95%CI: 38.1%-59.8%) at day 7; chest CT: 43.2% (95%CI: 32.7%-54.2%), bronchoscopy: 29.6% (95%CI: 20.3%-40.2%) at day 30]. There was a remarkable increase in FVC (mean difference: 0.35 liters, 95%CI: 0.16-0.53 liters), FEV1 (mean difference: 0.27 liters, 95%CI: 0.07-0.48 liters), Baseline Dyspnea Index (mean difference: 64.8%, 95%CI: 53.9-74.7%) and Functional Assessment of Cancer Therapy-Lung Cancer Subscale (mean difference: 6·9, 95%CI: 3.8-9.9) at day 7 post-treatment. We noted significantly reduced prevalence of atelectasis (by 42.9%) and Eastern Cooperative Oncology Group physical performance scale (mean difference: 7.2, 95%CI: 3.9-10.5). Median survival time was 394 days in full-analysis set and 460 days in per-protocol set. Adverse events were reported in 64.0% of subjects. Seven severe adverse events (7.9%) were reported, of which three led to death (drug-related in one case)., Conclusion: PTS intratumoral injection is effective and well tolerated for palliative therapy of NSCLC-SMAO., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Congenital airway obstruction is of varied etiology and uncommonly encountered. Prenatal care and imaging have enhanced detection of these abnormalities and allow for multi-disciplinary care planning for airway management at delivery. Despite the availability and advances in prenatal imaging, unanticipated airway obstruction may not be identified until the time of delivery., Methods: Case series., Results: Four airway emergencies were encountered in the labor and delivery suite over an eight-month period. Clinical history is correlated with autopsy findings. Congenital upper airway and laryngotracheal anomalies are reviewed. Recommendations to improve timely and efficient airway management in the labor and delivery suite are discussed and a protocol for a multi-disciplinary neonatal emergency airway response team is offered for consideration., Conclusions: The development and implementation of a multi-disciplinary emergency newborn airway protocol is both realistic and feasible. While it did not improve survivability in our small group, it did reduce response time. It, or a protocol like it, is recommended for institutions caring for high-risk pregnancies and with Neonatal Intensive Care Units with high acuity patients., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background/objectives: While upper airway obstruction is a common problem in the pediatric population, the first-line treatment, adenotonsillectomy, fails in up to 20% of patients. The decision to proceed to surgery is often made without quantitative anatomic guidance. We evaluated the use of a novel technique, long-range optical coherence tomography (LR-OCT), to image the upper airway of children under general anesthesia immediately before and after tonsillectomy and/or adenoidectomy. We investigated the feasibility of LR-OCT to identify both normal anatomy and sites of airway narrowing and to quantitatively compare airway lumen size in the oropharyngeal and nasopharyngeal regions pre- and post-operatively., Methods: 46 children were imaged intraoperatively with a custom-designed LR-OCT system, both before and after adenotonsillectomy. These axial LR-OCT images were both rendered into 3D airway models for qualitative analysis and manually segmented for quantitative comparison of cross-sectional area., Results: LR-OCT images demonstrated normal anatomic structures (base of tongue, epiglottis) as well as regions of airway narrowing. Volumetric rendering of pre- and post-operative images clearly showed regions of airway collapse and post-surgical improvement in airway patency. Quantitative analysis of cross-sectional images showed an average change of 70.52mm(2) (standard deviation 47.87mm(2)) in the oropharynx after tonsillectomy and 105.58mm(2) (standard deviation 60.62mm(2)) in the nasopharynx after adenoidectomy., Conclusions: LR-OCT is an emerging technology that rapidly generates 3D images of the pediatric upper airway in a feasible manner. This is the first step toward development of an office-based system to image awake pediatric subjects and thus better identify loci of airway obstruction prior to surgery., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: Adenoid hypertrophy (AH) is a common etiology of chronic upper airway obstruction. Upper respiratory tract obstruction may cause chronic alveolar hypoventilation and pulmonary vasoconstriction. In one previous study in patients with obstructive sleep apnea (OSA), it has been claimed that mean platelet volume (MPV), an indicator of platelet activation is increased and that MPV has an important role in the pathophysiology of cardiovascular diseases. We investigated in our study if MPV can be used as an indicator of obstruction due to adenoid hypertrophy., Methods: Our study includes 61 children that underwent adenoidectomy with a mean age of 7.12 (± 2.373). White blood cell, platelet count, MPV, platelet crit and platelet distribution width levels were measured before and 3 months after adenoidectomy. Children's symptoms for upper airway obstruction (UAO) (presence of snoring, mouth breathing or difficulty in breathing during sleep, obstructive breathing or apnea during sleep) were questioned in the preoperative and postoperative period by a standardized questionnaire., Results: There was no significant difference between preoperative and postoperative mean values of MPV, hemoglobin, platelet count (p > 0.05). White blood cell levels were significantly higher in the preoperative period values compared with postoperative period values (p < 0.05). Preoperative UAO scores were significantly higher than the postoperative UAO scores. After stratification of the degree of obstruction (as mild, moderate and severe) there was no significant difference in between groups in terms of MPV values., Conclusion: There was no significant relation between MPV levels and obstructive adenoid hypertrophy., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

