Dr. Balakrishnan is a pediatric otolaryngologist specializing in the care of children with complex disorders of breathing, voice, and swallowing. He is an expert in complex surgical reconstruction of the larynx (voice box) and trachea (windpipe); innovative approaches to pediatric airway reconstruction; and in vascular anomalies of the head and neck. He has interests in improving the quality, safety, and value of pediatric surgical care, reducing costs of care, and optimizing the patient and caregiver healthcare experience. He also has expertise in how cognitive and implicit bias may affect medical decision-making and in healthcare disparities and injustice.

Dr. Balakrishnan has nationally and internationally recognized expertise in these areas, with many national and international invited presentations. He has published over 70 peer-reviewed papers, multiple textbook chapters, and a textbook (Evidence-Based Management of Head and Neck Vascular Anomalies, 2019). He has also served as Associate Editor for the journal Otolaryngology – Head and Neck Surgery and the Journal of Vascular Anomalies. He serves on multiple national and institutional quality committees and is founding co-chair of the national multicenter Aerodigestive Research Collaborative. His commitment to quality care for children and surgical patients has been recognized with fellowships in the American College of Surgeons and American Academy of Pediatrics.

Dr. Balakrishnan was born and raised in Baltimore, Maryland and attended college at Harvard University. After taking a year to work as a high school teacher in Baltimore, he attended medical school at Johns Hopkins, with an additional year to complete a Howard Hughes Medical Institute research fellowship. He then completed residency in Otolaryngology – Head & Neck Surgery at the University of Washington. During residency, Dr. Balakrishnan completed a two-year NIH-funded research fellowship and a Master of Public Health degree with a focus on Health Services. He then completed a two-year fellowship at Cincinnati Children’s Hospital with a focus on complex reconstruction of the pediatric larynx and trachea and pediatric aerodigestive disorders.

In 2014, Dr. Balakrishnan joined the otolaryngology faculty at Mayo Clinic in Rochester, Minnesota, where he had a busy pediatric airway and aerodigestive practice and was a key contributor to the multidisciplinary aerodigestive, vascular anomalies, and velopharyngeal insufficiency programs. At the Mayo Clinic Children’s Center, Dr. Balakrishnan also served as a surgical quality leader and championed the development of a comprehensive pediatric surgical quality program. Dr. Balakrishnan joined the Stanford Department of Otolaryngology – Head & Neck Surgery and Lucile Packard Children’s Hospital faculty as associate professor in early 2020. With this appointment, he also took on the role of medical director for surgical performance improvement at Stanford Lucile Packard Children’s Hospital. He also serves in several other leadership roles in Stanford Medicine, including co-chair of the Teamwork Advisory Council, co-lead for the Otolaryngology department's diversity/equity/inclusion program, and NSQIP-Pediatric Surgeon Champion. Dr. Balakrishnan is also a committed educator. He was nominated for otolaryngology faculty Teacher of the Year at Mayo Clinic and has worked with Stanford residents to develop an innovative quality improvement education program for surgical trainees. He frequently works with international colleagues to provide otolaryngology education in multiple resource-limited settings as well.

Clinical Focus

  • Pediatric Otolaryngology
  • Airway Reconstruction
  • Airway Obstruction
  • Laryngeal Stenosis
  • Tracheal Stenosis
  • Vocal Cord Paralysis
  • Airway
  • Airway Surgery
  • Choanal Atresia
  • Vascular Anomalies
  • Tracheostomy
  • Tracheostomy Dependence
  • Swallowing Disorders
  • Aspiration

Academic Appointments

Administrative Appointments

  • Medical Director of Surgical Performance Improvement, Lucile Packard Children's Hospital, Stanford (2020 - Present)
  • Co-chair, Stanford Medicine Teamwork Advisory Council, Stanford Medicine Center for Improvement (2021 - Present)
  • Co-chair, Stanford Otolaryngology Diversity, Equity, and Inclusion (DEI) committee (2021 - Present)
  • Member, Stanford Medicine Healthy Equity Committee, Stanford Medicine Center for Improvement (2021 - Present)

Honors & Awards

  • Fellow, Stanford Medicine Center for Improvement
  • Fellow, American College of Surgeons
  • Fellow, American Academy of Pediatrics

Professional Education

  • Fellowship: Cincinnati Children's Medical Center Pediatric Otolaryngology (2014) OH
  • MPH, University of Washington, Health Services (2008)
  • Board Certification: American Board of Otolaryngology, Otolaryngology (2013)
  • Residency: University of Washington Otolaryngology Residency (2012) WA
  • Internship: University of Washington Dept of Surgery (2006) WA
  • Medical Education: Johns Hopkins University School of Medicine (2005) MD

Current Research and Scholarly Interests

Dr. Balakrishnan studies ways to improve outcomes of pediatric airway reconstruction for diseases such as laryngotracheal, subglottic and tracheal stenosis, congenital tracheal stenosis and complete tracheal rings, laryngeal clefts, and vocal fold immobility and paralysis. He also examines the same questions for vascular malformations such as lymphatic malformations, venous malformations and hemangiomas.

Dr. Balakrishnan's research focuses on ways to standardize treatments and measure outcomes in these complex diseases, as well as ways to reduce treatment costs and medical errors, particularly those related to cognitive bias. By improving outcomes and reducing costs, he aims to improve the value of care, while also optimizing patient and caregiver experience during the care process.

Focus areas
1. Standardizing outcomes and processes in pediatric airway reconstruction. Dr. Balakrishnan co-leads unique international and national multidisciplinary collaborative groups to develop standard processes and outcome measures for airway surgery and aerodigestive (breathing/voice/swallowing) care in children. His previous work has led to the development of similar standards for lymphatic malformations in the head and neck and for reconstructive surgery of the larynx (voice box) and trachea (windpipe) in children. He has internationally recognized expertise in developing consensus statements for these complex questions.
2. Costs of otolaryngology care. Dr. Balakrishnan has studied thousands of patients and otolaryngology operations to identify factors that may predict more costly medical care. This will lead to process improvements that will allow Stanford and other institutions to reduce the cost burden that patients and the U.S. health care system face while maintaining quality and access to care. Dr. Balakrishnan's current work connects these costs to the outcomes and value of care provided.
3. Cognitive bias and implicit bias and medical error. Dr. Balakrishnan is working to improve otolaryngology resident and provider education related to the effects of cognitive and implicit bias on medical decision-making, and ways to reduce medical errors related to those biases.
4. Evidence-based care of vascular anomalies. Dr. Balakrishnan leads a task force of colleagues around the country to develop better scientific evidence to guide the care of challenging vascular anomalies such as lymphatic malformations.
5. Innovative approaches to pediatric airway reconstruction. Dr. Balakrishnan has studied several minimally invasive endoscopic approaches to airway surgery and is currently developing new robotic techniques to reconstruct the airway.

