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Objectives: Off‐label use of Ciprodex® (ciprofloxacin‐dexamethasone: CPD), an antibiotic‐steroid combination solution, in the airway has been reported by pediatric otolaryngologists with anecdotal success. We examined national trends regarding off‐label CPD use including prevalence, common indications, prescriber patterns, adverse events, and accessibility. Methods: 15‐item cross‐sectional survey was distributed to American Society of Pediatric Otolaryngology members from January–April 2022. Univariate analyses were performed to compare responses for users of off‐label CPD versus non‐users. Ease of access was compared across geographies and practice types using multivariate logistic regressions. Results: Of the 163 complete responses (26.6% response rate), 156 (95.7%) reported using off‐label CPD. Most common indications for off‐label CPD were tracheal granulation (87.8%, n = 137) and choanal atresia (82.1%, n = 128). Ease of access was significantly increased in the Midwest (OR:18.79, 95%CI:3.63–1.24, p = 0.001) and West (OR:29.92, 95%CI:3.55–682.00, p = 0.006). Ease of access was significantly lower at tertiary referral centers (OR:0.11, 95%CI:0.01–0.64, p = 0.041) and private practices (OR:0.04, 95%CI:0.002–0.33, p = 0.009) compared to academic free‐standing children's hospitals. Two‐thirds of respondents reported feeling "Very Comfortable" with the safety profile of off‐label CPD; 99.4% (n = 156) felt that the benefits outweighed the risks of off‐label use. Seven respondents (4.5%) reported adverse events (e.g., local allergic reaction, cushingoid symptoms) from off‐label use. Conclusions: Our findings (26.6% response rate) suggest that off‐label CPD is commonly used by pediatric otolaryngologists, many of whom reported feeling that the benefits of off‐label CPD outweigh the risks. Our results establish a baseline for future efforts to assess the efficacy and safety of off‐label CPD and to improve its accessibility. Level of Evidence: V Laryngoscope, 134:2922–2930, 2024 [ABSTRACT FROM AUTHOR]

Objectives: Bronchial anomalies are rare but challenging conditions to treat in children, encompassing a variety of structural abnormalities that could compromise airway patency. This includes complete rings, absent cartilage, traumatic avulsions, bronchoesophageal fistulas, and cartilaginous sleeves. The objective of this study is to describe the characteristics and outcomes of a series of pediatric cases of bronchial anomalies that were treated by slide tracheobronchoplasty. Methods: This is a single‐institution retrospective case series of pediatric patients with bronchial anomalies who underwent surgical treatment between February 2004 and April 2020. Data extracted from electronic medical records included patient demographics, comorbidities, and surgical outcomes. Results: There were a total of 29 patients included in the study, of which 14 had complete bronchial rings, 8 had absent bronchial rings, 4 had traumatic bronchial avulsions, 2 had bronchoesophageal fistulas, and one had a cartilaginous sleeve. Median follow‐up time was 13 months (with a range of 0.5–213 months). The overall mortality rate was 17.2% (5 patients), all of whom had complete bronchial rings. Patients with complete bronchial rings also had a higher rate of not only cardiac (85.7%) and pulmonary comorbidities (85.7%) but also secondary airway lesions (78.6%). Conclusion: This is the largest series to date describing surgical treatment for bronchial anomalies. Complete bronchial rings were the most common anomaly treated, followed by absent rings and trauma. Surgical treatment can be successful but mortality rates are higher in patients with complete bronchial rings, possibly due to higher rates of pulmonary and cardiac comorbidities. Level of Evidence: 4 Laryngoscope, 133:3334–3340, 2023 [ABSTRACT FROM AUTHOR]

Introduction: The Medicare Physician Fee Schedule (PFS) is the basis for physician reimbursement by public and private payers. The PFS values physician services according to the estimated time and intensity required to perform them; intensity reflects the summation of technical skill, cognitive load, and risk‐related stress. The fee schedule uses relative value units (RVUs) as a metric that permits comparison across procedures. Recent debate has focused on whether the methods by which the Centers for Medicare & Medicaid Services (CMS) estimate procedural intensity are valid. We therefore sought to investigate current CMS estimates of intensity (RVUs/min) for surgical procedures performed by pediatric otolaryngologists. Methods: We performed a retrospective, cross‐sectional analysis of fiscal year 2021 PFS valuations for pediatric otolaryngology key indicator procedures specified by the Accreditation Council for Graduate Medical Education. We additionally examined general otolaryngology procedures, including adenotonsillectomy and tympanostomy tube insertion. We utilized the 2021 Medicare PFS conversion factor of $34.89/RVU to convert intensity (wRVUs/min) to a compensation rate ($/min). Primary outcomes were: (1) total compensation rate and (2) intraservice (i.e., incision‐to‐closure) compensation rate for each studied procedure. Results: Our study sample included 167 unique procedures. The mean (standard deviation) total compensation rate for all included procedures was $1.35/min ($0.29/min) and the mean intraservice rate was $1.71/min ($0.89/min). Intraservice compensation rates ranged from $‐1.50/min (drainage of throat abscess) to $4.75/min (pediatric tracheostomy). Discussion: Total and intraservice compensation rates under the Medicare PFS vary widely for surgical procedures performed by pediatric otolaryngologists. Further investigation is necessary to examine the validity of assumptions underlying these procedural intensity valuations. Level of Evidence: NA Laryngoscope, 133:1739–1744, 2023 [ABSTRACT FROM AUTHOR]

Objectives: Hospital prices vary substantially for myringotomy with tympanostomy tube placement (M&T) and adenotonsillectomy (T&A). The Centers for Medicare and Medicaid Services recently implemented hospital price transparency requirements to help families make financially informed decisions about where to seek care. We sought to determine price availability and the extent of price variation for these procedures. Methods: We performed a cross‐sectional analysis of the Turquoise Health Hospital Rates Data Platform, which extracts prices for facility fees from publicly available hospital chargemasters. We determined the proportion of hospitals serving pediatric patients that published payer‐specific prices for M&T and T&A. We additionally characterized the extent of variation in payer‐specific prices both across and within hospitals. Results: Approximately 40% (n = 909 of 2,266 hospitals) serving pediatric patients disclosed prices for M&T or T&A. Among disclosing hospitals, across‐center ratios (adjusted for Medicare hospital wage indices) ranged from 11.0 (M&T; 10th percentile adjusted median price: $536.80 versus 90th percentile adjusted median price: $5,929.93) to 23.4 (revision adenoidectomy age >12 years; 10th percentile: $393.82 versus 90th percentile: $9,209.88). Median within‐center price ratios for procedures ranged from 2.2 to 2.7, indicating that some private payers reimbursed the same hospital more than twice as much as other payers for the same procedure. Conclusion: The majority of hospitals serving pediatric patients were non‐compliant with federal requirements to disclose prices for M&T and T&A. Among disclosing hospitals, there was wide variation in payer‐specific prices between and within institutions. Further research is necessary to understand whether disclosure of prices will enable families to make more financially informed decisions. Level of Evidence: 3 Laryngoscope, 133:948–955, 2023 [ABSTRACT FROM AUTHOR]