We describe an unusual case of paradoxical vocal fold motion in a child with cerebral palsy. Clinically, the child presented with mild stridor, which worsened over months, eventually requiring emergency intubation. After an unsuccessful trial of medical management, microlaryngoscopy revealed abnormal adduction of the vocal folds during inspiration. This was successfully treated with periodic type A botulinum toxin injections to the vocal folds, sparing the child from tracheostomy., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: We examined if lack of on-site bronchoscopy facilities and the inexperience of initial treating physicians contributed to missed or delayed diagnosis of tracheobronchial foreign body aspiration (FBA) in pediatric patients presenting with respiratory distress., Methods: The medical records of 340 patients examined by bronchoscopy in our otolaryngology department from January 2009 to August 2012 were reviewed. Age, gender, clinical history, findings on physical examination, facilities at the initial treatment site (bronchoscopy or not), bronchoscopic findings (type and location of the FB), and initial diagnosis, were examined in terms of the delay between initial treatment and bronchoscopy-based diagnosis of FBA., Results: The vast majority of patients (324/340, 95.29%) were 3 years of age or younger and a foreign body was located in 309 (90.88%). Of these 340 cases, 261 had been referred from other facilities (76.76%) whereas 79 had come directly to our hospital (23.24%). The median delay between initial treatment and bronchoscopic diagnosis was significantly shorter in those treated initially in our institution compared to referrals (24 h [1 h to 60 days] vs. 168 h [1 h to 366 days]; P < 0.01). The initial diagnosis was FBA in 135/261 referral cases (51.72%), significantly lower than in cases first treated in our institution (69/79, 87.34%; P < 0.01). Foreign body aspiration was confirmed in 127/135 referral cases (94.07%) and 62/69 directly treated cases (89.86%) (χ(2) = 1.193, P > 0.05). Of the 126 referral cases diagnosed with other conditions before coming to our hospital, FBA was confirmed in 114. Complications were significantly less frequent in cases treated directly than in referrals (24/79, 30.38% vs. 155/261, 59.39%; P < 0.01)., Conclusions: Local treatment facilities, most lacking bronchoscopy facilities and physicians who were trained to recognize FBA, misdiagnosed at least 44% of patients with respiratory distress and this led to significant delays in treatment. Greater regional access to bronchoscopy and improved training of primary care physicians will enhance diagnostic accuracy and reduce treatment delays., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: An operative technique is described as a salvage treatment for severe subglottic and supraglottic laryngeal stenosis. In addition to expansion of the laryngeal framework with an anterior cartilage graft, as used in a classical laryngotracheal reconstruction, the scar tissue obliterating the airway lumen is excised and a mucosal graft is placed to reconstruct the inner lining of the airway. The graft is harvested from buccal mucosa., Methods: The operative technique is outlined. Three cases, 2 paediatric and one adult, with complete or near complete laryngeal stenosis are presented where this operative technique was employed. In all patients several surgeries had been performed previously which were unsuccessful., Results: In all 3 patients a patent airway was achieved with decannulation of the tracheostomy in the 2 paediatric patients., Conclusions: In patients with severe subglottic or supraglottic airway stenosis where other surgeries have failed, excision of endoluminal scar tissue and placement of a buccal mucosal graft, in addition to conventional laryngotracheal reconstruction, is a promising technique. In revision cases of subglottic stenosis cricotracheal resection might not be an option because of scarring from previous surgeries. This operation is an alternative, which allows an increase in the airway lumen by excising the scar tissue then re-lining the exposed internal lumen. The buccal mucosa reduces granulation formation and re-stenosis., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The objective of this study is to analyze the epidemiological, clinical, radiological and endoscopic characteristics of pediatric foreign body aspiration in Algeria., Methods: In this retrospective study, the results of 2624 children younger than 18 years admitted in our department for respiratory foreign body removal between 1989 and 2012, were presented. Most of them had an ambulatory rigid bronchoscopy., Results: The children (62.34% males and 37.65% females) were aged 4 months to 18 years with 66% between 1 and 3 years. Choking was related in 65% of cases. The delay between aspiration and removal was 2-8 days in 65.8% and within 24 h in 9.2%. In the most cases, the children arrived with cough, laryngeal or bronchial signs and unilateral reduction of vesicular murmur. The examination was normal in 13%. The most common radiologic finding was pulmonary air trapping (40.7%). The aspirated bodies were organic in 66.7%, dominated by peanuts, while sunflower seeds, beans and ears of wheat were the most dangerous. In the other cases, they were metallic or plastic as pen caps and recently scarf pins. The endoscopic removal by rigid bronchoscopy was successful and complete in 97%. Cases with extraction failure (3%) limited to certain FBs, all of them inorganic were assigned to surgery. The complications related to the endoscopic procedure were 0.29% with a mortality of 0.26%., Conclusion: Foreign body aspiration is a real public health problem in Algeria. The best way to manage it is an early diagnosis and a rigid bronchoscopy removal under general anesthesia used by fully trained staff. The prevention of this domestic accident should consider the population lifestyle and cultural habits to be more effective., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine characteristics of young children with gastroesophageal reflux (GER) who experienced complications within the first 24h after adenotonsillectomy., Study Design: Subset analysis of a larger retrospective cohort., Methods: A retrospective chart review was performed at a tertiary care children's hospital. Consecutive records of children 3 years old and younger undergoing adenotonsillectomy (AT) over a 5-year period were reviewed. Children with a clinical history of GER were selected for the study., Results: 993 children were included in the initial analysis, and GER was found to be a significant independent variable predictive of early complications. 81 children with a history of GER were included in this study and 8 (9.9%) were found to have experienced complications within the first 24h. Six of the complications were airway-related; two required re-intubation within the first 24h. All 8 children with complications had symptoms of sleep-disordered breathing and two had documented severe obstructive sleep apnea (AHI 18.6 and 27.2). Seven children had other risk factors for complications after AT. Eighteen (22%) children had a prolonged length of stay (range 2-7 days); additional risk factors were present in these patients as well., Conclusions: Knowledge of risk factors for complications following adenotonsillectomy is critical for identifying at-risk patients that may warrant closer post-operative observation. GER has been previously identified as a risk factor for complications in young children. Upon closer analysis, young children with GER who have other known risk factors may be at a further increased risk for airway complications and prolonged hospitalization. Parents of these children can be counseled on the post-operative risks and the possibility of a longer hospitalization., (Copyright © 2013. Published by Elsevier Ireland Ltd.)

