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This randomized trial showed no effect of early adenotonsillectomy, as compared with watchful waiting, on the primary outcome of attention and executive functioning in children with obstructive sleep apnea. Many secondary outcomes favored early surgery. The childhood obstructive sleep apnea syndrome is associated with numerous adverse health outcomes, including cognitive and behavioral deficits. 1 The most commonly identified risk factor for the childhood obstructive sleep apnea syndrome is adenotonsillar hypertrophy. Thus, the primary treatment is adenotonsillectomy, which accounts for more than 500,000 procedures annually in the United States alone. 2 Nevertheless, there has been no controlled study evaluating the benefits and risks of adenotonsillectomy, as compared with watchful waiting, for the management of the obstructive sleep apnea syndrome. The Childhood Adenotonsillectomy Trial (CHAT) was designed to evaluate the efficacy of early adenotonsillectomy versus watchful waiting with supportive . . .

Objectives We assessed the safety and efficacy of balloon dilation as treatment for recurrent stenosis after pediatric laryngotracheoplasty. Methods We studied a retrospective case series at an academic tertiary care children's hospital. We included all patients under the age of 18 years with subglottic or tracheal stenosis treated at our institution with balloon dilation between June 2007 and April 2009. The records were analyzed for patient demographics, presenting symptoms, surgical technique, and airway description. The outcome measures were airway diameter, postoperative symptoms, tracheotomy status, and complications. Results Ten patients (9 with subglottic stenosis and 1 with tracheal stenosis) underwent 20 balloon dilation procedures without complication. The average age at the time of the procedure was 17 months (range, 3 months to 9 years). The patient presenting symptoms were stridor in 7 cases and tracheotomy in 3 cases. Vascular balloons (diameter range, 6 to 12 mm; length, 20 mm) were inflated to 10 to 12 cm H2O pressure for an average of 40 seconds (range, 10 to 120 seconds). Each procedure consisted of 1 to 3 dilation cycles. The immediate postdilation airway area increased by an average factor of 4.9 (range, 1.9 to 9). Six patients had repeat procedures with an average interval between dilations of 67 days (range, 6 to 337 days). Stridor was eliminated or greatly improved in all patients on the first postoperative day; 7 patients sustained this benefit, with an average follow-up time of 10 months (range, 4 to 23 months). Six of the 10 patients had undergone previous laryngeal reconstruction (age range, 3 months to 4 years). Of these 6, 3 have no tracheotomy, with a mean follow-up of 12.5 months. The 3 children who benefited the least from dilation were noted to have more diffuse and chronic inflammation of the larynx in comparison to the responders. Conclusions This case series suggests that balloon dilation is a relatively safe and effective procedure. It may be particularly well suited to recent stenosis after laryngotracheal reconstruction.

This volume is an invaluable reference for the practicing pediatrician, audiologist, speech pathologist, nurse practitioner, physician assistant, and other allied health professionals, as well as the pediatric otolaryngologist, including pediatric otolaryngology fellows and residents.

Study Objectives: There are few studies measuring postoperative respiratory complications in obese children with obstructive sleep apnea (OSA) undergoing adenotonsillectomy (AT). These complications are further compounded by perioperative medications. Our objective was to study obese children with OSA for their respiratory characteristics and sleep architecture on the night of AT. Methods: This was a prospective study at a tertiary pediatric hospital between January 2009–February 2012. Twenty obese children between 8–17 years of age with OSA and adenotonsillar hypertrophy were recruited. Patients underwent baseline polysomnography (PSG) and AT with or without additional debulking procedures, followed by a second PSG on the night of surgery. Demographic and clinical variables, surgical details, perioperative anesthetics and analgesics, and PSG respiratory and sleep architecture parameters were recorded. Statistical tests included Pearson correlation coefficient for correlation between continuous variables and chi-square and Wilcoxon rank-sum tests for differences between groups. Results: Baseline PSG showed OSA with mean obstructive apnea-hypopnea index (oAHI) 27.1 ± 22.9, SpO 2 nadir 80.1 ± 7.9%, and sleep fragmentation-arousal index 25.5 ± 22.0. Postoperatively, 85% of patients had abnormal sleep studies similar to baseline, with postoperative oAHI 27.0 ± 34.3 ( P = .204), SpO 2 nadir, 82.0 ± 8.7% ( P = .462), and arousal index, 24.3 ± 24.0 ( P = .295). Sleep architecture was abnormal after surgery, showing a significant decrease in REM sleep ( P = .003), and a corresponding increase in N2 ( P = .017). Conclusions: Obese children undergoing AT for OSA are at increased risk for residual OSA on the night of surgery. Special considerations should be taken for postoperative monitoring and treatment of these children. Commentary: A commentary on this article appears in this issue on page 775. Citation: De A, Waltuch T, Gonik NJ, Nguyen-Famulare N, Muzumdar H, Bent JP, Isasi CR, Sin S, Arens R. Sleep and breathing the first night after adenotonsillectomy in obese children with obstructive sleep apnea syndrome. J Clin Sleep Med. 2017;13(6):805–811.