Objective: Tracheoesophageal fistula and esophageal atresia (TEA) and laryngeal cleft (LC) can coexist in some patients. The surgery‐specific success rate of LC repair in children with associated TEA has not been well described. The aim of the study is to determine if the history of TEA alters the LC repair outcomes. Study Design: Case series with chart review. Setting: Single‐institution academic medical center. Method: A retrospective review was conducted of patients with LC with and without TEA repair between January 2001 and November 2020. Data collected and analyzed included demographics and clinical characteristics, LC type, and LC with TEA timing of repairs. Results: An overall 282 patients met the inclusion criteria of LC repair: LC (n = 242, 85.8%) and LC + TEA (n = 40, 14.2%). Revision repair was required in 43 patients (15.2%) with 8 (2.8%) needing a second revision repair. The first LC revision rate in the LC group was 36/242 (14.9%) as compared with 7/40 (17.5%) in the LC + TEA group (P =.67). The second LC revision rate in the LC and LC + TEA groups was 7 (2.9%) and 1 (2.4%), respectively. The median time to revision was 5.1 months (interquartile range, 3.45–10.6) in the LC group as compared with 29.2 months (interquartile range, 4.8–44.2) in the LC + TEA group (P =.06). Conclusion: The incidence of TEA and LC was 14.2% in our study. Based on our findings, history of TEA repair is not associated with a higher revision rate vs LC alone. The history of TEA repair did not alter the outcomes of LC repair. [ABSTRACT FROM AUTHOR]

The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty‐one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p >.05). There was no difference between groups with respect to decannulation rate (85% primary vs 100% revision, p =.32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients. [ABSTRACT FROM AUTHOR]

Objective: Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. Study Design: Retrospective multi-institutional cohort study. Setting: Tertiary care pediatric hospital systems throughout North America. Methods: Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models. Results: In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism. Conclusion: These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Repair of large, recurrent, and complex tracheoesophageal fistulas (TEFs) is challenging and numerous different surgical approaches exist. These various techniques each carry a set of risks and possible complications such as fistula recurrence, tracheal stenosis or pouches, esophageal stenosis, and recurrent laryngeal nerve injury. Slide tracheoplasty is a reconstructive technique successfully used in many different airway pathologies, including TEF repair. This study examines the success, limits, and complications related to slide tracheoplasty for repair of complex TEFs. Study Design: Retrospective chart review. Methods: Patients undergoing TEF repair using a cervical or thoracic approach slide tracheoplasty, at a single institution, between July 2008 and December 2019 were retrospectively reviewed. Demographic data, comorbidities, TEF etiology and surgical history, slide tracheoplasty details and outcomes, and postoperative complication data were examined using descriptive statistics. Results: Twenty‐six patients underwent 27 slide tracheoplasties for TEF (20 cervical approaches, 7 thoracic approaches) with a mean age of 5.2 years (IQR 0.7–7.6) at time of surgery. The most common TEF etiologies included congenital (n = 13), tracheostomy tube erosion (n = 5), and button battery ingestion (n = 4). Fistulas ranged in size from <0.5 mm to 4 cm and 59% had previous endoscopic or open repairs. There were two TEF recurrences (7.4%), one of which was successfully revised and the other which was treated with stent placement. Postoperative complications included dehiscence (3.7%), unilateral vocal fold paralysis (3.7%), and mild tracheal stenosis (18.5%). Conclusions: Slide tracheoplasty is an effective surgical technique for treating complex congenital and acquired TEFs with lower rates of complications when compared to other techniques. Level of Evidence: 4 Laryngoscope, 132:1542–1547, 2022 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Determine surgical and swallowing outcomes after surgery for type III laryngotracheoesophageal cleft (LTEC). Study Design: Case series with chart review. Methods: Chart review was performed on patients with type III LTEC between 2000 and 2019. Demographics, surgical outcomes, and swallowing outcomes were collected and analyzed. Results: Thirty‐three patients met inclusion criteria (28 open and 5 endoscopic repairs). Mean age was 3.4 years for the open group and 0.9 years for the endoscopic group. Seventeen (51.5%) patients had a syndromic diagnosis, most commonly Opitz syndrome and Trisomy 21. Mean follow‐up was 33.6 months. Thirteen (39.4%) patients had a previous repair attempt prior to repair at our institution. Twenty‐four (70.6%) patients had a tracheostomy prior to or at the time of surgical repair and 13 (38.2%) remain tracheostomy‐dependent. Nine patients (27.3%) required a revision cleft repair and four (12.1%) required two revisions. Thirty‐one patients had an intact repair at last follow‐up (93.9). Two patients died outside the hospital over a year after surgery. Preoperatively 13 of 17 patients with swallowing evaluations aspirated. After repair, 11 of 20 patients were deemed safe for all consistencies and seven were safe for thickened. Endoscopic approaches were performed during the last 2 years of the study and had significantly lower operative time (354.4 minutes vs. 171.5 minutes). Conclusions: Endoscopic and open approaches are effective for treatment of type III LTEC with 27.3% requiring revision and 93.9% of repairs intact at last follow‐up. Overall swallowing outcomes were good in patients who underwent postoperative instrumental swallow evaluation. Level of Evidence: 4 Laryngoscope, 132:1112–1117, 2022 [ABSTRACT FROM AUTHOR]