This case report demonstrates neurologic sequela following treatment with doxycycline sclerotherapy. A six-week-old child presented with respiratory distress from a macrocystic lymphatic malformation, extending from the skull base to the anterior mediastinum. Following doxycycline sclerotherapy, the airway symptoms resolved; however, the child developed silent aspiration and Horner's syndrome. Two months following treatment the patient resumed oral diet and at one year post-intervention there has been no recurrence of symptoms, with only mild ptosis remaining. While neuropathies following doxycycline sclerotherapy have been described, aspiration has never been documented. This case demonstrates a single patient's clinical course and resolution of their neuropathies., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To describe microdebrider removal of subglottic hemangiomas and evaluate the efficacy of this procedure., Methods: This retrospective study was conducted at an otorhinolaryngology department. Seven consecutive patients with subglottic hemangiomas who failed to respond to pharmacologic treatment were treated by microdebrider removal under suspension laryngoscopy. Respiratory symptoms and hemangioma status were assessed preoperatively and postoperatively., Results: The mean age of patients at disease onset was 68 days (range, 24-120 days), and their mean age at the time of surgical treatment was 132 days (range, 55-195 days). Their initial pharmacologic treatment included steroids, propranolol, and/or antibiotics. The mean percentage of airway obstruction was initially 36% (range, 30-50%), and this value changed to 61% (50-80) before surgery. Microdebrider removal of hemangiomas was successful in all patients without any intraoperative or postoperative complication. The mean operative time was 30 min (range, 21-47 min). Three patients required orotracheal intubation for 12 or 24h after surgery, and no reintubation or tracheotomy was required in this series. Symptoms such as stridor and inspiratory retraction were resolved approximately 72 h after surgery, but wheezing was generally resolved at a later time point. One year later, no respiratory symptom was noted in these patients, and endoscopic examination revealed a sufficient glottis opening., Conclusions: Surgical removal with a microdebrider is advantageous as a routine surgical technique for small and moderate pediatric subglottic hemangioma., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: The most common indications for tracheotomy in pediatric patients include upper airway obstruction, prolonged ventilator dependence, and hypotonia secondary to neurologic impairment. In this study we review the indications for tracheotomy within our patient population over the last 11 years., Methods: We conducted a retrospective chart review of consecutive patients undergoing tracheotomy at a tertiary care pediatric hospital from January 2000 to April 2011. We evaluated patient age, sex, pre-operative and post-operative diagnosis, and direct laryngoscopic and bronchoscopic findings. Patients were divided into six groups based on their indication for tracheotomy. In order to assess changing indications for tracheotomy over time, we compared an early (2000-2005) and a late (2006-2011) patient group., Results: We had complete data available on 158/165 patients (95.8%) who underwent tracheotomy from 2000 to 2011. There was no significant difference in mean age between the early and late groups (4.73 ± 6.0 years vs. 3.6 ± 5.5 years, p=0.26). There was a change in the most common indication for tracheotomy between the early and late groups, with upper airway obstruction becoming more common in the late group and significantly fewer patients undergoing tracheotomy for prolonged ventilation in the late group (33/76 (43%) vs. 23/82 (28%), p=0.05). More patients underwent bronchoscopy at the time of tracheotomy in the late group (52/82 (63%) vs. 28/76 (37%), p=<0.01)., Conclusion: A review of our pediatric tracheotomy experience demonstrated a change in the most common indication for tracheotomy between 2000 and 2011. In our patient population, there was a significant decline in the number of tracheotomies performed for prolonged intubation and an increasing number of patients who required tracheotomy for upper airway obstruction., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Vallecular cyst is not a common disease of neonate and infant. However, it may cause severe airway obstruction and even death. Its clinical symptoms are similar to laryngomalacia, including stridor, suprasternal retraction, substernal retraction, feeding difficulties, vomiting, failure to thrive, feeding choking and desaturation. This study is aimed to evaluate the surgical outcomes of infantile vallecular cyst post CO₂ laser treatment and to explore the appropriate time point of surgery for infantile vallecular cyst., Methods: In a retrospective review, thirty three patients diagnosed as vellecular cyst were enrolled in this study. All the patients received awake fiberoptic videobronchoscopic examination in order to prove the diagnosis. Pre-operative and post-operative eight symptom items were both recorded for comparison of the surgical outcomes. The age of diagnosis, gender, operation, body weight at surgery, co-morbidities, dates of postoperative endotracheal intubation, ICU stays and admission days were all recorded for analysis., Results: Total 33 cases of vallecular cyst were diagnosed by fiberoptic videobrochoscopy at our department. Most infants were diagnosed at 2-3 months-old. Stridor was the most common pre-operative symptom (100%). Additionally, feeding choking was the most common post-operative one (29.41%). Two patients (6.06%) with newly onset postoperative feeding choking recovered spontaneously within 2 weeks. Failure to thrive got worse as age increased before the operation. Eighty-eight percent of patients had good or excellent improvement of symptoms after surgery. There was neither recurrence nor surgical complication in our study., Conclusion: Vallecular cyst often combined with laryngomalacia. Different from laryngomalacia, it had excellent outcomes after CO₂ laser treatment. Failure to thrive got worse if delay diagnosis. Therefore, if definite diagnosis is made, early laser excision of cyst is a good method and the surgical outcomes are excellent., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To estimate the prevalence of operative ear disease in pediatric patients with tracheostomy tubes, as well as to identify risk factors predictive of operative otologic interventions in this patient cohort., Methods: We hypothesize that the prevalence of operative middle ear disease in patients with a tracheostomy tube is greater than that of the population at large. To validate our anecdotal observations, we queried the CHCA hospital database (PHIS) regarding the association between tympanostomy tube placements in children with tracheostomies. To further investigate, a retrospective chart review was undertaken at our regional tertiary care children's hospital to determine the frequency at which tympanostomy tubes were placed in children who have a tracheostomy. Risk factors were analyzed, applying independent samples t-tests and Pearson's Chi-square test. Univariate and multivariate logistic regression models were constructed to estimate odds ratios (OR) and 95% confidence intervals (CI) for predictors of operative ear disease. Institutional review board (IRB) approval was obtained., Results: Of a population of 181 patients with tracheostomies, 37 (or 20%, 95% CI 15-26%) have undergone placement of ventilation tubes in the past 3 years. No statistically significant difference was noted with regards to gender or race. The operative group had an average age of 23.0 months at the time of tracheostomy, compared to 52.5 months in the non-operative group (p=0.0022). In addition, home living situation, term birth, and craniofacial abnormalities were more frequently observed in the operative versus the non-operative group. Multivariate logistic regression models revealed the same factors as predictors of operative ear disease., Conclusion: The presence of a tracheostomy is associated with an increased risk of requiring ventilation tube placement over the population at large. Risk factors for operative middle ear disease among these children include age at time of the tracheostomy, craniofacial abnormalities, term birth, and home living situation., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Laryngomalacia is the most common cause of neonatal stridor, accounting for up to 60% of cases [1]. Less common causes of neonatal stridor include subglottic or tracheal stenosis, or congenital masses of the upper airway. Neonates with an identified congenital etiology of symptomatic upper airway obstruction often have synchronous airway lesions leading to multilevel airway obstruction. These infants deserve an endoscopic evaluation to better diagnose and manage respiratory distress. Here we present a rare case of an infant initially diagnosed with croup, but ultimately found to have multilevel airway obstruction including severe laryngomalacia and an obstructing tongue base mass., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: Bilateral vocal cord abductor paralysis (BVCAbP) is considered a rare cause of stridor in the newborn. The goal of this work is to present a case series and to review systematically the literature on bilateral vocal cord abductor paralysis in the newborn to better characterize the current knowledge on this entity., Methods: We performed a systematic literature review with Medline (1950-2011). The authors screened all cases of BVCAbP reported and selected those affecting newborns., Results: Out of the 129 articles screened, 16 were included. A total of 69 cases could be retrieved and analyzed. Associated co-morbidities were found in 54% of the patients, most notably malformative conditions (intracranial or other), or a positive perinatal history (trauma/asphyxia, prematurity). Tracheostomy placement was required in 59% of children, and of these 44% were successfully decannulated. In terms of functional outcome full recovery or improvement were seen in 61% of patients. Major underlying co-morbidities affected negatively the functional outcome (p=.004), but not the need for tracheostomy (p=.604) or the decannulation success rate (p=.063)., Conclusion: BVCAbP in the newborn is a serious cause of airway obstruction. It can be seen either in a context of multisystem anomalies or as an isolated finding. Newborns with major co-morbidities affecting their normal development are more likely to have poor functional outcomes and to remain tracheostomy-dependant., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To measure the airway obstruction caused by adenoid hypertrophy in the sitting and recumbent positions in search of hypothesized differences., Methods: Forty eight children between the ages of 2 and 12 years who sought the department of otorhinolaryngology spontaneously complaining of snoring and/or nasal obstruction. Children could be either male or female and belong to any social or racial group. Patients underwent nasal videoendoscopy sitting and lying performed by the same investigator. An image of the posterior nasopharynx was obtained from each nasal cavity of each patient for both positions. The free area of the nasopharynx was measured and compared in both positions. Image analysis was performed by two researchers other than that who carried out the examination., Results: The nasopharynx free area obtained with seated patient is, on average, 53% bigger than the free area obtained with the patient lying down (confidence interval: 95%; p<0.001). Thus, adenoidal obstruction is larger when the examination is performed with the patient lying down., Conclusions: Nasal videoendoscopy to evaluate adenoid hypertrophy with the patient lying down makes testing more reliable, better reproducing the patient's position when sleeping. Such accuracy is essential since it influences the decision for surgical intervention in this important and widespread disease in the pediatric population., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: Ten children with pressure-dependent postcricoid masses (PDPCM) previously referred to in the literature as hemangiomas or vascular malformations are presented. We propose these lesions represent an anatomic variant. We review previously reported cases, and report the presentation, diagnosis, and management of the patients in our series, the largest series to date., Methods: Ten patients, aged five weeks to nine months, were diagnosed, and treated or observed. Of the patients undergoing intervention, one was treated with a gastrostomy tube, fundoplication, and Propranolol therapy; and the other with CHARGE association underwent a tracheotomy., Results: No PDPCMs demonstrated significant interval change in size or appearance, and eight of ten patients did well with observation., Conclusion: Based on current information, the majority of PDPCMs likely represent an anatomic variant rather than a hemangioma or vascular malformation. Diagnosis is most readily made with awake flexible fiberoptic laryngoscopy. Because the incidence of synchronous airway pathology is high, direct laryngoscopy and bronchoscopy without routine biopsy is recommended for symptomatic patients. Imaging should be individualized and may be helpful for ambiguous cases. Although numerous treatment modalities have been advocated based on the presumptive diagnosis of a hemangioma, treatment of PDPCMs is not necessary in the majority of cases, as most patients may be safely observed., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Obstructive adenoid and tonsillar hyperplasia may present with retardation of growth. An adenoid-nasopharynx (A/N) ratio determined by means of lateral cephalometric radiographs has long been used as a diagnostic tool in the assessment of adenoid size. This study was designed to investigate the effect of adenotonsillectomy on insulin-like growth factor-I (IGF-I) and insulin-like growth factor binding protein-3 (IGFBP-3) levels and correlation between A/N ratio and IGF-I and IGFBP-3 levels., Methods: Patients (n=48) that had been operated on our clinic with a diagnosis of adenotonsillar hypertrophy between July 2009 and January 2010 were included in the study. The routine ear-nose and throat examination was done in all patients. Blood samples were taken, and lateral cephalometric radiographs were obtained preoperatively and repeated at 6-9 months (mean 7.2 ± 1.0 mo) following tonsillectomy and adenoidectomy. The chemiluminescent enzyme-linked immunosorbent method was used to IGF-I and IGFBP-3 levels. Each cephalometric radiograph was evaluated by a blinded radiologist. The A/N ratio was calculated using the Fujioka method., Results: When the preoperative and postoperative results were compared, a statistically significant increase in serum IGF-I and IGFBP-3 and a decreased A/N ratio were found. However, although correlation between the Δ(preoperative-postoperative difference) IGFBP-3 and ΔA/N ratio was 40%, it was not statistically significant. Additionally, no statistically significant correlation between the ΔIGF-I and ΔA/N ratio was found., Conclusions: The results of the present study indicate that adenotonsillectomy could result in the relief of nasopharyngeal obstruction and have a positive effect on growth in children by decreasing the A/N ratio and increasing IGF-I and IGFBP-3. There was no correlation between the ΔA/N ratio and ΔIGF-I and ΔIGFBP-3 levels., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Hairy polyp is an unusual developmental malformation that is most frequently seen as a pedunculated tumor in the neonate. They are benign lesions containing elements of both ectodermal and mesodermal origin. The symptoms of hairy polyps relate both to their location and their size. Larger lesions produce symptoms due to feeding difficulties and airway obstruction while smaller lesions cause intermittent symptoms resulting from a ball-valve type of obstruction. We present two cases of a soft palate hairy polyp causing respiratory and feeding difficulties and review the literature., (Crown Copyright © 2011. Published by Elsevier Ireland Ltd. All rights reserved.)

