OBJECTIVE: Occurrence of post-intubation laryngotracheal stenosis (LTS) with respect to COVID-19 status.
METHODS: Retrospective cross-sectional inpatient database.
METHODS: Eleven Midwest academic and community hospitals, United States.
METHODS: Adults, mechanically ventilated, from January 2020 to August 2022, who were subsequently readmitted within 6 months with a new diagnosis of LTS.
METHODS: None.
RESULTS: Six thousand eight hundred fifty-one COVID-19 negative and 1316 COVID-19 positive patients were intubated and had similar distribution by age (median 63.77 vs. 63.16 yr old), sex (male, 60.8%; n = 4173 vs. 60%; n = 789), endotracheal tube size (≥ 7.5, 75.8%; n = 5192 vs. 75.5%; n = 994), and comorbidities. The ICU length of stay (median [interquartile range (IQR)], 7.23 d [2.13-16.67 d] vs. 3.95 d [1.91-8.88 d]) and mechanical ventilation days (median [IQR], 5.57 d [1.01-14.18 d] vs. 1.37 d [0.35-4.72 d]) were longer in the COVID-19 positive group. The occurrence of LTS was double in the COVID-19 positive group (12.7%, n = 168 vs. 6.4%, n = 440; p < 0.001) and was most commonly diagnosed within 60 days of intubation. In multivariate analysis, the risk of LTS increased by 2% with each additional ICU day (hazard ratio [HR], 1.02; 95% CI, 1.02-1.03; p < 0.001), by 3% with each additional day of ventilation (HR, 1.03; 95% CI, 1.02-1.04; p < 0.001), and by 52% for each additional reintubation (HR, 1.52; 95% CI, 1.36-1.71; p < 0.001). We observed no significant association COVID-19 status and risk of LTS.
CONCLUSIONS: The occurrence of post-intubation LTS was double in a COVID-19 positive cohort, with higher risk with increasing number of days intubated, days in the ICU and especially with the number of reintubations. COVID-19 status was not an independent risk factor for LTS.

OBJECTIVE: The possible etiological relationship of the vitamin D with laryngomalacia is unclear. The aim of the study was to demonstrate the relationship between laryngomalacia and vitamin D levels.
METHODS: Twenty-three non-syndromic babies under the age of 1 year who were diagnosed with laryngomalacia were included in the study group. Forty healthy babies were included in the control group. The detailed anamnesis was obtained and a complete systemic physical examination, a flexible endoscopic laryngeal examination, and laboratory tests [calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), parathormone (PTH), alanine transaminase (ALT), aspartate transaminase (AST), blood urea nitrogen (BUN), creatinine (Cre), and 25-hydroxy vitamin D (25-OH D)] were performed in all patients. All laboratory tests of the groups were compared.
RESULTS: It was observed that there was no significant difference in the parameters that could affect vitamin D levels, namely type of feeding, vitamin D supplement intake, and the season when the serum sample was taken (p > 0.05). The vitamin D level was significantly lower (p = 0.003, p < 0.05) and the P and ALP levels were significantly higher (p = 0.016 and p = 0.001, respectively; p < 0.05) in the laryngomalacia group. Although the correlation between vitamin D and PTH was not statistically significant according to the Pearson correlation analysis, it was lower in the laryngomalacia group compared to the control group (p = 0.381, p > 0.05).
CONCLUSIONS: In this study, it was observed that the vitamin D levels were lower in infants with laryngomalacia compared to the control group. We consider that vitamin D deficiency may be a factor in the etiology of laryngomalacia with a yet-to-be-clarified etiology.

BACKGROUND: Post-extubation upper airway obstruction (UAO) is a frequent complication causing stridor and respiratory distress, which occasionally require reintubation, thereby increasing morbidity and mortality rates. Contradictory results have been obtained in studies assessing the effectiveness of steroids in preventing post-extubation UAO, and the available evidence is limited. We designed a multicentric randomized, placebo-controlled study to explore the effectiveness of dexamethasone in preventing post-extubation UAO in children.
METHODS: A multicentric, prospective, double-blind, randomized, placebo-controlled, phase IV clinical trial has been designed. The sample will include pediatric patients who are between 1 month and 16 years of age and who have been intubated for more than 48 h. Patients who have airway disorders or who have received steroids within the previous seven days will be excluded. Patients will be randomly assigned to receive either placebo or a therapy with dexamethasone 0.25 mg/kg every 6 h to be started 6 to 12 h prior to extubation (to a total of four doses). Randomization will be performed at a 1:1 ratio. Follow-up of patients will be carried out for 48 h after extubation. The main objective of this study is to access the reduction in the incidence of moderate to severe UAO symptoms following extubation. Secondary objectives include assessing the decrease in the incidence of reintubation, evaluating the use of additional therapies for UAO, and monitoring potential side effects of dexamethasone.
CONCLUSIONS: The results of this study will contribute to the existing evidence on prophylaxis for post-extubation airway obstruction.
BACKGROUND: EudraCT identifier: 2009-016596-30. Registered on May 11, 2010.