We have performed fully atomistic molecular dynamics simulations of the intracellular domain of a model of the GABAA receptor with and without the GABA receptor associated protein (GABARAP) bound. We have also calculated the electrostatic potential due to the receptor, in the absence and presence of GABARAP. We find that GABARAP binding changes the electrostatic properties around the GABAA receptor and could lead to increased conductivity of chloride ions through the receptor. We also find that ion motions that would result in conducting currents are observed nearly twice as often when GABARAP binds. These results are consistent with data from electrophysiological experiments. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Endoscopic repair is the preferred surgical treatment for type 1 laryngeal clefts (T1LCs) and deep interarytenoid notches (DINs). No studies exist showing differences in repair rates using laser and cold steel. Our objective is to assess overall success and revision rate for endoscopic cleft repair and determine whether there is any difference in surgical outcomes between cold steel and laser techniques. Study Design: Retrospective chart review, cohort study. Methods: Retrospective review at a quaternary care pediatric hospital. Included all patients who underwent endoscopic repair for T1LCs and DINs between January 2010 and December 2019. Demographics, comorbidities, surgical data, outcomes, and revision status were collected and analyzed. We excluded patients who did not have a follow‐up at our institution. Results: A total of 194 patients were identified, 14 were excluded for lack of follow‐up data so 180 were analyzed. Of these, 127 had cold steel repair and 53 had laser repair. There is no significant difference in demographics or comorbidities. In the cold steel group, 4 of 127 (3.1%) had breakdown and in the laser group, 10 of 53 (18.9%) had breakdown. Patients who failed after a cold steel repair tended to break down later (median 12.7 months) when compared to laser repairs (median 2.1 months). Nine of the 10 patients with breakdown after laser repair were noted on initial postoperative evaluation. Conclusions: Endoscopic cleft repair is a well‐described and effective method for repair of T1LCs and DINs. Both cold steel and laser have high success rates; however, higher failure rates were noted in the laser repair group. Failure after laser repair may occur earlier than failure after cold steel repair. But this did not reach significance. Level of Evidence: 3 Laryngoscope, 131:2805–2810, 2021 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Evaluate swallowing and airway outcomes following laryngotracheoplasty with posterior grafting (LTP PCCG). Methods: Retrospective review of pediatric patients undergoing LTP PCCG from 2016 to 2019 at a tertiary care pediatric hospital. We included demographics, indications, approach, and revision status. We evaluated preoperative and postoperative instrumental and functional swallow evaluations, and we also gathered information on airway outcomes. Results: Thirty‐one patients were included in the study. Median (interquartile range [IQR]) age was 4.0 (2.0, 7.0) years old. Primary indication for surgery was bilateral vocal cord immobility (BVCI) in 11 (35.5%) and posterior glottic stenosis (PGS) in 20 (64.5%). Mean (standard deviation) length of follow‐up was 11.0 (8.3) months. Twelve patients had gastrostomy tubes (GT) before surgery, and no patients required placement of GT after surgery. Of the remaining 19 patients, 6 required nasogastric feeding for >4 weeks (average length 1.8 months, longest 3.5 months). At last follow‐up, 25 (80.6%) patients were primarily orally fed. Eighteen patients had tracheotomies prior to surgery. No patients without a tracheostomy required placement of tracheostomy before or after surgery and only 1 patient had a tracheostomy at last follow‐up. Average time to decannulation was 3.7 months, with surgery‐specific success of 87.1% and overall success of 96.8%. Four (12.9%) patients required a major intervention to achieve decannulation. Conclusion: LTP PCCG is an effective surgical technique to address PGS and BVCI with high decannulation rates. It may cause temporary swallowing dysfunction, but in this series a majority of children were orally fed at last follow‐up. Level of Evidence: 4 Laryngoscope, 131:2798–2804, 2021 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Create a competency‐based assessment tool for pediatric esophagoscopy with foreign body removal. Study Design: Blinded modified Delphi consensus process. Setting: Tertiary care center. Methods: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven‐point Likert scale. Consensus was determined with a goal of 7 to 25 final items. Results: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty‐four task‐specific and 7 previously‐validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task‐specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. Conclusions: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. Level of Evidence: 5. Laryngoscope, 131:1168–1174, 2021 [ABSTRACT FROM AUTHOR]

Objective: Our objective was to gather data that would enable us to suggest more specific guidelines for the management of children with airway disruption. Study Design Retrospective case series with data from five tertiary medical centers. Methods: Children younger than 18 years of age with a disrupted airway were enrolled in this series. Data pertaining to age, sex, etiology and location of the disruption, type of injury, previous surgery, presence of air extravasation, management, and outcome were obtained and summarized. Results: Twenty children with a mean age of 4.4 years (range 1 day–14.75 years) were included in the study. All were evaluated by flexible endoscopy and/or microlaryngoscopy in the operating room. Twelve (60%) children had tracheal involvement; seven had bronchial involvement; and one had involvement of the cricoid cartilage. Nine children had air extravasation, and all these children required surgical repair. Of the 11 who did not have air extravasation, only one underwent surgical repair. Complete healing of the disrupted airway was seen in all cases. Conclusion: This series suggests that if there is no continuous air extravasation demonstrated on imaging studies or clinical examination, nonoperative management may allow for spontaneous healing without sequelae. However, surgical repair may be considered in those patients with continuous air extravasation unless a cuffed tube can be placed distal to the site of injury. For children in whom airway injury occurs in a previously operated area, the risk of extravasation is reduced. This risk is also diminished if positive pressure ventilation can be avoided or minimized. Level of Evidence: 4 Laryngoscope, 131:921–924, 2021 [ABSTRACT FROM AUTHOR]

Objectives: Airway reconstruction for subglottic and tracheal stenosis is often successful in achieving tracheostomy decannulation and improving airway symptoms. However, one common reason for late failure is development of a tracheal A‐frame deformity, which can necessitate additional surgery. Although knowledge of this deformity exists, the incidence and risk factors have not been reported. This study seeks to determine the incidence of A‐frame following airway reconstruction and define factors that correlate with development of this deformity. Study Design: Retrospective case series. Methods: Patients under 21 years of age undergoing open airway reconstruction at our institution between January 2005–December 2006 were retrospectively reviewed. Demographic data, comorbidities, airway history/reconstruction type, and follow‐up airway findings were examined using multivariable logistic regression. Kaplan–Meier curves were used to examine time to A‐frame repair. Results: Two hundred patients underwent airway reconstruction and 69 (34.5%) developed an A‐frame deformity. History of tracheostomy was the most significant contributor to A‐frame development (P <.0001). Double‐ versus single‐stage procedures were not associated with increased odds of A‐frame development (P =.94), however, patients undergoing resection procedures as opposed to laryngotracheal reconstruction (LTR) with cartilage grafts had a significantly lower chance of developing this deformity (P =.004). Of the patients with an A‐frame, 27 (39%) required further surgical intervention. Conclusion: Approximately one‐third of patients undergoing airway reconstruction developed a tracheal A‐frame deformity, with a significantly higher rate among patients with a history of tracheostomy and those undergoing LTR. Patients should be followed long term to assess for the development of an A‐frame. Level of Evidence: IV Laryngoscope, 131:E1363–E1368, 2021 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology. Study Design: DELPHI survey. Methods: Twenty‐seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained. Results: The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high‐definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ‐specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre‐ and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery. Conclusions: International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery. Level of Evidence: 5 Laryngoscope, 131:E732–E737, 2021 [ABSTRACT FROM AUTHOR]