Laryngomalacia is a common source of stridor and can lead to significant upper airway obstruction and feeding disturbances in infants. We describe a unique case of supraglottic dysgenesis presenting as laryngomalacia featuring a prominent "s-shaped" epiglottis with both posterior edges fused to the right aryepiglottic fold/arytenoid complex. Although this anomaly is not accounted for in any of the current laryngomalacia classification schemes, modified laser supraglottoplasty was a satisfactory approach leading to successful decannulation. Laryngeal embryology and possible timing of the pathogenesis of this rare occurrence are reviewed as well., (Published by Elsevier Ireland Ltd.)

Objective: To determine the endotracheal tube (ETT) size and presence of subglottic narrowing in children less than 1 year old with Pierre Robin Sequence (PRS)., Materials and Methods: We performed a retrospective review from 2005 to 2009 of infants with PRS who underwent diagnostic laryngoscopy (DL) and intubation., Results: Fifteen children with a median age of 25 days were reviewed. All patients, except one, were born full term. Subglottic narrowing was visualized in 5 patients (33%). 73% of all patients required an ETT size smaller than what is recommended by intubation guidelines in the literature in regards to normative data based on age and weight., Conclusion: Infants with PRS may have a higher incidence of subglottic stenosis and require a smaller ETT compared to the normal population. This pilot study warrants a larger prospective investigation to validate these findings., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate the incidence, characteristics, flexible bronchoscopy (FB) findings, interventions and outcome of pediatric obstructive fibrinous tracheal pseudomembrane (OFTP) in our pediatric and neonatal intensive care units (ICUs)., Patients and Methods: This is a retrospective study of medical and FB video records in a single tertiary university-affiliated teaching hospital over a ten-year period. Data was collected from patients who were admitted and extubated of endotracheal tube in the ICUs with a FB diagnosis of an OFTP-like lesion. The associated medical information, FB interventions and video records were reviewed and analyzed., Results: Eight patients with OFTP were enrolled, with an incidence rate of 1.48% in the postextubation respiratory distress patients. Mean age was 32 ± 32 months (range, 2 months to 13 years); mean body weight was 13.7 ± 8.1 kg (range, 4.3-45 kg); mean intubation period was 37.6 ± 12.3h; mean time for symptoms to develop after extubation was 3.6 ± 1.4h. Symptoms lasted for 20.8 ± 20.3h before FB examination. All patients were accurately diagnosed with OFTP at the first postextubation FB examination and revealed various morphologies. The estimated cross-sectional tracheal lumen was reduced by 70-90% and the mean length of lesion was 18.1 ± 5.2mm (range, 10-30 mm). All OFTP were successfully ablated immediately after the diagnosis in one FB session by using various techniques and without any complication. Total duration for both diagnostic and interventional FB was 19.4 ± 2.5 min. No recurrence was noted thereafter., Conclusions: OFTP should always be considered in the event of postextubation respiratory distress, especially in the pediatric and neonatal ICUs. Early diagnosis and effective ablation can be achieved with aid of FB., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Many studies have been developed aiming to reveal the usefulness of cavum X-rays and telerradiographies as diagnostic tools for the detection of upper airway obstruction due to adenoid hypertrophy. However, the scientific literature is diverse and controversial. Therefore, a systematic review is proposed; with the objective to determine the diagnosis value of lateral X-ray view of the skull regarding adenoid hypertrophy., Methods: Searching was conducted on Pubmed, Lilacs, Cochrane Library, Embase, and Web of Knowledge databases; and was restricted to studies published in English, Portuguese or Spanish languages, carried out on humans under 18 years of age. All the obtained publications were first submitted to a pre-selection, and then, full-texts (n=66) were analyzed and selected by independent examiners. The resultant studies (n=11) were systematically and critically analyzed, and qualified according to QUADAS (Quality Assessment of Diagnostic Accuracy Studies) questionnaire, an assessment tool designed to qualify diagnostic tests accuracy studies., Results: Searching and selection procedures generated 11 studies which were considered adequate to be systematically analyzed. Accordingly, large variation was observed concerning the evaluation methods of radiographic and fibronasoendoscopic exams, and the sample characteristics. Additionally, little amount of scientific evidences could be provided, since few radiographic variables were analyzed simultaneously. Moreover, assessment methods were, at most, subjective or poorly described. QUADAS application revealed other significant limitations related to the sampling, such as inadequate spectrum of the investigated "disease" (adenoid hypertrophy), and poor report of the subjects' enrollment and participation process. Further, QUADAS revealed inadequacies regarding methodological features, including poor description of the radiographic exams and assessment methods. In addition, it was also shown that most of the studies did not specify the moment in clinical time when both exams were performed; neither reported a strategy of "blindness" by the examiners., Conclusions: Despite such limitations, the majority of the resultant data indicates that lateral X-rays might be considered somewhat useful, even though it could not be clearly demonstrated. Future research should then adhere to greater methodological rigor, in order to investigate the significance of radiographies as a screening test., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: The aim of this paper is to study the respiratory muscle strength by evaluating the maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and lung volume before and 3 and 6 months after adenotonsillectomy. This is an interventional, before and after trial. It was set at the Department of Otolaryngology, University of São Paulo, School of Medicine. We included 29 children (6-13 years old), both genders, consecutively recruited from the waiting list for adenotonsillectomy. Children were submitted to maximal inspiratory pressures (MIP), maximal expiratory pressure (MEP) evaluation using an analog manovacuometer, lung volume, using incentive expirotometer and thoracic and abdominal perimeter using a centimeter tape. Children were evaluated in 3 different moments: 1 week before and 3 and 6 months after surgery., Results: MIP improved significantly 3 months (p < 0.001) after adenotonsillectomy and MEP did not change (p = 1). There were increases in lung volume (p = 000), chest (p = 0.017) and abdominal perimeter (p = 0.05). Six months after surgery, all parameters improved. MIP (p = 0), MEP (p = 0), lung volume (p = 0.02), chest (p = 0.034) and abdominal perimeter (p = 0.23)., Conclusion: This study suggests that there was an improvement in respiratory muscular strength, once there was a significant improvement in maximal inspiratory pressure, lung volume and other parameters after adenotonsillectomy.