Objective Measure the effects of a structured morbidity and mortality conference format on the attitudes of resident and faculty participants. Study Design Prospective cohort study. Setting Otorhinolaryngology–head and neck surgery residency training program. Subjects and Methods Two changes were implemented to the structure of our morbidity and mortality conference: (1) we adopted a recently described presentation framework called situation‐background‐assessment‐recommendation and (2) appointed a faculty moderator to lead the conference. Surveys were distributed to residents and faculty before and after these modifications were implemented to measure changes in attitude of conference attendees. Results After implementing the above changes to the morbidity and mortality conference, participant engagement increased from “moderately engaged” to “extremely engaged” (P <. 01). Among both faculty and residents, the perceived educational value of conference also improved from “moderately educational” to “extremely educational” (P <. 01). Finally in the attending cohort, the impact on future patient care increased from “no change” to “greatly enhanced” (P <. 01). Conclusion By implementing the situation‐background‐assessment‐recommendation framework and appointing a faculty moderator to morbidity and mortality conference, participants reported significantly enhanced engagement during the conference, increased educational value of the session, and a positive impact on future patient care.

Background. LCH is a benign vascular growth of the skin and mucous membranes commonly affecting the head and neck. Since it was first described in the nineteenth century, this entity has been variously known as “human botryomycosis” and “pyogenic granuloma.” The shifting nomenclature reflects an evolving understanding of the underlying pathogenesis. We review the histopathology of and current epidemiological data pertaining to LCH which suggests that the development of these lesions may involve a hyperactive inflammatory response influenced by endocrine factors. We report two new cases of pediatric lobular capillary hemangioma (LCH) of the nasal cavity and review current theories regarding the etiology, diagnosis, and treatment of nasal LCH. Methods. Retrospective case series. Case Series. Two adolescent females presented with symptoms of recurrent epistaxis, nasal obstruction, and epiphora. Both patients underwent computed tomography imaging and biopsy of their intranasal mass. The tumors were excised using image-guided transnasal endoscopic technique. Seven other cases of nasal LCH have been reported to date in the pediatric population. Conclusion. Nasal LCH is a rare cause of an intranasal mass and is associated with unilateral epistaxis, nasal obstruction, and epiphora. We advocate for image-guided endoscopic excision of LCH in the adolescent population.

Objectives: We report the frequency and success rates of adjunctive airway procedures after pediatric single-stage laryngotracheoplasty (LTP) and review different adjunctive techniques in a prospectively enrolled and retrospectively reviewed case series. Methods: Of 31 LTP procedures performed from 2008 to 2011 at an academic tertiary care children's hospital, 10 were single-stage LTP procedures. These 10 cases were analyzed to determine the number and type, if any, of adjunctive procedures required after LTP, as well as the subglottic response and decannulation rates. Results: Of the 10 patients with single-stage LTP procedures, 6 patients required a total of 16 postoperative adjunctive airway procedures. The adjunctive procedures included granulation tissue removal with forceps or a carbon dioxide laser, stent placement, mitomycin C application, and triamcinolone acetonide injection. One patient also required tracheotomy placement and, eventually, cricotracheal resection. All 6 patients had significant improvement of subglottic and/or tracheal stenosis on their most recent endoscopic examination. With a minimum follow-up of 12 months, all 6 patients were decannulated. Conclusions: In this series, more than half of our pediatric patients who underwent single-stage LTP required 1 or more postoperative adjunctive procedures, and all had successful outcomes.

Objective Measure the effects of a structured morbidity and mortality conference format on the attitudes of resident and faculty participants. Study Design Prospective cohort study. Setting Otorhinolaryngology–head and neck surgery residency training program. Subjects and Methods Two changes were implemented to the structure of our morbidity and mortality conference: (1) we adopted a recently described presentation framework called situation-background-assessment-recommendation and (2) appointed a faculty moderator to lead the conference. Surveys were distributed to residents and faculty before and after these modifications were implemented to measure changes in attitude of conference attendees. Results After implementing the above changes to the morbidity and mortality conference, participant engagement increased from “moderately engaged” to “extremely engaged” (P < .01). Among both faculty and residents, the perceived educational value of conference also improved from “moderately educational” to “extremely educational” (P < .01). Finally in the attending cohort, the impact on future patient care increased from “no change” to “greatly enhanced” (P < .01). Conclusion By implementing the situation-background-assessment-recommendation framework and appointing a faculty moderator to morbidity and mortality conference, participants reported significantly enhanced engagement during the conference, increased educational value of the session, and a positive impact on future patient care.

Objectives: We sought to assess the quantity of intraoperative bleeding from microdebrider intracapsular tonsillectomy (IT) relative to electrocautery tonsillectomy (ET). Methods: Intraoperative tonsil bleeding was measured prospectively for all children younger than 19 years of age who underwent primary tonsillectomy for recurrent tonsillitis or adenotonsillar hypertrophy at a tertiary care academic children's hospital. We performed IT in 57 patients (33 male, 24 female; mean age, 64.3 months) and ET in 51 patients (20 male, 31 female; mean age, 92.4 months). Results: Microdebrider IT resulted in more intraoperative bleeding than ET (27.9 versus 8.7 mL, p = 0.003; and 1.2 versus 0.2 mL/kg, p < 0.001). The median and maximum blood losses, respectively, were 0.6 and 9.5 mL/kg for IT and 0 and 2.0 mL/kg for ET. Blood loss for ET was not related to whether a resident versus an attending physician was the operating surgeon (p = 0.11). A linear regression model did not demonstrate greater bleeding with recurrent tonsillitis (IT, p = 0.39; ET, p = 0.89) or with increased patient age (IT, p = 0.08; ET, p = 0.62). Conclusions: Microdebrider IT produces more intraoperative bleeding than ET. The difference in blood loss is statistically but not clinically significant. Microdebrider IT causes bleeding within acceptable limits, and thus patients and physicians should not be discouraged from choosing this procedure solely on the basis of the amount of intraoperative blood loss.