Objectives: Tracheal A-frame deformity is a known consequence of tracheostomy that may lead to obstruction after decannulation. The goal of this study is to demonstrate the feasibility and success of endoscopic carbon dioxide (CO2 ) laser-assisted tracheoplasty of tracheal A-frame deformity in children.Methods: Retrospective case series of symptomatic children with tracheal A-frame deformity with no other site of airway obstruction (2016-2018). All patients underwent CO2 -laser assisted endoscopic resection tracheoplasty.Results: Eight patients (six male) were included with a median age of 15.4 (IQR 12.3-17.9) years. Patients had a median of two previous open airway surgeries (IQR 1-2.5) and all patients had a history of tracheostomy with successful decannulation. Tracheal A-frame deformity presented as dyspnea on exertion for all patients (n = 8, 100%). Obstructive sleep apnea was confirmed for all patients who underwent polysomnography (4/4, 100%). Median interval from decannulation to development of symptoms was 8.7 years (IQR 5.8-9.3). All patients sized with an age-appropriate endotracheal tube despite the deformity. Endoscopic A-frame tracheoplasty was successful for 7/8 (87.5%) patients and was performed with overnight observation for these patients (8/8, 100%). Unilateral A-frame tracheoplasty was performed successfully for five patients (62.5%), bilateral A-frame tracheoplasty was performed successfully for two patients (25.0%), and one patient (12.5%) did not have complete resolution of symptoms after bilateral A-frame tracheoplasty due to multi-level airway obstruction.Conclusions: CO2 laser-assisted tracheoplasty is an innovative endoscopic technique to relieve symptoms of airway obstruction for selected patients with tracheal A-frame deformity although avoiding the morbidity and hospital stay duration associated with tracheal resection.Level Of Evidence: 4 Laryngoscope, 131:E719-E723, 2021. [ABSTRACT FROM AUTHOR]

Objective: Congenital airway stenosis secondary to absent tracheal or bronchial rings is a rare congenital anomaly that is difficult to manage both clinically and surgically. This typically manifests as severe segmental tracheomalacia, and only isolated cases with short-term follow-up have been previously described. We aim to describe a series of children with absent tracheal or bronchial rings who underwent surgical management and had long-term follow-up. Study Design: Case series with chart review. Setting: Tertiary care pediatric hospital. Methods: Patients with absent tracheal or bronchial rings from 2002 to 2016. Electronic and paper medical records were queried to obtain demographics, age at diagnosis and surgery, pre- and postoperative symptoms, location of absent rings, procedure performed, length of follow-up, and adjunctive procedures performed. Results: Nine subjects were identified who underwent slide tracheoplasty for correction of congenital absent tracheal or bronchial rings. Age at diagnosis ranged from 10 days to 5 years of age (median, 4 weeks). Age at surgery ranged from 3 weeks to 5 years of age (median, 5 weeks). Six out of 9 subjects were extubated on postoperative day 1. Only 1 subject required additional intervention, which included balloon dilation, tracheobronchial stenting, and aortopexy to alleviate the obstruction. Mean follow-up time was 5.89 years. Conclusions: This is the largest series of children with absent tracheal rings who underwent slide tracheoplasty with long-term follow-up presented to date. Slide tracheoplasty is an effective surgical intervention for the treatment of absent tracheal or bronchial rings in infants and young children. [ABSTRACT FROM AUTHOR]

Anthropogenic climate change is affecting virtually all ecosystems across the globe. Some of the noticeable effects of the changing climate are the shifting of frost dates in the fall and spring, and how warm temperatures are distributed throughout the year. The degree to which an ecosystem is affected by these changes depends upon many factors, including where the ecosystem is located and what regional variabilities in climate surround that ecosystem. One ecosystem that experiences a unique microclimate is the region surrounding Lake Erie, the southernmost Laurentian Great Lake. Using historic climate data dating from 1948 to 2017, we set out to determine how changes in temperature and frost dates differ between the coastal and inland regions of the southern coast of Lake Erie, and to hypothesize as to why these effects may be occurring differently between these regions. We found that, for both coastal and inland regions, the first frost in the fall has begun later, while the last frost in the spring has begun earlier, leading to both regions experiencing longer frost‐free seasons. However, although both regions have experienced these shifts, the rate at which these shifts occurred differed between the coastal and inland regions. The average date that the frost events occurred also differs between the two regions. It was also found that average temperatures have been increasing for each region, primarily in coastal regions, due to increased minimum temperatures over time. The results from this study highlight the importance of regional climate variability in large‐scale climatic studies. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Create a competency-based assessment tool for pediatric tracheotomy.Study Design: Blinded, modified, Delphi consensus process.Methods: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.Results: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.Conclusions: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.Level Of Evidence: 5 Laryngoscope, 130:2700-2707, 2020. [ABSTRACT FROM AUTHOR]

Background: Using data from the English & Romanian Adoptees (ERA) study, we recently reported that early time‐limited exposure to severe institutional deprivation is associated with early‐onset and persistent neurodevelopmental problems and later‐onset emotional problems. Here, we examine possible reasons for the late emergence of emotional problems in this cohort. Our main focus is on testing a developmental cascade mediated via the functional impact of early‐appearing neurodevelopmental problems on late adolescent functioning. We also explore a second putative pathway via sensitization to stress. Methods: The ERA study includes 165 Romanian individuals who spent their early lives in grossly depriving institutions and were subsequently adopted into UK families, along with 52 UK adoptees with no history of deprivation. Age six years symptoms of neurodevelopmental problems and age 15 anxiety/depression symptoms were assessed via parental reports. Young adult symptoms of depression and anxiety were assessed by both parent and self‐reports; young adults also completed measures of stress reactivity, exposure to adverse life events, and functioning in work and interpersonal relationships. Results: The path between early institutional deprivation and adult emotional problems was mediated via the impact of early neurodevelopmental problems on unemployment and poor friendship functioning during the transition to adulthood. The findings with regard to early deprivation, later life stress reactivity, and emotional problems were inconclusive. Conclusions: Our analysis suggests that the risk for adult depression and anxiety following extreme institutional deprivation is explained through the effects of early neurodevelopmental problems on later social and vocational functioning. Future research should more fully examine the role of stress susceptibility in this model. [ABSTRACT FROM AUTHOR]

Objective: Primary tracheobronchial tumors (PTTs) are rare heterogeneous lesions arising from any part of the tracheobronchial tree. Nonspecific symptoms may lead to delayed diagnosis that requires more aggressive surgical treatment. An analysis of cases collected by the International Network of Pediatric Airway Team was undertaken to ensure proper insight into the behavior and management of PTTs.Methods: Patients <18 years of age with a histological confirmation of PTT diagnosed from 2000 to 2015 were included in this multicenter international retrospective study. Medical records, treatment modalities, and outcomes were analyzed. The patient presentation, tumor management, and clinical course were compared between malignant and benign histotypes. Clinical and surgical variables that might influence event-free survival were considered.Results: Among the 78 children identified, PTTs were more likely to be malignant than benign; bronchial carcinoid tumor (n = 31; 40%) was the most common histological subtype, followed by inflammatory myofibroblastic tumor (n = 19; 25%) and mucoepidermoid carcinoma (n = 15; 19%). Regarding symptoms at presentation, wheezing (P = 0.001) and dyspnea (P = 0.03) were more often associated with benign growth, whereas hemoptysis was more frequently associated with malignancy (P = 0.042). Factors that significantly worsened event-free survival were age at diagnosis earlier than 112 months (P = 0.0035) and duration of symptoms lasting more than 2 months (P = 0.0029).Conclusion: The results of this international study provide important information regarding the clinical presentation, diagnostic workup, and treatment of PTTs in children, casting new light on the biological behavior of PTTs to ensure appropriate treatments.Level Of Evidence: NA Laryngoscope, 130:E243-E251, 2020. [ABSTRACT FROM AUTHOR]