Objective: Determine clinical signs or symptoms associated with a more complicated clinical course in patients with retropharyngeal abscesses (RPAs)., Design: Retrospective chart review at a tertiary care level Children's hospital. Main Outcome Measures Age, presenting signs and symptoms, laboratory tests, imaging results, antibiotic therapy, surgical approach, pathogens isolated, and duration of hospitalization were evaluated to determine any factors associated with a more complicated clinical course (CCC)., Results: Fifteen of one hundred thirty pediatric patients with RPA were identified with a complicated clinical course (CCC). Eight of the fifteen required more than one procedure before the abscess resolved. Patients with multiple abscess sites had a statistically significantly greater chance of requiring multiple procedures to clear the infections (p<0.001). Another seven presented with airway obstruction requiring an admission into the Pediatric Intensive Care (PICU) and/or intubation. All the patients requiring admission to the PICU presented with signs or symptoms of airway obstruction compared to ten of the one hundred fifteen patients (8.7%) with a smooth clinical course (SCC) (p<0.001). Five patients from the CCC group required a bronchoscopy to secure the airway; seven patients required intubation following incision and drainage of the abscess for an average of 5+/-3 days. There was no statistically significant difference between the two groups with respect to pathogens isolated, or antibiotics used., Conclusion: Our study suggests that patients with a CCC are more likely to present with airway obstruction or multiple abscess sites than patients with SCC., (Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To assess the usefulness of intraoperative photographs taken during paediatric upper airway endoscopy used as an educational tool for parents and to define their attitudes towards seeing these photographs., Design and Setting: Questionnaire based survey of 50 parents at a tertiary referral centre for paediatric otolaryngology in North West England., Results: The response rate was 82%. All parents wanted to see the intraoperative images and reported improved understanding of their child's condition. No parents reported lasting anxiety. 79.2% of parents seeing photographs for the first time found the images to be informative; 82.4% of parents reported reassurance from being able to see progress in treatment; 17.6% found it easier to accept further intervention from seeing the photographs., Conclusion: Intraoperative photographs are useful as an educational tool for parents; they provide reassurance and help parents accept clinical management.

