Faculty Bibliography

Pediatric voice disorders are increasing being noted as a barrier to success in school and socialization. Significant advances over the past decade in evaluation, diagnosis, and management of pediatric voice disorders have improved both short-term and long-term outcomes. Practitioners should have a thorough understanding of anatomy and physiology, accurately work up a pediatric voice disorder, and efficiently treat voice disorders. Comprehensive voice evaluation in children is essential to properly assessing pediatric dysphonia. Diagnosis and treatment are best managed by a multidisciplinary team. Accurate diagnosis allows for effective treatment, which includes voice therapy, medical therapy, and surgical intervention as needed.

Movement disorder emergencies of the aerodigestive tract are dramatic and often life threatening. With appropriate timely evaluation and intervention, most patients can be effectively managed and major morbidity avoided. This chapter provides a comprehensive review of both the causes and appropriate treatment of breathing disturbances secondary to primary disorders and iatrogenic causes, as well as swallowing emergencies. Additionally, basic physiology, anatomy, and various methods for assessment of the upper aerodigestive tract are reviewed. Specific disorders that are addressed include the following: spasmodic dysphonia, adductor laryngeal breathing dystonia, Shy-Drager abductor weakness, drug-induced tardive dystonia, oromandibulolingual dystonia, multiple system atrophy, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease, Huntington's disease, and palatal myoclonus.
Copyright

INTRODUCTION/BACKGROUND:Neonates with severe Pierre Robin sequence (PRS) can be treated by mandibular distraction osteogenesis (MDO), tongue-lip adhesion, or tracheostomy; however, there is an active debate regarding the indications of MDO in this patient population. Published algorithms identify tracheomalacia, bronchomalacia, laryngomalacia, hypotonic syndromes, and central sleep apnea as contraindications for MDO and indications for tracheostomy, but these comorbidities may exist along a spectrum of severity. The authors propose that appropriately selected neonates with PRS who concurrently express 1 or more of these traditional contraindications may be successfully treated with MDO. METHODS:The authors performed a 5-year retrospective chart review of all neonates who underwent MDO for treatment of severe PRS. All patients expressed a comorbidity previously identified as an indication for tracheostomy. Pre- and postoperative characteristics were recorded. Apnea/hypopnea index (AHI) before and after MDO were compared using 2-tailed repeated measures t-test. RESULTS:The authors identified 12 patients with severe PRS and conditions associated with contraindications to MDO: 9 (75.0%) patients had laryngomalacia, 6 (50.0%) patients had tracheomalacia, 2 (16.6%) patients had bronchomalacia, 1 (8.3%) patient had central sleep apnea, and 3 (25.0%) patients had hypotonia. Five (41.7%) patients underwent concurrent gastrostomy tube placement due to feeding insufficiency. Average birthweight was 3.0 kg. Average pre-op AHI was 34.8. Average post-op AHI was 7.3. All patients successfully underwent MDO with avoidance of tracheostomy. CONCLUSIONS:By employing an interdisciplinary evaluation of patient candidacy, MDO can safely and effectively treat upper airway obstruction and avoid tracheostomy in higher-risk neonatal patients with traditional indications for tracheostomy.

Multisystem inflammatory syndrome in children (MIS-C) is thought to follow SARS-CoV-2 infection and presents with fever and multisystem dysfunction. We report three children with suspected MIS-C found to have retropharyngeal edema without evidence of a bacterial etiology. We raise the possibility that an association between MIS-C and retropharyngeal edema exists.

General and local anesthetics are generally well tolerated in the healthy population. Complications may arise affecting the surgical and anesthetic course. We present a case of severe bradycardia and hypotension, along with ST depressions which developed following general anesthesia and local injection of lidocaine with epinephrine to the nose in a healthy male during routine otolaryngological surgery. Symptoms improved with atropine, epinephrine and chest compressions. Subsequent electrocardiogram and Troponin were abnormal, and normalized within days. Reviewing the literature, several possible etiologies arise. These include the Trigeminocardiac Reflex, Takotsubo cardiomyopathy and others. These are discussed and the condition's immediate management recommended.