Objectives: To compare the clinical outcomes of patients with prophylactic petiole suspension (PPS) at the time of laryngofissure and patients without PPS.Study Design: Retrospective case series.Setting: Tertiary pediatric hospital from May 2003 to August 2017.Subjects and Methods: Patients included those undergoing airway reconstruction with complete laryngofissure. Patients in the study group had PPS at the time of laryngofissure, while control group patients did not.Results: Eighty-one patients underwent complete laryngofissure (22 study patients, 59 controls) at a median age of 4.8 years (interquartile range, 2.1-9.7). Patients in the control group were younger at the time of the surgery (3.7 vs 6.5 years, P = .04). Other demographic and clinical data, including subglottic stenosis (SGS) grades, were similar. For patients with SGS, 53.8% and 46.2% in the study group had a grade 1-2 and 3-4 SGS, respectively, as compared with 46.2% and 53.8% in the control group (P = .65). Manifestations of petiole prolapse included failure of decannulation (8.6%), exercise intolerance (16.0%), and obstructive sleep apnea (11.1%). After 4 years of follow-up, 4.5% of the study group versus 27.1% of the control group had prolapse of the petiole (P = .04). Petiole prolapsed affected >50% of patients with no PPS after 10 years of follow-up. Patients with petiole prolapse at the first surveillance microlaryngoscopy and bronchoscopy after stent removal had an odds ratio of 10.2 (95% CI, 1.1-94.8; P = .04) of becoming symptomatic.Conclusion: Patients with PPS had significantly fewer symptoms after complete laryngofissure as compared with patients without PPS. PPS should be considered when a complete laryngofissure is being performed during airway reconstruction. [ABSTRACT FROM AUTHOR]

Objective: Epiglottic petiole prolapse is an overlooked entity that could lead to supraglottic airway obstruction for patients with complex airway history. Classical symptoms include exercise intolerance, obstructive sleep apnea, and difficulty with decannulation. The goal of this project was to evaluate the factors associated with epiglottic petiole repositioning success.Methods: Retrospective case series of patients with a complex history of airway reconstruction evaluated by the aerodigestive team at a tertiary pediatric hospital from May 2003 to August 2017. All patients underwent repositioning for petiole prolapse.Results: We had a total of 59 patients (14 females, 23.7%) with complex airway anomalies with petiole prolapse noted during a microlaryngoscopy and bronchoscopy. Mean age was 12.9 ± 6.1 year old (range 1.3-35.9). Patients had a history of 2.2 (1-5) open airway surgeries, and 51 of 58 (87.9%) of them had a prior complete laryngofissure. Laryngotracheoplasty and petiole repositioning were performed as a double-stage surgery for 54 of 58 (91.5%) patients. Epiglottic petiole prolapse was persistent in 20 patients (33.9%) and became symptomatic for 14 of them (23.7%). The main preventive factor of petiole prolapse recurrence was pre-epiglottic fat debulking at the time of the repositioning, with an odds ratio of 0.06 (95% confidence interval 0.007-0.6, P = 0.01). Stent placement, longer duration of stent placement, and double-stage procedure also increased the likelihood of success (all P < 0.05).Conclusion: Patients with petiole prolapse have a history of complete laryngofissure and multiple open airway surgeries. Pre-epiglottic fat debulking and longer stent placement at the time of the repositioning surgery appear to significantly increase the long-term success rate.Level Of Evidence: 4 Laryngoscope, 129:1984-1988, 2019. [ABSTRACT FROM AUTHOR]

Objective: This study documents the growth and course of repaired complete tracheal rings over time after slide tracheoplasty.Study Design: Case series with review.Setting: Tertiary pediatric academic medical center.Subjects/methods: Medical records of pediatric patients with confirmed tracheal rings on bronchoscopy who underwent slide tracheoplasty between January 2001 and December 2015 were reviewed. Patients who had operative notes documenting tracheal sizing over time were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings, surgical repair prior to presentation at our institution, or lack of adequate sizing information. The postoperative follow-up was examined and airway growth over time documented.Results: Of 197 slide tracheoplasties performed during the study time period, 139 were for complete tracheal rings, and 40 of those children met inclusion criteria. The median age at time of surgery was 7 months, and the median initial airway size was 3.9 mm (n = 34). The median growth postoperatively was 1.9 mm over a median follow-up period of 57 months (0.42 mm/year), which is similar to growth rates of unrepaired complete tracheal rings (P = .53). Children underwent a median of 10 postoperative endoscopies, with time between endoscopies increasing further out from surgery. The most commonly performed adjunctive procedure was balloon dilation.Conclusions: This is the first study documenting continued growth of repaired complete tracheal rings after slide tracheoplasty. Postoperative endoscopic surveillance ensures adequate growth. Intervals between airway endoscopies can be increased as the child gets older, as the airway increases in size, and as long as symptoms are minimal. [ABSTRACT FROM AUTHOR]

Objectives: 1) Evaluate success rates for adults undergoing cervical slide tracheoplasty. 2) Examine complication rates of slide tracheoplasty in adults.Methods: A retrospective cohort of adults > 21 years of age undergoing cervical slide tracheoplasty for tracheal stenosis between October 2011 and August 2017 was reviewed. Comorbidities, stenosis grade, etiology of stenosis, primary versus revision surgery, complications, and number of adjunct endoscopic procedures required postoperatively were evaluated.Results: Nineteen patients (63% female) underwent cervical slide tracheoplasty during the study period (median age 30 years, range 21-70). The most common etiology of stenosis was iatrogenic (68%), followed by congenital etiologies (26%). Fifty-eight percent of patients had undergone a previous open airway procedure. Thirty-nine percent were tracheostomy-dependent prior to surgery, and the remainder had severe exercise intolerance. Sixty-three percent were successfully extubated on the operating room table at the end of the procedure. Six (32%) patients experienced surgical complications, including one anastomotic dehiscence, three neck abscesses requiring incision and drainage (I&D), and replacement of adjunctive airway device in two patients. Seventy percent of the patients required ≥ 1 endoscopic dilation in the first 12 months following surgery, with a median of one (range 1-8) procedure. At most recent follow-up (median 8 months, range 4-64 months), 18 of 19 (95%) of patients had minimal airway symptoms without need for tracheostomy. The one patient who was not decannulated expired of a presumed cardiac event prior to decannulation.Conclusion: Cervical slide tracheoplasty is an excellent reconstructive option for adult patients with tracheal stenosis, including those with history of previous airway reconstruction.Level Of Evidence: 4 Laryngoscope, 129:818-822, 2019. [ABSTRACT FROM AUTHOR]