Objective: To identify and characterize food items with high risk of airway obstruction in children younger than 15 years., Methods: This retrospective study collected injury data from 1989 to 1998 for 26 pediatric hospitals in the United States and Canada. Aspiration, choking, ingestion, and insertion injuries due to food items were analyzed. The data included 1429 infants and children. Results were compared with fatality data published by the American Association of Pediatrics in 1984., Results: The 10 food objects with the highest frequency for both injuries and fatalities were identified. Peanuts caused the highest frequency of injury, and hot dogs were most often associated with fatal outcomes. The severity of respiratory distress prior to hospital evaluation varied for different foods. Age younger than 3 years was the highest-risk factor. Key characteristics such as bite size, shape, and texture were analyzed and found to demonstrate relationships with severity of clinical outcomes., Conclusions: Children younger than 3 years remain at greatest risk of food injury and death. We found that hard, round foods with high elasticity or lubricity properties, or both, pose a significant level of risk. Consideration of the key characteristics of the most hazardous foods may greatly decrease airway obstruction injuries. Food safety education can help pediatricians and parents select, process, and supervise appropriate foods for children younger than 3 years to make them safer for this highest-risk population.

We report the first case of a hamartoma, arising from peripheral lung tissue, which extended proximally over several decades to occlude the large airways. The patient's symptoms were originally attributed to asthma and the correct diagnosis was only made when she developed life-threatening airway obstruction. The endobronchial component of the hamartoma was debulked with urgent laser therapy, while the peripheral base of the tumour was resected by elective right middle lobectomy.

Management of the pediatric airway can be extremely challenging. A useful algorithm is presented that can be used when faced with even the most difficult of airways. A new adjuvant airway tool is also presented, as well as a list of equipment for the operating room. We will attempt to emphasize key points while presenting a patient that we have recently treated.

Objectives: To review the outcomes of paediatric patients with laryngotracheal stenosis treated at our institution by laryngotracheal reconstruction (LTR)., Methods: A single surgeon personal series retrospective review of case notes over a 10-year period from a single site tertiary referral paediatric otolaryngology department in patients with laryngotracheal stenosis treated with laryngotracheal reconstruction. Evaluation was based on the last laryngotracheal endoscopy, and a retrospective review of the patient's data., Results: Seventy-three open laryngotracheal procedures were undertaken for paediatric laryngotracheal stenosis from the period 1995-2005. Fourteen were cricoid split operations and will be described elsewhere. The remaining 59 procedures were cartilage graft laryngtracheal reconstructions, performed on 53 patients (37 single stage and 16 staged) with 6 having required revisions., Conclusions: LTR provides good results for subglottic stenosis (SGS) as primary or salvage operations. The procedure has no deleterious effects on laryngeal growth. The causes of failed procedures are discussed.