OBJECTIVES/OBJECTIVE:To provide recommendations to otolaryngologists, pulmonologists, and allied clinicians for tracheostomy decannulation in pediatric patients. METHODS:An iterative questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group. RESULTS:Twenty-six members completed the survey. Recommendations address patient criteria for decannulation readiness, airway evaluation prior to decannulation, decannulation protocol, and follow-up after both successful and failed decannulation. CONCLUSION/CONCLUSIONS:Tracheostomy decannulation recommendations are aimed at improving patient-centered care, quality and safety in children with tracheostomies.

Although the majority of attention to the health care impact of COVID-19 has focused on adult first responders and critical care providers, the pandemic has had a profound effect on the entire health care industry, including the pediatric otolaryngology community. This article highlights the unique ramifications of COVID-19 on pediatric otolaryngology, with a focus on the immediate and potential long-term shifts in practice. Specifically, the article is divided into 3 sections (care for the patient, care for the practitioner, and care for the practice) and details the unique effects of the pandemic on the pediatric otolaryngology specialty.

Mycobacterium avium-intracellulare complex (MAC) is one of the most common forms of non-tuberculous mycobacterial (NTM) infection. MAC is a ubiquitous bacterium that resides in both natural and man-made environments. Surgical intervention is well established in NTM infections causing cervical lymphadenitis, but its role in airway disease is not well understood. Invasive pulmonary infection is usually associated with immunocompromised patients, but it occurs in otherwise healthy children as well. We present a challenging clinical case of an 18-month-old female with severe mediastinal MAC causing bilateral bronchogenic obstruction and respiratory compromise requiring emergent intubation and intervention, likely due to a genetic predisposition secondary to Interferon Gamma Receptor 2 (IFNGR2) haploinsufficiency. During the initial bronchoscopy, the left bronchus was 99% obstructed while the right bronchus was 60% obstructed. The right lesion was biopsied and drained whitish fluid with improvement in clinical status shortly thereafter. A culture was sent. Follow-up bronchoscopy with excision of residual right mass allowed for extubation in the operating room with discharge on azithromycin, rifabutin, and ethambutol. Repeat bronchoscopy after discharge revealed recurrence of bilateral lesions. The patient was started on nebulized amikacin in addition to her current regimen with full resolution after treatment. Despite subtotal removal of MAC lesions possibly increasing the chances of recurrence, surgical intervention in this patient resulted in rapid improvement in respiratory status, and it may represent the preferred treatment in patients with any airway concerns.

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

OBJECTIVE:Laryngopharyngeal and Gastroesophageal reflux (LPR and GER) are distinct clinical entities that present with a range of non-specific symptoms. The exact prevalence in the pediatric population is unknown. While there has been an increase in the use of PPIs, lack of clear guidelines, conflicting evidence regarding efficacy and safety concerns with long-term use require physicians to use their own anecdotal experience and clinical judgement when treating patients. The goal of this study was to evaluate practice patterns among pediatric otolaryngologists regarding the use of proton-pump inhibitors for reflux-related conditions. METHODS:A survey was submitted to American Society of Pediatric Otolaryngology (ASPO) members to determine practice patterns regarding use of PPIs for reflux-related conditions in the newborn and infant population. Statistical analysis using Fisher's exact test was performed. RESULTS:37% of respondents would not prescribe PO PPIs in neonates, with 50% not prescribing IV PPIs. 60% would prescribe a PPI as second or third-line treatment for infants (10 weeks to 1-year). Only 10% would prescribe as first-line in this age group. 48% would prescribe PPIs once daily and 19% as BID. No significant practice differences exist based on years of experience, number of relevant patients seen, and setting of practice. CONCLUSION/CONCLUSIONS:There was no agreement regarding dosage, frequency and duration of PPI treatment for reflux disease in neonates and infants. There was also no correlation with experience or practice setting. This emphasizes the need for a multidisciplinary approach and consensus statement to guide management of GER and LPR in this population.