To determine the agreement of paediatric otolaryngologists on classifying laryngomalacia (LM).
Intra- and interobserver agreement study of two classification systems.
Three tertiary referral paediatric centres.
Three paediatric otolaryngologists, who were blinded to any clinical details, interpreted the videos of children diagnosed with LM using the Holinger and Olney classifications independently. They rated the videos twice with a washout period of at least 2 weeks.
Inter- and intra-observer agreement measured by overall Fleiss kappa and unweighted Cohen\'s kappa coefficients. The secondary outcome measures were inter- and intra-observer agreement on the individual anatomical subunits of the supraglottis affected by LM, characterised by the subcategories of the classifications.
Video records of infants and children <18 years who had an endoscopic diagnosis of LM from 2012 to 2017 were retrospectively chosen for inclusion (n = 73). The overall Fleiss kappa coefficient was 0.25 (95% CI 0.18-0.32) amongst the raters using the Holinger classification and 0.31 (95% CI 0.21-0.42) for the Olney classification. Intra-observer agreement using the Holinger classification was 0.30 (95% CI 0.18-0.42), 0.62 (95% CI 0.23-0.85) and 0.84 (95% CI 0.75-0.94], whilst the Olney classification yielded values of 0.41 (95% CI 0.26-0.56), 0.51 (95% CI 0.29-0.63) and 0.63 (95% CI 0.48-0.78).
The agreement on types of LM between expert observers is modest using the Holinger and Olney classifications. This has significant implications for accurately diagnosing LM and exposes potential obstacles against credible pooling of data and extrapolation of information.

OBJECTIVE: Prolonged endotracheal intubation may lead to laryngeal damage, with stridor being the most relevant clinical symptom. Our objective was to determine the incidence of post-extubation stridor and their clinical consequences in children within a tertiary referral center and to identify contributing factors.
METHODS: 150 children, aged 0-16 years, intubated for more than 24 h were prospectively enrolled until discharge of the hospital. Potential relevant factors, thought to mediate the risk of laryngeal damage, were recorded and analyzed.
RESULTS: The median duration of intubation was 4 days, ranging from 1 to 31 days. Stridor following extubation occurred in 28 patients (18.7%); 3 of them required reintubation due to respiratory distress and in 1 child stridor persisted for which a surgical intervention was necessary. In multivariate analyses, we found the following independent predictors of stridor: intubation on the scene, the use of cuffed tubes and lower age.
CONCLUSIONS: Despite a high incidence for post-extubation stridor, only few children need reintubation or surgical intervention as a result of post-extubation lesions. Intubation on the scene, the use of cuffed tubes and young age are associated with a significant increased risk of post-extubation stridor. Awareness of these factors gives the possibility to anticipate on the situation and to minimize laryngeal injury and its possible future consequences.

The neuroanatomical substrate of stridor associated with Multiple System Atrophy (MSA) remains unclear. We evaluated stridor-related gray matter (GM) changes in MSA.
36 MSA patients underwent standardized nocturnal video-polysomnography and brain MRI. Differences in GM density between MSA patients with and without stridor and a sample of 22 matched healthy controls were evaluated with Voxel Based Morphometry protocol supplemented by a specific tool (SUIT) for analysing infratentorial structures.
Stridor was confirmed in 14 patients (10 MSA-cerebellar variant; 10 M; mean ± SD age = 61.6 ± 8.9years; disease duration = 5.2 ± 2.9years) and absent in 22 (11 MSA-cerebellar variant; 18 M; age = 61.4 ± 9.9years; disease duration = 4.8 ± 3.4years). Compared to MSA without stridor, patients with stridor showed higher GM density in the cerebellum (p < 0.05, corrected for the MSA-cerebellar variant and uncorrected when considering both MSA-variants) and lower in the striatum (p < 0.05, uncorrected).
This preliminary study has demonstrated for the first time in MSA stridor-related GM changes in striatal and cerebellar regions. Abnormalities in these regions were previously reported in dystonic disorders affecting laryngeal muscles, suggesting the hypothesis that stridor pathophysiology is dystonia-related. These results need however to be confirmed in a larger sample of patients.

Laryngoscopy is the gold standard to diagnose exercise-induced laryngeal obstruction, though inspiratory flow-volume loop may provide a clue. We combined tidal flow-volume loop analysis plus laryngoscopy during exercise and found that cigar-shaped - not flattened - inspiratory loops are associated with obstruction. Pursed-lip breathing slows inhalation thereby reducing vocal fold adduction.

BACKGROUND: In the past 2 decades, usage of high-volume-low-pressure microcuffed tracheal tubes in smaller children has increased. However, there is paucity of evidence of its usage in smaller children undergoing congenital cardiac surgery. The aim of this study was to assess if microcuff endotracheal tubes in neonates and younger children undergoing congenital cardiac surgery is associated with better outcomes than uncuffed tubes.
METHODS: We carried out this single-center, prospective, randomized study between June and November 2016. Eighty patients were randomized into those receiving microcuff tracheal tubes and conventional uncuffed tubes. Primary outcome was stridor postextubation. Secondary outcomes measured included number of tube changes, volume of anesthetic gases required, and cost incurred.
RESULTS: The 2 groups were comparable in terms of baseline characteristics and duration of intubation. Incidence of stridor was significantly higher in conventional uncuffed tubes (12 [30%] vs 4 [10%]; P = .04) and so was the number of tube changes required (17/40 [42.5%] vs 2/40 [5%]; P ≤ .001). Tube change was associated with more than 3-fold risk of stridor (odds ratio = 3.92; 95% confidence interval = 1.23-12.43). Isoflurane (29.14 ± 7.01 mL vs19.2 ± 4.81 mL; P < .0001) and oxygen flow requirement ( P < .0001) and the resultant cost (7.46 ± 1.4 vs 5.77 ± 1.2 US$; P < .0001) were all significantly higher in the conventional uncuffed group.
CONCLUSIONS: Microcuff pediatric tracheal tube is associated with significantly lower incidence of stridor, tube changes, and anesthetic gas requirement. This leads to significant cost reduction that offsets the higher costs associated with usage of a microcuff tracheal tube.

Aortic arch anomalies underlie numerous congenital disorders. Effectively diagnosing and treating them requires close understanding of cardiovascular embryology. As our Center serves the entire pediatric population of our country, we performed a comprehensive retrospective analysis of all aortic arch anomalies diagnosed at our Center over the past 20 years. We analyzed 40 children with aortic arch anomalies, distinguishing two defect types: Group 1 displayed ring-forming anomalies, and Group 2 other types of aortic arch anomalies that did not form a vascular ring. We performed detailed morphological analyses using echocardiography, angiography, computed tomography, or magnetic resonance imaging and generated a catalog of all aortic arch anomalies present. Group 1 was represented by 25 patients; 40% with persistent both aortic arches, and 60% with various forms of right aortic arch and an incomplete left aortic arch. Group 2 was represented by 15 patients with complex heart defects. On the basis of our dataset, the incidence of all aortic arch anomalies was 0.033%, and of ring-forming pathologies 0.021%. Although aortic arch anomalies are rare, it is important to diagnose them correctly. It is critical to distinguish ring-forming types. Although in complex defects the aortic arch anomaly represents only an additive diagnosis, its correct definition could be crucial for further management. Cumulatively, this unique, long-term study provides a systematic patient registry and offers critical epidemiological data to aid the study of rare congenital cardiovascular defects. Clin. Anat. 30:929-939, 2017. © 2017 Wiley Periodicals, Inc.

Noisy breathing is a common presenting symptom in children. The purpose of this study is to (a) assess parental ability to label wheeze, (b) compare the ability of parents of children with and without asthma to label wheeze and (c) determine factors affecting parental ability to label wheeze correctly.
This cross-sectional study in a tertiary hospital in Kuala Lumpur, Malaysia involved parents of children with asthma. Parents of children without asthma were the control group. Eleven validated video clips showing wheeze, stridor, transmitted noises, snoring or normal breathing were shown to the parents. Parents were asked, in English or Malay, \"What do you call the sound this child is making?\" and \"Where do you think the sound is coming from?\"
Two hundred parents participated in this study: 100 had children with asthma while 100 did not. Most (71.5 %) answered in Malay. Only 38.5 % of parents correctly labelled wheeze. Parents were significantly better at locating than labelling wheeze (OR 2.4, 95 % CI 1.64-3.73). Parents with asthmatic children were not better at labelling wheeze than those without asthma (OR1.04, 95 % CI 0.59-1.84). Answering in English (OR 3.4, 95 % CI 1.69-7.14) and having older children with asthma (OR 9.09, 95 % CI 3.13-26.32) were associated with correct labelling of wheeze. Other sounds were mislabelled as wheeze by 16.5 % of respondents.
Parental labelling of wheeze was inaccurate especially in the Malay language. Parents were better at identifying the origin of wheeze rather than labelling it. Physicians should be wary about parental reporting of wheeze as it may be inaccurate.