Fetus in fetu is a condition in which there is a monozygotic diamniotic fetus encased within the body of its larger more developed twin. We report a case of airway obstruction in a full-term fetus caused by fetus in fetu. Prenatal ultrasound revealed a large cervical mass compressing the neonate's trachea and esophagus. The Ex Utero Intrapartum Treatment procedure was utilized to secure the fetus's airway. Upon resection, a fetiform structure, covered by skin with vertebral tissue and two appendages was appreciated. To our knowledge, this is the first reported case of cervical fetus in fetu in the literature.

Although pulmonary hypertension secondary to upper airway obstruction caused by adenotonsillar hyperplasia has been well described, the association between laryngeal papillomatosis and pulmonary hypertension has not previously been documented. We report three patients with pulmonary hypertension due to upper airway obstruction caused by laryngeal papillomatosis. Pulmonary hypertension can contribute to significant preoperative and postoperative morbidity and cause intraoperative complications. Preoperative diagnosis and treatment of pulmonary hypertension is therefore essential in these patients.

Unlabelled: Patients with Coloboma, Heart defect, choanal Atresia, Retarded development, Genitorenal and Ear abnormalities (CHARGE) syndrome have been reported to be at high risk for aspiration and swallowing difficulties. Aspiration has been implicated as the most common cause of mortality in these patients. To date, however, aspiration and swallowing disorders in CHARGE patients have not been independently studied., Objective: To determine the prevalence of aspiration and swallowing dysfunction in children with CHARGE syndrome., Methods: A retrospective chart review of 30 children with CHARGE syndrome was performed., Results: Eighteen (60%) children had aspiration observed on video swallow study (VSS), flexible endoscopic evaluation of swallowing (FEES), and/or had otherwise unexplained bronchiectasis noted on CT scan of the chest. Twenty-four children (80%) had evidence of abnormal swallowing such as laryngeal penetration, dyscoordination, poor bolus mobility, or pooling of secretions., Conclusion: Aspiration and swallowing dysfunction are common in children with CHARGE syndrome. Formal evaluation of swallowing function should be part of the standard otolaryngologic examination for these patients.

Tracheal involvement in Crohn's disease is extremely rare and can present with airway obstruction in any age group, including the pediatric patient. We describe the case of a 9-year-old female who presented with a 2-week history of intermittent stridor, resolving temporarily with the administration of systemic steroids. The patient denied any abdominal complaints and was otherwise healthy. Bronchoscopy revealed progressive tracheal inflammation necessitating an urgent tracheotomy. Subsequent laboratory investigation confirmed the diagnosis of Crohn's disease. This is the first reported case of previously undiagnosed Crohn's disease presenting with airway manifestations.

Tracheomalacia (TM) is an occult central airway problem that may block the endotracheal tube (ETT) tip and cause ventilation risk. Traditional physical examination, chest radiograph, end-tidal CO2 monitoring and blood gas analysis do not easily make the correct diagnosis. Ultra-thin flexible bronchoscopy (FB) is convenient and useful to verify this rare type of ETT obstruction and can also guide the adjustment of the ETT tip to a correct location. We report two TM infants who were successfully diagnosed and managed by FB to correctly reposition the ETT tip.

We describe a newborn boy with a gastric heterotopia located in the nasopharynx, which caused airway obstruction soon after delivery. Gastric heterotopia is an uncommon lesion generally found throughout the alimentary tract, but nasopharynx is an exceptional location. To our knowledge, this is the second reported case of gastric heterotopia located in the nasopharynx, and the first one presenting in a newborn with symptoms at birth and with an associated central nervous system mass.

Laryngeal web is a rare congenital anomaly. The primary goals of management for congenital laryngeal web are to provide a patent airway and to achieve a good voice quality. However, vocal cords have a tendency for fibrosis and granulation tissue formation after surgical interventions. Traditionally, the treatment of choice for laryngeal web is laryngofissure and placement of a stent or keel. This report presents the successful management of a congenital laryngeal web in a 10-month-old boy with endoscopic lysis and topical mitomycin-C application.

Objective: Adenotonsillar hypertrophy, a common malady in children may lead on to cardiopulmonary dysfunction in untreated cases. The present study was designed to see alteration in pulmonary function tests i.e. spirometric parameters and blood oxygen saturation consequent to adenotonsillar hypertrophy and subsequent changes after adenotonsillectomy., Methods: Spirometry and pulse oximetry were carried out in 40 children with adenotonsillar hypertrophy of both sexes between the age of 7 and 14 years and 40 age and sex matched healthy children. The test was repeated one and half months after surgery in study group and data was statistically analyzed using students' t-test., Results: The flow volume plot was abnormal in all the patients along with hypoxia, reduced FIF50% and, increased FEF50%/FIF50%, FEV1/PEFR, FEV1/FEV0.5 ratios. There was statistically significant improvement in above parameters following surgery., Conclusions: Spirometry can prove an useful diagnostic tool in adenotonsillar hypertrophy for deciding early intervention to prevent cardio pulmonary complications.