Significance to patient care
Complex and rare conditions such as airway stenosis and vascular malformations greatly impact children's survival and quality of life, but treatment pathways and standardization of care are still lacking. Dr. Balakrishnan hopes that increasing standardization of care and outcome reporting for these conditions will help doctors provide better care for these patients, with reduced costs and a better experience for children and their families and caregivers. Meanwhile, by developing and studying new and potentially better ways to do airway surgery, Dr. Balakrishnan hopes to provide families with innovative options that may better suit their children's needs.

Stanford Advisees

All Publications

  • Effects of Social Determinants of Health Care on Pediatric Thyroid Cancer Outcomes in the United States. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Gruszczynski, N. R., Low, C. M., Choby, G., Meister, K. D., Smith, B. H., Balakrishnan, K. 2021: 1945998211032901


    OBJECTIVE: To identify social determinants of health care that are associated with poorer pediatric well-differentiated thyroid cancer (WDTC) outcomes and increased stage at presentation.STUDY DESIGN: Using the SEER database (Surveillance, Epidemiology, and End Results), we retrospectively gathered data on pediatric WDTC across the United States between 1973 and 2015.SETTING: All patients between 0 and 19 years old with a diagnosis of WDTC were included.METHODS: Patient variables were analyzed for relationships to AJCC stage at presentation (American Joint Committee on Cancer), overall survival, and disease-specific survival.RESULTS: Among 3913 patients with pediatric thyroid cancer, 3185 were female (81.4%), 3366 had papillary thyroid cancer (85.3%), and 367 had follicular thyroid cancer (9.4%). Two- and 5-year overall and disease-specific survival approached 100%. However, when outcomes were analyzed by specific populations, male sex, non-Caucasian race, poverty, and language isolation were linked to worse overall survival. Male sex and poverty were associated with poorer disease-specific survival. Regarding overall AJCC stage at presentation, male sex and Black race were related to higher overall presenting AJCC stage. Later AJCC T stage at presentation was seen in male, Hispanic, Asian, and Black patients. There were no variables significantly related to following through with recommended surgery.CONCLUSION: Pediatric WDTC continues to carry an excellent prognosis in the United States. However, when we consider specific populations, the social determinants of health care affect survival and disease burden at presentation: male sex, poverty, language isolation, and race affected survival and/or AJCC stage at presentation in pediatric WDTC.

    View details for DOI 10.1177/01945998211032901

    View details for PubMedID 34311618

  • Opioid-Free Tonsillectomy With and Without Adenoidectomy: The Role of Regional Anesthesia in the "New Era". Anesthesia and analgesia Tsui, B. C., Pan, S., Smith, L., Lin, C., Balakrishnan, K. 2021; 133 (1): e7-e9

    View details for DOI 10.1213/ANE.0000000000005567

    View details for PubMedID 34127598

  • Sinonasal adenocarcinoma: A population-based analysis of demographic and socioeconomic disparities. Head & neck Low, C. M., Balakrishnan, K., Smith, B. M., Stokken, J. K., O'Brien, E. K., Van Gompel, J. J., Rowan, N. R., Choby, G. 2021


    BACKGROUND: Sinonasal adenocarcinoma (SNAC) is a rare tumor. The impact of health disparities on survival, stage at presentation, and utilization of surgery is not well understood in patients with SNAC.METHODS: The Surveillance, Epidemiology, and End Results database was queried for cases of SNAC from 1973 to 2015. Cases were analyzed to assess for disparities in presentation, treatment, and survival.RESULTS: SNAC was identified in 630 patients. In a multivariate model of overall survival, an age increase of 10years (Hazard Ratio (HR)=1.37, p<0.001), male sex (HR=1.26, p=0.045), and more recent decade of diagnosis (HR=0.74, p<0.001) were significantly related to time-to-death. There is a higher rate of SNAC-related death in counties with more rural populations (p=0.027).CONCLUSION: Future interventions targeting rural and less well-educated populations may improve care with the goal of increasing the span of healthy life and reducing survival disparities related to SNAC.

    View details for DOI 10.1002/hed.26783

    View details for PubMedID 34117674

  • Pediatric Bilateral Vocal Fold Paralysis CURRENT OTORHINOLARYNGOLOGY REPORTS Kohn, J., Balakrishnan, K., Sidell, D. 2021; 9 (2): 127-133
  • Suprazygomatic maxillary (SZM) nerve blocks for perioperative pain control in pediatric tonsillectomy and adenoidectomy. Journal of clinical anesthesia Smith, L., Balakrishnan, K., Pan, S., Tsui, B. C. 2021; 71: 110240

    View details for DOI 10.1016/j.jclinane.2021.110240

    View details for PubMedID 33756446

  • Laryngeal and Tracheal Pressure Injuries in Patients With COVID-19-Reply JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY Balakrishnan, K., Brenner, M. J., Hillel, A. T. 2021

    View details for DOI 10.1001/jamaoto.2021.0004

    View details for Web of Science ID 000621913100001

    View details for PubMedID 33630077

  • Laryngeal and Tracheal Pressure Injuries in Patients With COVID-19. JAMA otolaryngology-- head & neck surgery Balakrishnan, K., Brenner, M. J., Hillel, A. T. 2021

    View details for DOI 10.1001/jamaoto.2021.0001

    View details for PubMedID 33630075

  • Postoperative dysphagia immediately following pediatric endoscopic laryngeal cleft repair. International journal of pediatric otorhinolaryngology Kiessling, P., Smith, A., Puccinelli, C., Balakrishnan, K. 2021; 142: 110625


    OBJECTIVES: In pediatric patients undergoing endoscopic laryngeal cleft repair, immediate postoperative dysphagia is not well-characterized. This study examined whether worsened dysphagia is present in the immediate postoperative period as detected by clinical swallow evaluation, and evaluated how this relates to postoperative change in presenting symptoms and findings on swallow studies.METHODS: A retrospective cohort was conducted at a tertiary academic medical center, evaluating all pediatric patients who underwent endoscopic laryngeal cleft repair by a single surgeon from October 2014 through December 2018. All patients underwent instrumental swallow evaluation preoperatively and clinical swallow evaluation within 24h following surgery.RESULTS: Thirty-nine patients met inclusion criteria. Based on clinical swallow evaluation performed within 24h after surgery, 4 patients (10%) were recommended to thicken their diet from preoperative baseline; all others were unchanged. All patients were admitted to the PICU for observation; 34 (87%) discharged on postoperative day 1. Thirty-seven patients attended 6-week follow-up, with 2 (5%) requiring thicker diet since discharge; all others were stable or improved. Prevalence of recurrent respiratory infections, subjective dysphagia, chronic cough, and wheezing significantly decreased after surgery. No statistically significant change occurred in prevalence of aspiration or penetration on instrumental swallow studies postoperatively.CONCLUSION: Endoscopic laryngeal cleft repair is well-tolerated in pediatric patients, and most do not have obviously worsened dysphagia at immediate postoperative evaluation. Improvement in symptoms postoperatively may be a more useful indicator of surgical outcomes beyond instrumental swallow studies alone. The relative stability of these patients provides further evidence that they can likely be managed on the floor or as outpatients rather than in the ICU postoperatively.

    View details for DOI 10.1016/j.ijporl.2021.110625

    View details for PubMedID 33454453

  • Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement. The Laryngoscope Sidell, D. R., Balakrishnan, K., Best, S. R., Zur, K., Buckingham, J., De Alarcon, A., Baroody, F. M., Bock, J. M., Boss, E. F., Bower, C. M., Campisi, P., Chen, S. F., Clarke, J. M., Clarke, K. D., Cocciaglia, A., Cotton, R. T., Cuestas, G., Davis, K. L., DeFago, V. H., Dikkers, F. G., Dossans, I., Florez, W., Fox, E., Friedman, A. D., Grant, N., Hamdi, O., Hogikyan, N. D., Johnson, K., Johnson, L. B., Johnson, R. F., Kelly, P., Klein, A. M., Lawlor, C. M., Leboulanger, N., Levy, A. G., Lam, D., Licameli, G. R., Long, S., Lott, D. G., Manrique, D., McMurray, J. S., Meister, K. D., Messner, A. H., Mohr, M., Mudd, P., Mortelliti, A. J., Novakovic, D., Ongkasuwan, J., Peer, S., Piersiala, K., Prager, J. D., Pransky, S. M., Preciado, D., Raynor, T., Rinkel, R. N., Rodriguez, H., Rodriguez, V. P., Russell, J., Scatolini, M. L., Scheffler, P., Smith, D. F., Smith, L. P., Smith, M. E., Smith, R. J., Sorom, A., Steinberg, A., Stith, J. A., Thompson, D., Thompson, J. W., Varela, P., White, D. R., Wineland, A. M., Yang, C. J., Zdanski, C. J., Derkay, C. S. 2021


    OBJECTIVES/HYPOTHESIS: The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.STUDY DESIGN: Delphi method-based survey series.METHODS: A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up.RESULTS: The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).CONCLUSION: This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes.LEVEL OF EVIDENCE: 5. Laryngoscope, 2021.

    View details for DOI 10.1002/lary.29343

    View details for PubMedID 33405268

  • International Pediatric Otolaryngology Group (IPOG) survey: Efforts to avoid complications in home tracheostomy care. International journal of pediatric otorhinolaryngology Caloway, C., Balakrishnan, K., Boudewyns, A., Chan, K. H., Cheng, A., Daniel, S. J., Fayoux, P., Garabedian, N., Hart, C., Moreddu, E., Muntz, H., Nicollas, R., Nuss, R., Pransky, S., Rahbar, R., Russell, J., Rutter, M., Sidell, D., Smith, R. J., Soma, M., Spratley, J., Thompson, D., Ward, R. F., Watters, K., Wyatt, M., Zalzal, G., Hartnick, C. 2020; 141: 110563


    OBJECTIVE: To provide guidance for home care tracheostomy management in the pediatric population. The mission of the IPOG is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care.METHODS: Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG).RESULTS: Survey results provide guidance for caregiver teaching, the reuse of tracheostomies and suction catheters while inpatient and following discharge, acceptable sterilization practices for tracheostomies, tracheitis workup and management, and outpatient follow-up practices.CONCLUSION: This presentation of common home tracheostomy care practices are aimed at improving patient-centered care in the pediatric population.

    View details for DOI 10.1016/j.ijporl.2020.110563

    View details for PubMedID 33360407

  • Endotracheal metallic stent removal: A novel ABC (airway balloon collapse) technique. International journal of pediatric otorhinolaryngology Cofer, S. A., Badaoui, J. N., Boesch, R. P., Balakrishnan, K. 2020: 110490


    To illustrate a previously unreported method of tracheal stent removal that appears to cause less mucosal injury we present a case of a 9-year-old Down syndrome patient with a history of tracheoesophageal fistula, brought to our attention after recurrent bouts of exacerbating cough and tracheo-bronchitis. Endoscopic examination under general anesthesia noted the presence of severe tracheomalacia with inspiratory collapse, and a 10-mm balloon expandable metallic stent (BEMS) was deployed and symptomatic improvement was noted. The initial stent was then removed to consider a definitive procedure using the typical grasping fashion with an alligator forceps and expected mucosal excoriation was noted. Due to symptom recurrence, the patient underwent placement of a second BEMS stent. Initial improvement was noted followed by recurrent episodes of respiratory distress due to granulation tissue formation and stent compression and a decision to remove the stent was made. A new method of stent removal deemed ABC (airway balloon collapse) method was utilized where an expandable airway balloon is placed outside the stent between the stent and tracheal wall and then inflated to collapse the stent, facilitating easy removal.

    View details for DOI 10.1016/j.ijporl.2020.110490

    View details for PubMedID 33229032

  • Oral Intubation Attempts in Patients With a Laryngectomy: A Significant Safety Threat. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Brenner, M. J., Cramer, J. D., McGrath, B. A., Balakrishnan, K., Stepan, K. O., Pandian, V., Roberson, D. W., Shah, R. K., Chen, A. Y., Brook, I., Nussenbaum, B. 2020: 194599820960728


    It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.

    View details for DOI 10.1177/0194599820960728

    View details for PubMedID 33048019

  • Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus. The Laryngoscope Faucett, E. A., Wolter, N. E., Balakrishnan, K., Ishman, S. L., Mehta, D., Parikh, S., Nguyen, L. H., Preciado, D., Rutter, M. J., Prager, J. D., Green, G. E., Pransky, S. M., Elluru, R., Husein, M., Roy, S., Johnson, K. E., Friedberg, J., Johnson, R. F., Bauman, N. M., Myer, C. M., Deutsch, E. S., Gantwerker, E. A., Willging, J. P., Hart, C. K., Chun, R. H., Lam, D. J., Ida, J. B., Manoukian, J. J., White, D. R., Sidell, D. R., Wootten, C. T., Inglis, A. F., Derkay, C. S., Zalzal, G., Molter, D. W., Ludemann, J. P., Choi, S., Schraff, S., Myer, C. M., Cotton, R. T., Vijayasekaran, S., Zdanski, C. J., El-Hakim, H., Shah, U. K., Soma, M. A., Smith, M. E., Thompson, D. M., Javia, L. R., Zur, K. B., Sobol, S. E., Hartnick, C. J., Rahbar, R., Vaccani, J., Hartley, B., Daniel, S. J., Jacobs, I. N., Richter, G. T., de Alarcon, A., Bromwich, M. A., Propst, E. J. 2020


    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, 2020.

    View details for DOI 10.1002/lary.29126

    View details for PubMedID 33034397

  • Opioid Prescribing Patterns Following Pediatric Tonsillectomy in the United States, 2009-2017. The Laryngoscope Qian, Z. J., Alyono, J. C., Jin, M. C., Cooperman, S. P., Cheng, A. G., Balakrishnan, K. 2020


    OBJECTIVES: Assess national trends in opioid prescription following pediatric tonsillectomy: 1) overall percentage receiving opioids and mean quantity, 2) changes during 2009-2017, and 3) determinants of prescription patterns.METHODS: Cross-sectional analysis using 2009-2017 Optum claims data to identify opioid-naive children aged 1-18 with claims codes for tonsillectomy (n = 82,842). Quantities of opioids filled in outpatient pharmacies during the perioperative period were extracted and converted into milligram morphine equivalents (MMEs) for statistical comparison. Demographic, clinical, and socioeconomic predictors of opioid fill rate and quantity were determined using regression analyses.RESULTS: In 2009, 83.3% of children received opioids, decreasing to 58.3% by 2017. Rates of all-cause readmissions and post-tonsillectomy hemorrhages were similar over time. Mean quantity received was 153.47MME (95% confidence intervals [95%CI]: 151.19, 155.76) and did not significantly change during 2009-2017. Opioids were more likely in older children and those with higher household income, but less likely in children with obstructive sleep apnea, other comorbidities, and Hispanic race. Higher quantities of opioids were more likely in older children, while lower quantities were associated with female sex, Hispanic race, and higher household income. Outpatient steroids were prescribed to 8.04% of patients, who were less likely to receive opioids.CONCLUSION: While the percentage of children receiving post-tonsillectomy opioids decreased during 2009-2017, prescribed quantities remain high and have not decreased over time. Prescription practices were also influenced by clinical and sociodemographic factors. These results highlight the need for guidance, particularly with regard to opioid quantity, in children after tonsillectomy.LEVEL OF EVIDENCE: N/A Laryngoscope, 2020.

    View details for DOI 10.1002/lary.29159

    View details for PubMedID 33026683

  • Intraoperative Sentinel Events in the Era of Surgical Safety Checklists: Results of a National Survey. OTO open Cramer, J. D., Balakrishnan, K., Roy, S., David Chang, C. W., Boss, E. F., Brereton, J. M., Monjur, T. M., Nussenbaum, B., Brenner, M. J. 2020; 4 (4): 2473974X20975731


    Objective: Despite the implementation of advanced health care safety systems including checklists, preventable perioperative sentinel events continue to occur and cause patient harm, disability, and death. We report on findings relating to otolaryngology practices with surgical safety checklists, the scope of intraoperative sentinel events, and institutional and personal response to these events.Study Design: Survey study.Setting: Anonymous online survey of otolaryngologists.Methods: Members of the American Academy of Otolaryngology-Head and Neck Surgery were asked about intraoperative sentinel events, surgical safety checklist practices, fire safety, and the response to patient safety events.Results: In total, 543 otolaryngologists responded to the survey (response rate 4.9% = 543/11,188). The use of surgical safety checklists was reported by 511 (98.6%) respondents. At least 1 patient safety event in the past 10 years was reported by 131 (25.2%) respondents; medication errors were the most commonly reported (66 [12.7%] respondents). Wrong site/patient/procedure events were reported by 38 (7.3%) respondents, retained surgical items by 33 (6.4%), and operating room fire by 18 (3.5%). Although 414 (79.9%) respondents felt that time-outs before the case have been the single most impactful checklist component to prevent serious patient safety events, several respondents also voiced frustrations with the administrative burden.Conclusion: Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.

    View details for DOI 10.1177/2473974X20975731

    View details for PubMedID 33344877

  • Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Meister, K. D., Pandian, V., Hillel, A. T., Walsh, B. K., Brodsky, M. B., Balakrishnan, K., Best, S. R., Chinn, S. B., Cramer, J. D., Graboyes, E. M., McGrath, B. A., Rassekh, C. H., Bedwell, J. R., Brenner, M. J. 2020: 194599820961990


    OBJECTIVE: In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.DATA SOURCES: PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.REVIEW METHODS: Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.CONCLUSIONS: Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.IMPLICATIONS FOR PRACTICE: Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

    View details for DOI 10.1177/0194599820961990

    View details for PubMedID 32960148

  • Laryngotracheal Reconstruction in a Patient With a Central Conducting Lymphatic Anomaly. The Laryngoscope Macielak, R. J., Low, C. M., Tollefson, M. M., Balakrishnan, K. 2020

    View details for DOI 10.1002/lary.29071

    View details for PubMedID 32902851

  • International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction. International journal of pediatric otorhinolaryngology Puricelli, M. D., Rahbar, R., Allen, G. C., Balakrishnan, K., Brigger, M. T., Daniel, S. J., Fayoux, P., Goudy, S., Hewitt, R., Hsu, W., Ida, J. B., Johnson, R., Leboulanger, N., Rickert, S. M., Roy, S., Russell, J., Rutter, M., Sidell, D., Soma, M., Thierry, B., Trozzi, M., Zalzal, G., Zdanski, C. J., Smith, R. J. 2020; 138: 110281


    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.

    View details for DOI 10.1016/j.ijporl.2020.110281

    View details for PubMedID 32891939

  • Speech Pathology Utilization and Stroboscopy Before and After Adult Medialization Laryngoplasty. Journal of voice : official journal of the Voice Foundation Orbelo, D. M., Ekbom, D. C., Van Houten, H. K., Bayan, S. L., Balakrishnan, K. 2020


    OBJECTIVES: Evaluation of trends and utilization of speech-language-pathology (SLP) services, including stroboscopy, before and after medialization laryngoplasty (ML) over 11 years.METHODS: Retrospective national US database study conducted using OptumLabs Data Warehouse. Study cohort included patients (age ≥18 years) who underwent ML between January 2007 and December 2016. Primary outcomes were rates of SLP visits in the 12 months before and 12 months after ML. Linear regression analysis was performed assessing for trends utilization across years. Secondary outcomes were predictors of utilization After-ML using multivariable logistic regression.RESULTS: 1114 patients met criteria. Services, including stroboscopy, were utilized by 774 (69%) Before-ML and 697 (63%) After-ML. SLP services, excluding stroboscopy, were utilized by 512 (46%) Before-ML and 478 (43%) After-ML. Vocal cord paralysis was the most common diagnosis, 945 (84.8%) patients. Other service billed were stroboscopy, [Before-ML 676 (60.7%); After-ML 567 (50.9%)], voice evaluation [Before-ML 431(38.7%); After-ML 366 (32.9%)], voice therapy [Before-ML 309 (27.7%); After-ML 339 (30.4%)], laryngeal function studies, [Before-ML 175 (15.7%); After-ML 164 (14.7%)], swallow evaluations [Before-ML 150 (13.5%); After-ML 90 (8.1%)], and swallow therapy [Before-ML 53 (4.8%); After-ML 47 (4.2%)]. SLP utilization Before-ML predicted SLP utilization After-ML [Odds Ratio (95% Confidence Interval): 9.31 (6.78, 12.77)]. Nearly half (49%) of visits occurred in the 6 months around ML. Of those who had voice therapy, the majority (73.7%) had a total of 1 to 5 sessions.CONCLUSION: Based on this retrospective US national database study, SLP services and stroboscopy are a complementary component of assessment and treatment of patients who undergo ML with the majority of services occurring in the 3 months before and after ML. Future work would benefit from outcome data.

    View details for DOI 10.1016/j.jvoice.2020.06.024

    View details for PubMedID 32690345

  • The Difficult Airway and Aerosol-Generating Procedures in COVID-19: Timeless Principles for Uncertain Times. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Smith, J. D., Chen, M. M., Balakrishnan, K., Sidell, D. R., di Stadio, A., Schechtman, S. A., Brody, R. M., Kupfer, R. A., Rassekh, C. H., Brenner, M. J. 2020: 194599820936615


    The impact of the COVID-19 pandemic on otolaryngology practice is nowhere more evident than in acute airway management. Considerations of preventing SARS-CoV-2 transmission, conserving personal protective equipment, and prioritizing care delivery based on acuity have dictated clinical decision making in the acute phase of the pandemic. With transition to a more chronic state of pandemic, heightened vigilance is necessary to recognize how deferral of care in patients with tenuous airways and COVID-19 infection may lead to acute airway compromise. Furthermore, it is critical to respect the continuing importance of flexible laryngoscopy in diagnosis. Safely managing airways during the pandemic requires thoughtful multidisciplinary planning. Teams should consider trade-offs among aerosol-generating procedures involving direct laryngoscopy, supraglottic airway use, fiberoptic intubation, and tracheostomy. We share clinical cases that illustrate enduring principles of acute airway management. As algorithms evolve, time-honored approaches for diagnosis and management of acute airway pathology remain essential in ensuring patient safety.

    View details for DOI 10.1177/0194599820936615

    View details for PubMedID 32571147

  • COVID-19 Pandemic: What Every Otolaryngologist-Head and Neck Surgeon Needs to Know for Safe Airway Management. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Balakrishnan, K., Schechtman, S., Hogikyan, N. D., Teoh, A. Y., McGrath, B., Brenner, M. J. 2020: 194599820919751


    The novel coronavirus disease 2019 (COVID-19) pandemic has unfolded with remarkable speed, posing unprecedented challenges for health care systems and society. Otolaryngologists have a special role in responding to this crisis by virtue of expertise in airway management. Against the backdrop of nations struggling to contain the virus's spread and to manage hospital strain, otolaryngologists must partner with anesthesiologists and front-line health care teams to provide expert services in high-risk situations while reducing transmission. Airway management and airway endoscopy, whether awake or sedated, expose operators to infectious aerosols, posing risks to staff. This commentary provides background on the outbreak, highlights critical considerations around mitigating infectious aerosol contact, and outlines best practices for airway-related clinical decision making during the COVID-19 pandemic. What otolaryngologists need to know and what actions are required are considered alongside the implications of increasing demand for tracheostomy. Approaches to managing the airway are presented, emphasizing safety of patients and the health care team.

    View details for DOI 10.1177/0194599820919751

    View details for PubMedID 32286909

  • Pediatric tracheostomy practice patterns. International journal of pediatric otorhinolaryngology Sioshansi, P. C., Balakrishnan, K., Messner, A., Sidell, D. 2020; 133: 109982


    OBJECTIVE: Despite recent guidelines and the frequency of pediatric tracheostomy, surgical techniques and perioperative management are variable. We aim to describe the post-operative practice patterns following tracheostomy in children.METHODS: An electronic cross-sectional survey was distributed to American Society of Pediatric Otolaryngologists (ASPO) members in academic and private practice settings. Responses were collected anonymously and analyzed by percentages of respondents who employ specific management strategies. Statistical analysis of response distributions performed using the Z test of proportions for binary questions and the Mantel-Haenszel chi-square test for questions with more than two options. For questions with ordered categorical responses, Cuzick's nonparametric test of trend was used.RESULTS: One-hundred twenty-four responses were received (22.3%). Most respondents were fellowship trained and practiced in academic medical centers. A greater number of tracheostomies were performed by respondents practicing in the Midwest region (p=0.042). There was no variability in the number of tracheostomies performed based on practitioner age, hospital setting, or fellowship training. The majority perform stoma maturation and/or stay suture techniques intraoperatively and send patients to the intensive care unit postoperatively. The routine use of postoperative paralysis was reported by a minority of respondents and 50% reported the use of sedation. There was a roughly-even distribution of respondents who reported postoperative immobilization, mobilization to a chair, and ambulation respectively. Routine; postoperative airway evaluations were reported by 35% of respondents. Clinic follow-up was; variable.CONCLUSION: These results demonstrate ongoing variability in the postoperative management strategies following tracheostomy in children and highlight areas for further study.

    View details for DOI 10.1016/j.ijporl.2020.109982

    View details for PubMedID 32171147

  • Sclerotherapy for lymphatic malformations of head and neck: Systematic review and meta-analysis. Journal of vascular surgery. Venous and lymphatic disorders De Maria, L., De Sanctis, P., Balakrishnan, K., Tollefson, M., Brinjikji, W. 2020; 8 (1): 154–64


    BACKGROUND: Percutaneous sclerotherapy is a commonly used modality for treatment of lymphatic malformations (LMs) of the head, face, and neck. The safety and efficacy of sclerotherapy with various agents for diverse pathologic types of LMs have not been fully established. We present the results of a systematic review and meta-analysis examining the safety and efficacy of percutaneous sclerotherapy for treatment of LMs of the head, face, and neck.METHODS: We searched PubMed, MEDLINE, and Embase from 2000 to 2018 for studies evaluating the safety and efficacy of percutaneous sclerotherapy of head, face, and neck LMs. Two independent reviewers selected studies and abstracted data. The primary outcomes were complete and partial resolution of the LM. Data were analyzed using random-effects meta-analysis.RESULTS: There were 25 studies reporting on 726 patients included. The overall rate of complete cure of any pathologic type of LM after percutaneous sclerotherapy with any agent was 50.5% (95% confidence interval, 36.6%-64.3%). Macrocystic lesions had a cure rate of 53.1% compared with cure rates of 35.1% for microcystic lesions and 31.1% for mixed lesions. Regarding agents, doxycycline had the highest cure rate (62.4%) compared with all other agents. Overall permanent morbidity or mortality was 1.2% (95% confidence interval, 0.4%-2.0%) with no deaths. I2 values were >50% for most outcomes, indicating substantial heterogeneity.CONCLUSIONS: Our systematic review and meta-analysis of 25 studies and >700 patients found that percutaneous sclerotherapy is a safe and effective modality for treatment of LMs of the head, neck, and face.

    View details for DOI 10.1016/j.jvsv.2019.09.007

    View details for PubMedID 31734224

  • Sclerotherapy for Venous Malformations of Head and Neck: Systematic Review and Meta-Analysis. Neurointervention De Maria, L. n., De Sanctis, P. n., Balakrishnan, K. n., Tollefson, M. n., Brinjikji, W. n. 2020


    We performed a systematic review and meta-analysis of studies performing sclerotherapy for treatment of venous malformations (VMs) of the face, head and neck. It is our hope that data from this study could be used to better inform providers and patients regarding the benefits and risks of percutaneous sclerotherapy for treatment of face, head and neck VMs. We searched PubMed, MEDLINE, and EMBASE from 2000-2018 for studies evaluating the safety and efficacy of percutaneous sclerotherapy of neck, face and head VMs. Two independent reviewers selected studies and abstracted data. The primary outcomes were complete and partial resolution of the VM. Data were analyzed using random-effects meta-analysis. Thirty-seven studies reporting on 2,067 patients were included. The overall rate of complete cure following percutaneous sclerotherapy with any agent was 64.7% (95% confidence interval [CI], 57.4-72.0%). Sodium tetradecyl sulfate had the lowest complete cure rate at 55.5% (95% CI, 36.1-74.9%) while pingyangmycin had the highest cure rate at 82.9% (95% CI, 71.1-94.7%). Overall patient satisfaction rates were 91.0% (95% CI, 86.1-95.9%). Overall quality of life improvement was 78.9% (95% CI, 67.0-90.8%). Overall permanent morbidity/mortality was 0.8% (95% CI, 0.3-1.3%) with no cases of mortality. Our systematic review and meta-analysis of 37 studies and over 2,000 patients found that percutaneous sclerotherapy is a very safe and effective treatment modality for treatment of VMs of the head, neck and face.

    View details for DOI 10.5469/neuroint.2019.00213

    View details for PubMedID 31940716

  • The Relationship between Croup and Gastroesophageal Reflux: A Systematic Review and Meta-Analysis. The Laryngoscope Coughran, A. n., Balakrishnan, K. n., Ma, Y. n., Vaezeafshar, R. n., Capdarest-Arest, N. n., Hamdi, O. n., Sidell, D. R. 2020


    The mechanism by which recurrent croup occurs is unknown. Gastroesophageal reflux is commonly implicated, although this relationship is only loosely documented. We conducted a systematic review with a meta-analysis component to evaluate the relationship between recurrent croup and gastroesophageal reflux disease (GERD), and to assess for evidence of improvement in croup symptoms when treated.Systematic Review and Meta Analysis.We searched five separate databases. Studies were included if they discussed the relationship between croup and GERD in children, >5 subjects, and available in English. Literature retrieved was assessed according to pre-specified criteria. Retrieved articles were reviewed by two independent authors and decisions mediated by a third author. If there was a difference of opinion after first review, a second review was performed to obtain consensus. Heterogeneity was calculated and summarized in forest plots.Of 346 initial records, 15 met inclusion criteria. These were two retrospective cohort and 13 cross-sectional studies. Thirteen of 15 articles support an association between recurrent croup and GERD. Although heterogeneity is high among studies that reported prevalence of GERD, there is less uncertainty in results for improvement to recurrent croup after GERD treatment. Most studies lacked a control group and all carry a moderate-to-high risk of bias.There is limited evidence linking GERD to recurrent croup; Further research is needed to assess for causality as most studies are retrospective, lack a control group, and have a study design exposing them to bias. Patients treated with reflux medication appear to demonstrate a reduced incidence of croup symptoms.1 Laryngoscope, 2020.

    View details for DOI 10.1002/lary.28544

    View details for PubMedID 32040207

  • International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA). International journal of pediatric otorhinolaryngology Benedek, P. n., Balakrishnan, K. n., Cunningham, M. J., Friedman, N. R., Goudy, S. L., Ishman, S. L., Katona, G. n., Kirkham, E. M., Lam, D. J., Leboulanger, N. n., Lee, G. S., Le Treut, C. n., Mitchell, R. B., Muntz, H. R., Musso, M. F., Parikh, S. R., Rahbar, R. n., Roy, S. n., Russell, J. n., Sidell, D. R., Sie, K. C., Smith, R. J., Soma, M. A., Wyatt, M. E., Zalzal, G. n., Zur, K. B., Boudewyns, A. n. 2020; 138: 110276


    To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea.A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG).Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA.The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA.

    View details for DOI 10.1016/j.ijporl.2020.110276

    View details for PubMedID 32810686

  • International Pediatric Otolaryngology Group (IPOG) management recommendations: Pediatric tracheostomy decannulation. International journal of pediatric otorhinolaryngology Kennedy, A. n., Hart, C. K., de Alarcon, A. n., Balakrishnan, K. n., Bowudewyns, A. n., Chun, R. n., Fayoux, P. n., Goudy, S. L., Hartnick, C. n., Hsu, W. C., Johnson, R. F., Kuo, M. n., Peer, S. n., Pransky, S. M., Rahbar, R. n., Rickert, S. n., Roy, S. n., Russell, J. n., Sandu, K. n., Sidell, D. R., Smith, R. J., Soma, M. n., Spratley, J. n., Thierry, B. n., Thompson, D. M., Trozzi, M. n., Watters, K. n., White, D. R., Wyatt, M. n., Zalzal, G. H., Zdanksi, C. J., Zur, K. B., Rutter, M. J. 2020; 141: 110565


    To provide recommendations to otolaryngologists, pulmonologists, and allied clinicians for tracheostomy decannulation in pediatric patients.An iterative questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group.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.Tracheostomy decannulation recommendations are aimed at improving patient-centered care, quality and safety in children with tracheostomies.

    View details for DOI 10.1016/j.ijporl.2020.110565

    View details for PubMedID 33341719

  • Sequential Minimally Invasive Fetal Interventions for Two Life-Threatening Conditions: A Novel Approach. Fetal diagnosis and therapy Ruano, R. n., Ibirogba, E. R., Wyatt, M. A., Balakrishnan, K. n., Qureshi, M. Y., Kolbe, A. B., Dearani, J. A., Boesch, R. P., Segura, L. n., Arendt, K. W., Bendel-Stenzel, E. n., Salik, S. S., Klinkner, D. B. 2020: 1–8


    In utero interventions are performed in fetuses with "isolated" major congenital anomalies to improve neonatal outcomes and quality of life. Sequential in utero interventions to treat 2 anomalies in 1 fetus have not yet been described.Here, we report a fetus with a large left-sided intralobar bronchopulmonary sequestration (BPS) causing mediastinal shift, a small extralobar BPS, and concomitant severe left-sided congenital diaphragmatic hernia (CDH). At 26-week gestation, the BPS was noted to be increasing in size with a significant reduction in right lung volume and progression to fetal hydrops. The fetus underwent ultrasound-guided ablation of the BPS feeding vessel leading to complete tumor regression. However, lung development remained poor (O/E-LHR: 0.22) due to the left-sided CDH, prompting fetal endoscopic tracheal occlusion therapy at 28-week gestation to allow increased lung growth. After vaginal delivery, the newborn underwent diaphragmatic repair with resection of the extralobar sequestration. He was discharged home with tracheostomy on room air at 9 months.Sequential in utero interventions to treat 2 severe major anomalies in the same fetus have not been previously described. This approach may be a useful alternative in select cases with otherwise high morbidity/mortality. Further studies are required to confirm our hypothesis.

    View details for DOI 10.1159/000510635

    View details for PubMedID 33080593

  • International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population. International journal of pediatric otorhinolaryngology Doody, J. n., Alkhateeb, A. n., Balakrishnan, K. n., Bedwell, J. n., Carter, J. n., Choi, S. S., Cheng, A. T., Daniel, S. J., Dahl, J. n., De Alarcon, A. n., Fayoux, P. n., Hart, C. K., Hartnick, C. n., Jonas, N. n., Kuo, M. n., Mills, N. n., Muntz, H. n., Nicollas, R. n., Pransky, S. n., Nuss, R. n., Propst, E. J., Rahbar, R. n., Rossi, M. E., Rutter, M. J., Sandu, K. n., Sidell, D. R., Sittel, C. n., Smith, R. J., Soma, M. n., Spratley, J. n., Thierry, B. n., Thompson, D. n., Watters, K. n., Wine, T. n., Wyatt, M. n., Zalzal, G. n., Zdanski, C. J., Zur, K. B., Russell, J. n. 2020; 139: 110427


    Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation.Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy.Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method.Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: CONCLUSION: This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

    View details for DOI 10.1016/j.ijporl.2020.110427

    View details for PubMedID 33120101

  • COVID-19 pandemic and health care disparities in head and neck cancer: Scanning the horizon. Head & neck Graboyes, E. n., Cramer, J. n., Balakrishnan, K. n., Cognetti, D. M., López-Cevallos, D. n., de Almeida, J. R., Megwalu, U. C., Moore, C. E., Nathan, C. A., Spector, M. E., Lewis, C. M., Brenner, M. J. 2020


    The COVID-19 pandemic has profoundly disrupted head and neck cancer (HNC) care delivery in ways that will likely persist long term. As we scan the horizon, this crisis has the potential to amplify preexisting racial/ethnic disparities for patients with HNC. Potential drivers of disparate HNC survival resulting from the pandemic include (a) differential access to telemedicine, timely diagnosis, and treatment; (b) implicit bias in initiatives to triage, prioritize, and schedule HNC-directed therapy; and (c) the marked changes in employment, health insurance, and dependent care. We present four strategies to mitigate these disparities: (a) collect detailed data on access to care by race/ethnicity, income, education, and community; (b) raise awareness of HNC disparities; (c) engage stakeholders in developing culturally appropriate solutions; and (d) ensure that surgical prioritization protocols minimize risk of racial/ethnic bias. Collectively, these measures address social determinants of health and the moral imperative to provide equitable, high-quality HNC care.

    View details for DOI 10.1002/hed.26345

    View details for PubMedID 32562325

  • Coordinated approach to spinal and tracheal reconstruction in a patient with morquio syndrome. International journal of pediatric otorhinolaryngology Kiessling, P., Stans, A. A., Dearani, J. A., Boesch, R. P., Fogelson, J. L., Matsumoto, J. M., Haile, D. T., Balakrishnan, K. 2020; 128: 109721


    Morquio syndrome (Mucopolysaccharidosis IVA) is an autosomal recessive lysosomal storage disease with manifestations ranging from mild to severe phenotype. Mechanical spinal cord injury and airway insufficiency are major causes of mortality. A 17-year-old male patient with severe Morquio syndrome presented with cervical and upper thoracic spinal stenosis with spinal cord myelopathy, and progressive severe tracheal stenosis. Coordinated care among otolaryngology, orthopedic surgery, neurosurgery, anesthesiology, cardiovascular surgery, radiology, and pulmonology teams facilitated the successful planning and execution of two major surgical interventions in rapid succession. This is the first description of a successful coordinated spine and airway repair in the literature.

    View details for DOI 10.1016/j.ijporl.2019.109721

    View details for PubMedID 31639621

  • International Pediatric ORL Group (IPOG) Robin Sequence consensus recommendations. International journal of pediatric otorhinolaryngology Fayoux, P., Daniel, S. J., Allen, G., Balakrishnan, K., Boudewyns, A., Cheng, A., De Alarcon, A., Goel, D., Hart, C. K., Leboulanger, N., Lee, G., Moreddu, E., Muntz, H., Rahbar, R., Nicollas, R., Rogers-Vizena, C. R., Russell, J., Rutter, M. J., Smith, R. J., Wyatt, M., Zalzal, G., Resnick, C. M. 2019; 130: 109855


    OBJECTIVE: To provide recommendations for the comprehensive management of airway obstruction in patients with Robin Sequence.METHODS: Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG).RESULTS: The consensus statement provides recommendations for medical specialists who manage infants with Robin Sequence including: evaluation and treatment considerations for commonly debated issues in post-natal airway obstruction, assessment of antenatal obstruction and perinatal airway management.CONCLUSION: Consensus recommendations are aimed at improving management of airway obstruction in patients with Robin Sequence.

    View details for DOI 10.1016/j.ijporl.2019.109855

    View details for PubMedID 31896499

  • Inability to Mask Ventilate During Myringotomy Tube Replacement: A Case Report. A&A practice Wong, A. V., Balakrishnan, K., Nemergut, M. E. 2019


    We present the case of a 3-year-old female with multiple congenital anomalies, including postprandial otorrhea, who developed the inability to be mask ventilated secondary to a combination of velopharyngeal insufficiency and tympanic membrane perforation. When applied by mask, positive pressure ventilation was observed to preferentially escape the patient's left ear, resulting in significant air leak, insufficient tidal volumes, hypoventilation, and severe hypoxemia. The problem was remedied by the insertion of a finger into the patient's external auditory meatus, which controlled the air leak until the surgical team could provide definitive surgical correction of the velopharyngeal insufficiency and nasopharyngeal reflux.

    View details for DOI 10.1213/XAA.0000000000001151

    View details for PubMedID 31850923

  • Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus. The Laryngoscope Propst, E. J., Wolter, N. E., Ishman, S. L., Balakrishnan, K., Deonarain, A. R., Mehta, D., Zalzal, G., Pransky, S. M., Roy, S., Myer, C. M., Torre, M., Johnson, R. F., Ludemann, J. P., Derkay, C. S., Chun, R. H., Hong, P., Molter, D. W., Prager, J. D., Nguyen, L. H., Rutter, M. J., Myer, C. M., Zur, K. B., Sidell, D. R., Johnson, L. B., Cotton, R. T., Hart, C. K., Willging, J. P., Zdanski, C. J., Manoukian, J. J., Lam, D. J., Bauman, N. M., Gantwerker, E. A., Husein, M., Inglis, A. F., Green, G. E., Javia, L. R., Schraff, S., Soma, M. A., Deutsch, E. S., Sobol, S. E., Ida, J. B., Choi, S., Uwiera, T. C., Shah, U. K., White, D. R., Wootten, C. T., El-Hakim, H., Bromwich, M. A., Richter, G. T., Vijayasekaran, S., Smith, M. E., Vaccani, J., Hartnick, C. J., Faucett, E. A. 2019


    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, 2019.

    View details for DOI 10.1002/lary.28461

    View details for PubMedID 31821571

  • Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA(2)) OTOLARYNGOLOGY-HEAD AND NECK SURGERY Balakrishnan, K., Brenner, M. J., Gosbee, J. W., Schmalbach, C. E. 2019; 161 (6): 911–21


    With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA2) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education.

    View details for DOI 10.1177/0194599819878683

    View details for Web of Science ID 000491698000001

    View details for PubMedID 31570058

  • Temporary bronchial stenting for airway compression in the interstage palliation of functional single ventricle ANNALS OF PEDIATRIC CARDIOLOGY Barnes, J., Boesch, R., Balakrishnan, K., Said, S. M., Van Dorn, C. S. 2019; 12 (3): 308–11


    The Norwood procedure is the first of three palliative surgical procedures offered for hypoplastic left heart syndrome (HLHS). Due to the small size of the thorax and proximity of airway and vascular structures, compression of the airway is possible following the Norwood procedure. We describe the management of an infant with HLHS following Stage I surgical palliation who developed refractory respiratory failure secondary to severe left bronchial compression.

    View details for DOI 10.4103/apc.APC_94_18

    View details for Web of Science ID 000482007400018

    View details for PubMedID 31516290

    View details for PubMedCentralID PMC6716319

  • Predictors of High Costs of Care among Otolaryngology Patients OTOLARYNGOLOGY-HEAD AND NECK SURGERY Balakrishnan, K., Moriarty, J. P., Rosedahl, J., Driscoll, C. L., Borah, B. J. 2019; 161 (2): 271–77


    Identify predictors of high-cost otolaryngology care.Cross-sectional.Tertiary academic multispecialty hospital.All patients undergoing ≥1 otolaryngologic procedures from 2011 to 2015. Encounter costs were standardized using previously described methods approximating Medicare reimbursement. Patients were stratified by adult/pediatric and inpatient/outpatient. "Outliers" were defined as total encounter costs ≥95th percentile. Logistic regression measured predictors of outlier status.In total, 2433 adult inpatient encounters (95th percentile $57,611), 10,031 adult outpatient encounters ($10,772), 346 pediatric inpatient encounters ($84,639), and 3027 pediatric outpatient encounters ($8978) were included. For adult inpatient and outpatient, isolated head and neck oncologic procedures were the reference group. Among adult inpatients, laryngology and facial plastics procedures predicted higher odds of outlier status (odds ratio [OR] = 4.1 and 7.2). Involvement of multiple otolaryngology subspecialties increased the odds (OR = 4.7). Neck dissection and reconstructive procedures were the most common primary operations for adult inpatient outliers. For adult outpatients, several subspecialties had lower odds than head and neck (OR ≤0.44). Increased comorbidities predicted outliers for adult inpatient care (OR = 1.5); sex, age, race, and ethnicity did not. Cochlear implant was the most common primary operation among adult and pediatric outpatient outliers. Greater subspecialty involvement and increasing age predicted pediatric outpatient outliers (OR = 8.0 and 1.1); younger age and female sex predicted pediatric inpatient outliers (OR = 0.8 and 3.5). