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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., (© 2022 The Authors. Otolaryngology-Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

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., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

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., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

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., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

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., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

The head and neck are the most common site of involvement for vascular tumors and malformations, with more than half of all vascular anomalies seen in this region. Lesions in this location can cause significant disfigurement and can be associated with airway obstruction, impairment in vision or hearing, swallowing disorders and hemorrhage. Accurate diagnosis is critical in determining treatment, and interdisciplinary care is essential for optimal management. We review clinical and imaging features that are key to establishing the correct diagnosis, and review treatment modalities, with emphasis on interventional and surgical procedures., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Inc.)

Objectives: To understand that yolk sac tumors (YSTs) of the head and neck (H&N) are exceedingly rare and typically carry a poor prognosis. To acknowledge the possibility of increased incidence in patients with Aicardi Syndrome and the ramifications this has on early diagnosis and treatment in this population., Methods: To date, four germ cells tumors of the H&N have been reported in patients with Aicardi Syndrome. This report presents the second known case of a H&N YST in a patient with Aicardi syndrome. In both cases, the patient was initially misdiagnosed given unconvincing radiologic evidence. However, tissue diagnosis and elevated alpha-fetoprotein (AFP) levels were suggestive of a YST., Results: In contrast to the poor prognosis previously described, both patients with Aicardi syndrome had an excellent chemotherapeutic response exhibited by normalization of AFP levels and imaging., Conclusions: Rare germ cell tumors of the H&N, such as YSTs, have now been documented in several patients with Aicardi syndrome, indicating a possible association given the rarity of these tumors in the population. YSTs should be considered in the differential diagnosis of H&N masses in these patients, with emphasis on early tissue diagnosis and treatment.

Differentiated thyroid cancer (DTC) is the most common cancer in adolescents and young adults. In 2015, the American Thyroid Association published guidelines for management of pediatric DTC. We report our institutional experience and highlight changing practices and new opportunities. A retrospective analysis of all patients diagnosed with DTC from 2001 to 2016 was performed. Among 59 eligible patients, 31 (53%), 15 (25%), and 13 (22%) had low-risk, intermediate-risk, and high-risk disease, respectively. Half (15/31) of low-risk and all intermediate-risk/high-risk patients received radioactive iodine (I-131) ablation. For low-risk patients, average I-131 dose decreased from 80 to 42.05 mCi, and the percentage of patients who received I-131 decreased over time. Eleven of 16 patients with tumor genomic data were found to have somatic targetable (n=6) or germline (n=5) mutations. Persistent/recurrent disease was only present in high-risk (n=8) and intermediate-risk (n=1) patients. Two patients with iodine-refractory disease received trametinib to enhance radioiodine uptake. All patients were alive at follow-up (median, 5 y; range, 1 to 15 y). Coincident with the recent American Thyroid Association guidelines, the use of I-131 in low-risk patients has decreased over time in our practice. Tumor sequencing and cancer genetic evaluation may help redefine opportunities for treatment of high-risk patients and family counseling.

Background: Vascular malformations isolated to skeletal muscles are rare and often debilitating due to pain and very challenging to treat. Multi-modal management options include compression garments, medical therapy, sclerotherapy, and surgical resection., Methods: A retrospective review of patients who underwent sclerotherapy for intramuscular venous malformations (IVM) between 2008 and 2016 was performed. Demographics, indications, and clinical follow-up were analyzed., Results: Twenty patients underwent sclerotherapy for IVM. Six males and 14 females underwent 58 procedures. All patients presented with pain and were treated initially with compression garments. Median age at first treatment was 13years (+/- 5.06years). Initial protocol consisted of 2 sclerotherapy procedures with sodium tetradecyl sulfate (STS) within a 2-3month interval. Median volume of the lesion was 40cm 3 (+/- 28.7), mostly located in the lower extremities (15/20). Median number of treatments was 2 (+/- 1.95). Treatment prior to puberty resulted in a median symptom-free time of 4years (+/- 2.18), while after puberty resulted in a symptom-free time of 2years (+/- 2.28). Two patients had an underlying coagulopathy and were admitted for observation and peri-procedural Lovenox. No procedure related complications were noted with a median follow-up of 4years (+/- 2.27)., Conclusion: IVMs are rare but can be incapacitating secondary to pain. Sclerotherapy is a useful minimally invasive procedure generally requiring at least two consecutive treatments. Treatment of patients prior to puberty appears to provide a more durable result, and surgical resection may be avoided., Type of Study: retrospective., Level of Evidence: IV., (Copyright © 2018. Published by Elsevier Inc.)

Importance: Obtaining sufficient operating room time for inpatient consults requiring an operative intervention is a persistent challenge for otolaryngologists., Objective: To examine the institution of an otolaryngology-specific operating room (OR) for unscheduled (add-on) cases for its association with time from initial consultation to surgery and, secondarily, to determine utilization of a dedicated block of time., Design, Setting, and Participants: Retrospective review of medical records of a tertiary care pediatric hospital for patients treated between January 1, 2015, and March 31, 2016; analysis was concluded by June 2016. Included were all patients undergoing inpatient otolaryngology consultations who required nonemergency operative procedures., Interventions: In August 2015, a once-weekly 5-hour block of OR time dedicated to inpatient otolaryngology consults was instituted. Prior to this, cases were placed on an add-on list shared between all surgical services., Main Outcomes and Measures: It was hypothesized that institution of a dedicated block of OR time would decrease the time from initial consultation to operative intervention and would be utilized at a high rate. Operating room utilization was calculated by dividing scheduled OR time by actual OR time utilized. Time from initial consultation to OR intervention was compared before and after the institution of the dedicated OR block., Results: A total of 316 inpatient add-on pediatric cases (including 108 patients from the intensive care unit [ICU]) were scheduled during the study period. The most common cases were microlaryngoscopy/bronchoscopy (79%) and tracheostomy (8%). Mean (SD) time between consultation and OR intervention was 7.8 (1.6) days prior to establishing the add-on OR and 4.4 (1.3) days after it was established (absolute difference of 3.4 days; 95% CI, 3.1-3.7 days). Mean (SD) time between consultation and OR intervention was 7.4 (5.0) days for ICU patients prior to intervention and 5.6 (3.0) days after intervention (absolute difference of 1.8 days; 95% CI, 1.6-2.0 days). Total utilization of the OR block time was 74%, and adjusted utilization was 86%. There was a 15% drop in the number of unscheduled add-on cases after the intervention (from 10 cases/mo to 8.5 cases/mo; absolute difference of 1.5 cases; 95% CI, 1.1-1.9 cases)., Conclusions and Relevance: Instituting a dedicated otolaryngology add-on OR was associated with significantly reduced time between initial consultation and operative care, by approximately 3 days, decreased the number of unscheduled add-on cases, and was utilized at a high level.

Objective Study the performance of a pediatric critical airway response team. Study Design Case series with chart review. Setting Freestanding academic children's hospital. Subjects and Methods A structured review of the electronic medical record was conducted for all activations of the critical airway team. Characteristics of the activations and patients are reported using descriptive statistics. Activation of the critical airway team occurred 196 times in 46 months (March 2012 to December 2015); complete data were available for 162 activations (83%). For 49 activations (30%), patients had diagnoses associated with difficult intubation; 45 (28%) had a history of difficult laryngoscopy. Results Activation occurred at least 4 times per month on average (vs 3 per month for hospital-wide codes). The most common reasons for team activation were anticipated difficult intubation (45%) or failed intubation attempt (20%). For 79% of activations, the team performed an airway procedure, most commonly direct laryngoscopy and tracheal intubation. Bronchoscopy was performed in 47% of activations. Surgical airway rescue was attempted 4 times. Cardiopulmonary resuscitation occurred in 41 activations (25%). Twenty-nine patients died during or following team activation (18%), including 10 deaths associated with the critical airway event. Conclusion Critical airway team activation occurred at least once per week on average. Direct laryngoscopy, tracheal intubation, and bronchoscopic procedures were performed frequently; surgical airway rescue was rare. Most patients had existing risk factors for difficult intubation. Given our rate of serious morbidity and mortality, primary prevention of critical airway events will be a focus of future efforts.

Simulation is an emerging and viable means to increase pediatric airway surgical training. A variety of simulators currently exist that may be used or modified for laryngoscopy, bronchoscopy, and endoscopic intervention, although anatomic realism and utility for complex procedures are limited. There is a need for further development of improved endoscopic and anatomic models. Innovative techniques are enabling small-scale manufacturing of generalizable and patient-specific simulators. The high acuity of the pediatric airway patient makes the use of simulation an attractive modality for training, competency maintenance, and patient safety quality-improvement studies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To compare clinicians' ratings of videolaryngoscopy (VLS) and high-speed videoendoscopy (HSV) and assess confidence of ratings with VLS and HSV in patients with supraglottic phonation., Methods: The VLS and HSV video samples were taken from 11 adolescents post airway reconstruction who use supraglottic tissues for voice. The 22 recordings were randomized and presented to 4 clinicians: 2 speech-language pathologists and 2 pediatric otolaryngologists. Additionally, a 5-point Likert scale was used to rate level of confidence of ratings., Results: Clinicians were more likely to rate regularity on HSV versus VLS videos (P = .003). Presence of mucosal wave was rated similarly on both imaging modalities; however, HSV was more likely to identify location (P = .002). Supraglottic phase symmetry (P = .014) and number of vibratory tissues used for phonation were rated more often with HSV versus VLS. Clinicians were more confident with HSV ratings compared to VLS ratings for determining vibration source, vibration pattern, and ability to make treatment decisions (P < .0001)., Conclusions: The HSV improves the ability to rate tissue vibratory characteristics when compared with VLS in children with supraglottic phonation. This information may allow better understanding of the underlying mechanisms of voice production in these individuals, leading to improved therapeutic and surgical recommendations., (© The Author(s) 2016.)

Objective: Pediatric dysphagia occurs in 500,000 children each year; however, there is not a common tool to assess these children. Our aim was to identify validated patient- or parent-reported outcome assessment tools evaluating pediatric dysphagia., Data Sources: Scopus, EMBASE, PubMed, Cochrane Library, and CINAHL electronic databases (all indexed years through August 2014)., Review Methods: Inclusion criteria included English-language articles containing instruments evaluated in children. Two investigators independently reviewed all articles, and the review was performed according to PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses)., Results: The initial search yielded 1697 abstracts; 158 studies were assessed further. Four symptom questionnaires, validated in adults, were used to report pediatric dysphagia outcomes. Four outcomes tools assessing dysphagia were validated in pediatrics in selected populations. The Dysphagia in Multiple Sclerosis questionnaire and the Dysphagia Symptom Questionnaire for eosinophilic esophagitis were validated in adolescents and adults. The Symptom Questionnaire for Eosinophilic Esophagitis was validated in children with eosinophilic esophagitis. The Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module, validated in children with gastrointestinal disorders, includes 2 domains that assess swallowing function., Conclusion: We did not identify any validated patient- or parent-reported outcome assessment tools examining dysphagia symptoms in a general pediatric population. However, we identified 4 questionnaires that have been validated in specific pediatric disease cohorts. Having a standardized assessment instrument validated in all children would allow clinicians to systematically report symptoms and compare results of pediatric clinical trials. With this in mind, we recommend establishing a standard questionnaire for the broader pediatric population., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Disinfection caps are increasingly being used to prevent catheter-associated bloodstream infections. These devices, designed for continuous passive disinfection of catheter hubs, are typically small and often brightly colored. As such, they have the potential to become pediatric airway and esophageal foreign bodies. We report two patients who developed esophageal foreign body following ingestion of disinfection caps. Given the increasing use of these devices, it is imperative that health care providers be aware of this potential iatrogenic problem. We propose that the use of disinfection caps may not be appropriate in pediatric patients with risk factors for foreign body ingestion., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Suture closure and fibrin glue placement have been advocated as alternatives to healing by secondary intention. The aim of this study was to examine the tensile strength of these microflap closure techniques., Study Design: Basic research., Methods: Three pairs of excised bovine true vocal folds underwent microflap creation and closure by either single 6-0 polyglactin suture or fibrin glue. Vocal folds were distracted to failure on a universal testing system. Excised porcine true vocal folds underwent microflap creation and were closed with either single 6-0 polyglactin suture or fibrin glue, or were left without closure. Tensile strength testing was performed with a universal testing system measuring load at 1 mm, 5 mm, and 10 mm of distraction., Results: The bovine vocal fold model failed after an average extension of 22.6 mm (range, 21.4-23.9 mm) corresponding to 11.61 N (range, 8.04-13.47 N), with no failure of the suture prior to model failure. Fibrin glue did not demonstrate any measureable resistance to tension application. In the porcine vocal fold model, there was a significant difference between the median tensile load of suture closure (2.91 N) and no closure (1.16 N) at 10 mm of distraction (P = .01). There was no significant difference in median load of vocal folds undergoing fibrin glue closure or no closure., Conclusions: There is no significant difference in tensile strength of a microflap closed with fibrin glue or not closed. Suture closure of a microflap provides a significantly stronger mechanical closure than no closure. This suggests that use of fibrin glue is of little benefit on the vocal folds., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Attrition is a disruptive problem in residency training programs. Resident attrition has been more thoroughly investigated and reported in other medical fields with limited data specific to otolaryngology. Using a Web-based survey of otolaryngology residency program directors, information regarding a 5-year cohort of residents was collected. The survey response rate was 61% (59 of 97 programs), representing 779 of 1239 training positions (63%). Forty-two percent of responding programs (25 of 59) lost a total of 47 residents (range, 1-7; mode 1). The overall attrition rate was 6% for the 5-year cohort (47 of 779) or 1.2% annually. Involuntary attrition affected 6 residents. Eighteen residents voluntarily left for other medical programs. Four left medicine entirely. The remaining 19 residents' career paths were not described. Attrition within otolaryngology occurs with less frequency than general surgery and is likely comparable to other surgical subspecialties.

Objectives: Applying the concept of the ACGME general competencies, it is possible to define the essential job objectives and competencies of a junior otolaryngology resident. The objective of this study is to incorporate commercially available tools of business in the identification of competencies specific to the junior otolaryngology resident and develop behavioral-based interview questions and techniques designed to identify these qualities in candidates for residency., Study Design: Institution of a pilot program involving a focus group within an otolaryngology department, a professional development consultant, commercial business software for occupational analysis and personnel selection, and an interview technique training seminar for faculty and residents., Methods: In coordination with a university-based professional development consultant, a formal job analysis was conducted to define the job objectives and competencies of a junior otolaryngology resident. These results were used to generate behavioral-based interview questions for use in the resident selection process. All interviewing faculty and residents were trained in behavioral-based interviewing., Results: Occupational objectives for the junior resident position specific to a particular university department of otolaryngology were identified. Additionally, the essential skills, areas of knowledge, and competencies were identified. Behavioral-based questions specific to the competencies were created and incorporated into the current resident selection interview., Conclusions: Using tools of occupational analysis and personnel selection, a list of job objectives and competencies for the junior otolaryngology resident can be created. Using these results, behavioral-based interviews may be implemented to complement traditional interviews with the ultimate goal of improving candidate selection.