A 6-month-old female presented for 2 months of noisy breathing. Flexible laryngoscopy showed limited bilateral vocal fold abduction. Computed tomography revealed a non-enhancing 3.6 × 2.3 × 3.5 cystic prevertebral mass spanning C2-T. Using an endoscopic approach, the overlying mucosa was incised, and the cyst was freed and fully excised from the surrounding mucosa with blunt microlaryngeal instruments without complication. Three months postoperatively she had no respiratory issues and was eating well. Flexible laryngoscopy revealed bilateral vocal fold mobility. We propose that endoscopic removal of a cervical esophageal duplication cyst in selected cases is an alternative to open excision. Laryngoscope, 130:2053-2055, 2020. [ABSTRACT FROM AUTHOR]

Croup is the most common infectious cause of stridor in the pediatric population. When excluding the first patient who required two subglottic cautery procedures, there was a mean decrease in the number of croup episodes from 5.33 per year preoperatively to 0.33 per year postoperatively ( I P i = 0.008).MLB = microlaryngoscopy amd bronchoscopy. Patient 1 had five episodes of croup after the first procedure, although these were less severe than the patient's preoperative episodes. [Extracted from the article]

Objectives/hypothesis: Over the past decade, thoracic slide tracheoplasty (TST) has become the principal operation in the management of congenital tracheal stenosis. The purpose of this report was to describe our experience with revision TST following unsuccessful prior tracheal reconstruction.Study Design: Retrospective analysis at an academic children's hospital.Methods: Patients undergoing TST on cardiopulmonary bypass between January 2005 and May 2014 were reviewed. Patients with a history of prior airway surgery were extracted for further analysis. Preoperative patient variables and postoperative outcomes were evaluated and compared between patients undergoing revision slide tracheoplasty (RTST) and a control group of 26 matched patients undergoing primary surgery TST.Results: Twenty-six revision patients (25 referrals, one primary patient) of 162 patients reviewed over the study period met inclusion criteria. Twenty-three patients had a history of complete tracheal rings, and three patients had cartilaginous deficiency. A total of 41 airway reconstruction procedures had been performed prior to RTST. When compared to primary TST, patients undergoing RTST required fewer cardiac procedures intraoperatively, and fewer mean ventilator hours (P = .01) postoperatively. There was no significant difference in the median length of stay, requirement of >48 hours ventilation, or postoperative complications between groups. There was one nonsurgical postoperative mortality following RTST.Conclusions: Despite some differences in the postoperative management when compared to nonrevision cases, revision TST can be successfully performed after prior tracheal reconstruction with good postoperative outcomes.Level Of Evidence: 4. Laryngoscope, 128:2181-2186, 2018. [ABSTRACT FROM AUTHOR]

Objectives To document the natural growth pattern of unrepaired complete tracheal rings (UCTRs) and describe the patient population managed conservatively. Study Design Case series with chart review. Setting Tertiary pediatric academic center. Subjects/Methods Medical records of patients with confirmed complete tracheal rings on bronchoscopy from 1993 to 2017 were reviewed. Patients aged 0 to 18 who had documented tracheal sizing over time and did not require surgical intervention were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings. Comorbidities and airway characteristics were documented in addition to endoscopic findings. These were compared with children requiring surgical repair. Results In total, 149 patients with complete tracheal rings were identified. Twenty-five had UCTRs for an overall 16.8% rate of conservative management. Nineteen patients met inclusion criteria and underwent a total of 90 microlaryngoscopy and bronchoscopies (MLBs) with sizing. The growth of the UCTRs over time, based on MLB sizing, was chronicled. The median airway growth noted was 0.38 mm/y. A moderately strong positive correlation was seen between age and airway size ( rs = 0.72, P < .0001). Children with UCTRs were less likely to have long-segment involvement than those who required repair (92%, P = .024). Conclusions A select group of children with complete tracheal rings can be managed expectantly without surgical intervention. Conservative management may be less successful in children with long-segment complete tracheal rings. Airway growth does occur in this population and can be monitored over time. Having a standardized method for sizing UCTRs allows for more effective communication between providers and assurance of continued growth of the airway while following these patients. [ABSTRACT FROM AUTHOR]

Objectives Suprastomal stents are routinely used in laryngotracheal reconstruction (LTR) to stabilize grafts and provide framework to sites of repair. However, the duration of stenting varies according to patient history and physician preference. We examined outcomes of short- versus long-term stenting in children with subglottic stenosis (SGS) undergoing LTR. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-six children <18 years old who underwent double-stage LTR for SGS from January 2012 to January 2015 were included. Demographic data, stenosis grade, and decannulation rates were compared between children with short-term stenting (≤21 days; n = 14) and those with long-term stenting (>21 days; n = 22). Results No significant difference between groups was seen for sex, age, race, or previous repair. Children in the short-term group were stented for 10.9 ± 4.9 days, compared with 44.0 ± 10.6 for those long-term ( P < .0001). A similar number of children with short- versus long-term stents had grade 3/4 stenosis preoperatively (71.4% vs 77.2%). Although time to decannulation was not significantly different, 72.7% of children with long-term stents were decannulated, as opposed to 35.7% with short-term stents ( P = .03). After adjusting for grade at surgery and age, children with long-term stents had 4.3 greater odds (95% CI, 1.0-18.3) of decannulation than children with short-term stents. Conclusions Children with long-term stenting were more likely to be successfully decannulated. Although long-term stenting improved outcomes for children with SGS, additional research is needed to better define ideal candidates for short- versus long-term stenting. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Children with bilateral true vocal fold immobility (BTVFI) may present with significant airway distress necessitating tracheostomy. The objective of this study was to review our preliminary experience with the anterior-posterior cricoid split (APCS), an endoscopic intervention used as an alternative to tracheostomy in children with BTVFI.Study Design: Multicenter review.Methods: A review of patients undergoing endoscopic APCS for BTVFI at four institutions was performed. Patients were evaluated for the ability to ventilate without the requirement for tracheostomy or reintubation. Additional data extracted included the duration of intubation following APCS, the requirement for additional procedures, and demographics. Surgical success was defined as the ability to avoid tracheostomy and to cap or decannulate without respiratory symptoms if a tracheostomy was present prior to APCS.Results: Nineteen APCS procedures were performed between October 2010 and June 2016. There were 12 male patients, the mean age at APCS was 4.7 months. BTVFI was primarily idiopathic (58%) and associated with other comorbidities (74%). All patients were candidates for tracheostomy prior to APCS. Fourteen patients (74%) were considered surgical successes. Of the unsuccessful patients, three (66%) required tracheostomy following APCS, and one was treated with a posterior cartilage graft. There was one nonsurgical mortality greater than 2 months after APCS and thought to be unrelated to the airway.Conclusions: Endoscopic APCS appears to be a safe and effective intervention for pediatric BTVFI. Under the correct circumstances, this can be performed as a single procedure, obviating tracheostomy. Further study is warranted.Level Of Evidence: 4. Laryngoscope, 128:257-263, 2018. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Evaluate and compare surgical outcomes of slide tracheoplasty for the treatment of congenital tracheal stenosis in children with and without pulmonary malformations.Study Design: Retrospective chart review at a tertiary care pediatric medical center.Methods: We identified patients with tracheal stenosis who underwent slide tracheoplasty from 2001 to 2014, and a subset of these patients who were diagnosed with congenital pulmonary malformations. Hospital course and preoperative and postoperative complications were recorded.Results: One hundred thirty patients (18 with pulmonary malformations, 112 with normal pulmonary anatomy) were included. Pulmonary malformations included unilateral pulmonary agenesis (61%) and hypoplasia (39%). Children with pulmonary malformations had a greater median age compared to their normal lung anatomy counterparts. Preoperatively, patients with pulmonary malformations more frequently required preoperative mechanical ventilation (55.6% vs. 21.3%, P = .007), extracorporeal membrane oxygenation (ECMO) (11% vs. 0.9%, P = .05), and tracheostomy (22.2% vs. 3.6%, P = .01). Postoperatively, patients with pulmonary malformations more frequently required mechanical ventilation >48 hours (78% vs. 37%, P =.005) and ECMO use (11% vs. 0.9%, P = .05). Pulmonary malformation patients and children with normal anatomy did not differ in terms of postoperative tracheostomy (16.7% vs. 4.4%, P > .05), dehiscence (6% vs. 0%, P > .05%), restenosis (11% vs. 6%, P > .05) or postoperative figure 8 deformity (6% vs. 3%, P > .05). Mortality, however, was significantly increased (22.2% vs. 3.6%, P = .01) in children with pulmonary malformations.Conclusions: Although slide tracheoplasty can be successfully performed in patients with abnormal pulmonary anatomy, surgeons and families should anticipate a more difficult postoperative course, with possible associated prolonged mechanical ventilation, ECMO use, and higher mortality than in children with tracheal stenosis alone.Level Of Evidence: 4. Laryngoscope, 127:1283-1287, 2017. [ABSTRACT FROM AUTHOR]

Background: Early-life institutional deprivation is associated with attention-deficit/hyperactivity disorder (ADHD) later in childhood and adolescence. In this article, we examine, for the first time, the persistence of deprivationrelated ADHD into young adulthood in a sample of individuals adopted as young children by UK families after periods in extremely depriving Romanian orphanages. Methods: We estimated rates of ADHD at age 15 years and in young adulthood (ages 22–25 years) in individuals at low (LoDep; nondeprived UK adoptees and Romanian adoptees with less than 6-month institutional exposure) and high deprivation-related risk (HiDep; Romanian adoptees with more than 6-month exposure). Estimates were based on parent report using DSM-5 childhood symptom and impairment criteria. At age 15, data were available for 108 LoDep and 86 HiDep cases, while in young adulthood, the numbers were 83 and 60, respectively. Data on education and employment status, IQ, co-occurring symptoms of young adult disinhibited social engagement (DSE), autism spectrum disorder (ASD), cognitive impairment, conduct disorder (CD), callous-unemotional (CU) traits, anxiety, depression and quality of life (QoL) were also collected. Results: ADHD rates in the LoDep group were similar to the general population in adolescence (5.6%) and adulthood (3.8%). HiDep individuals were, respectively, nearly four (19%) and over seven (29.3%) times more likely to meet criteria, than LoDep. Nine ‘onset’ young adult cases emerged, but these had a prior childhood history of elevated ADHD behaviours at ages 6, 11 and 15 years. Young adult ADHD was equally common in males and females, was predominantly inattentive in presentation and co-occurred with high levels of ASD, DSE and CU features. ADHD was associated with high unemployment and low educational attainment. Conclusion: We provide the first evidence of a strong persistence into adulthood of a distinctively complex and impairing deprivation-related variant of ADHD. Our results confirm the powerful association of early experience with later development in a way that suggests a role for deepseated alterations to brain structure and function. [ABSTRACT FROM AUTHOR]

Background The etiology of Autism Spectrum Disorder ( ASD) has been recently debated due to emerging findings on the importance of shared environmental influences. However, two recent twin studies do not support this and instead re-affirm strong genetic effects on the liability to ASD, a finding consistent with previous reports. This study conducts a systematic review and meta-analysis of all twin studies of ASD published to date and explores the etiology along the continuum of a quantitative measure of ASD. Methods A PubMed Central, Science Direct, Google Scholar, Web of Knowledge structured search conducted online, to identify all twin studies on ASD published to date. Thirteen primary twin studies were identified, seven were included in the meta-analysis by meeting Systematic Recruitment criterion; correction for selection and ascertainment strategies, and applied prevalences were assessed for these studies. In addition, a quantile DF extremes analysis was carried out on Childhood Autism Spectrum Test scores measured in a population sample of 6,413 twin pairs including affected twins. Results The meta-analysis correlations for monozygotic twins ( MZ) were almost perfect at .98 (95% Confidence Interval, .96-.99). The dizygotic ( DZ) correlation, however, was .53 (95% CI .44-.60) when ASD prevalence rate was set at 5% (in line with the Broad Phenotype of ASD) and increased to .67 (95% CI .61-.72) when applying a prevalence rate of 1%. The meta-analytic heritability estimates were substantial: 64-91%. Shared environmental effects became significant as the prevalence rate decreased from 5-1%: 07-35%. The DF analyses show that for the most part, there is no departure from linearity in heritability. Conclusions We demonstrate that: (a) ASD is due to strong genetic effects; (b) shared environmental effects become significant as a function of lower prevalence rate; (c) previously reported significant shared environmental influences are likely a statistical artefact of overinclusion of concordant DZ twins. [ABSTRACT FROM AUTHOR]

Background Conventional cohort studies have consistently shown that exposure to maternal smoking in pregnancy is associated with about twice the risk of attention deficit hyperactivity disorder (ADHD) in the offspring. However, recent studies using alternative designs to disentangle the effect of social and genetic confounders have suggested that confounding may account for the association. In this study we aimed to estimate the association by a sibling design. Methods We used a design with half and full siblings in a Danish national register-based cohort on all singletons born between January 1991 and December 2006 and followed until January 2011. Data were available for 90% ( N = 968,665) of the singleton live births in the period. We used the combination of the International Classification of Diseases (10th version) diagnosis of hyperkinetic disorder (HKD) and ADHD medication to identify children. We used sibling-matched (conditional) Cox regression to control social and genetic confounding. Results Using conventional cohort analyses, we found the expected association between pregnancy smoking and offspring ADHD (adjusted HR 2.01, 95% CI 1.94-2.07). In the sibling analysis, however, we did not detect such a strong association (adjusted HR 1.07, 95% CI 0.94-1.22). There was no difference between results for half- and full sibling analyses. The link between pregnancy smoking and low birth weight remained robust in the sibling design (adjusted OR 1.68, 95% CI 1.33-2.12). Conclusions We found no support for prenatal smoking as a strong causal factor in ADHD. Our findings suggest that the strong association found in most previous epidemiological studies is likely to be due to a strong link between maternal smoking and maternal ADHD genetics or shared family environment. Pregnant women should still be encouraged to stop smoking because of other risks, but we have no reason to believe that this would reduce the risk of ADHD in the offspring. [ABSTRACT FROM AUTHOR]

Background Suggestions have been made that many claims concern false-positive findings in the field of child psychology and psychiatry. Findings The literature was searched for concepts and findings on the validity of child psychiatry and psychology. Substantial progress has been made in some, but not all, areas and considerable challenges remain in all. Conclusions The two major threats to validity concern the inability to examine brain tissues in life and the evidence that there is a high overlap among disorders. We emphasize the need to follow published guidelines on preplanned analyses and we note the dangers associated with unregulated flexibility in data analysis. We note the very important clinical and developmental findings that have been ignored, perhaps partly because of an excessive focus on technologies. Nevertheless, we are positive about both the accomplishments and the ways in which challenges are being met. [ABSTRACT FROM AUTHOR]

Although suprastomal granulomas are a common complication of tracheotomy, they usually are an incidental finding and do not always require treatment. However, large granulomas may require removal, either to assist with speech production or to make the airway safer in the event of an accidental decannulation. Very large suprastomal granulomas extending up to or even through the vocal cords have been described. However, inverting suprastomal granulomas extending distally down the length of a tracheotomy tube have not been previously described. We present two cases of large suprastomal granulomas that extended distally down the trachea. Both extended beyond the tip of the tracheotomy tube, causing partial airway obstruction, and therefore required excision. Laryngoscope, 127:2883-2885, 2017. [ABSTRACT FROM AUTHOR]

Clinical genetic studies confirm the broader autism phenotype (BAP) in some relatives of individuals with autism, but there are few standardized assessment measures. We developed three BAP measures (informant interview, self-report interview, and impression of interviewee observational scale) and describe the development strategy and findings from the interviews. International Molecular Genetic Study of Autism Consortium data were collected from families containing at least two individuals with autism. Comparison of the informant and self-report interviews was restricted to samples in which the interviews were undertaken by different researchers from that site (251 UK informants, 119 from the Netherlands). Researchers produced vignettes that were rated blind by others. Retest reliability was assessed in 45 participants. Agreement between live scoring and vignette ratings was very high. Retest stability for the interviews was high. Factor analysis indicated a first factor comprising social-communication items and rigidity (but not other repetitive domain items), and a second factor comprised mainly of reading and spelling impairments. Whole scale Cronbach's alphas were high for both interviews. The correlation between interviews for factor 1 was moderate (adult items 0.50; childhood items 0.43); Kappa values for between-interview agreement on individual items were mainly low. The correlations between individual items and total score were moderate. The inclusion of several factor 2 items lowered the overall Cronbach's alpha for the total set. Both interview measures showed good reliability and substantial stability over time, but the findings were better for factor 1 than factor 2. We recommend factor 1 scores be used for characterising the BAP. Autism Res 2015, 8: 522-533. © 2015 International Society for Autism Research, Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Objective: Decannulation readiness is approached in several ways and is tailored to the individual patient. While microlaryngoscopy and bronchoscopy evaluate airway patency at all levels, polysomnography assesses sleep-related upper airway physiology. There are limited data in the literature on the utility of these tools. Thus, the main objectives of this study were (1) to identify sleep and respiratory parameters associated with successful decannulation and (2) to determine the agreement between microlaryngoscopy and bronchoscopy and polysomnography.Study Design: Case series with chart review.Setting: Quaternary care pediatric hospital.Subjects and Methods: A retrospective review of medical records, microlaryngoscopy and bronchoscopy, and polysomnographs was performed on subjects preparing for decannulation from 2005 to 2010. Fifty-nine subjects who underwent overnight polysomnography with a tracheostomy capping trial and microlaryngoscopy and bronchoscopy were included. Prediction of successful decannulation from polysomnography parameters was determined using logistic regression analysis.Results: Fifty-nine subjects with a total of 78 polysomnographs were subdivided into 2 groups: 42 polysomnographs were classified as successfully decannulated, and 36 polysomnographs belonged to the group that did not decannulate. Logistic regression analysis determined that the Apnea Hypopnea Index (P = .0423) and maximal end-tidal CO2 (P = .046) were significant predictors for successful decannulation.Conclusion: Airway evaluation by microlaryngoscopy and bronchoscopy is an essential tool in the assessment of decannulation readiness. Polysomnography is an important additional tool for children with complex airway problems. Our results indicate that certain polysomnographic parameters such as Apnea Hypopnea Index and maximal end-tidal CO2 are valuable in predicting successful tracheostomy decannulation. [ABSTRACT FROM AUTHOR]

Background Conduct Disorder ( CD) is a markedly heterogeneous psychiatric condition. Moffitt (1993) proposed that subclassification of CD should be according to age of onset. Our goals were to compare childhood-onset and adolescent-onset CD in terms of differences in phenotypic risk factors, genetic analyses, and factors associated with the persistence of antisocial behavior into young adulthood. Methods The data are from the Virginia Twin Study of Adolescent Behavioral Development ( VTSABD) and Young Adult Follow-Up ( YAFU). Childhood-onset CD was defined as CD beginning at or before age 11. Adolescent-onset CD was defined as having CD onset between ages 14 and 17. These subgroups were compared on ADHD, young adult antisocial behavior ( ASB), family dysfunction, and parental depression. Genetic analyses compare childhood-onset and adolescent-onset CD, as well as their cooccurrence with ADHD and ASB. Finally, predictors of persistence were examined. Results Childhood-onset CD was significantly associated with ADHD, ASB, family dysfunction, and parental depression. Adolescent-onset CD was marginally associated with parental depression ( p = .05) but not with any of the other risk factors. Univariate genetic models showed that both childhood-onset and adolescent-onset CD involve a large genetic liability accounting for 62% and 65% of the variance, respectively. A common genetic factor (as well as an ADHD-specific factor) accounted for the cooccurrence of childhood-onset CD and ADHD. The cooccurrence of childhood-onset CD and ASB are reflected by a common genetic factor with genetic specific effects on ASB. There was no etiological link between adolescent-onset CD and either ADHD or ASB. Both ADHD and family dysfunction were significantly associated with the persistence of antisocial behavior into young adulthood. Conclusions Phenotypic findings differentiated between childhood-onset and adolescent-onset CD. ADHD and family dysfunction predicted persistence of antisocial behavior into young adulthood. [ABSTRACT FROM AUTHOR]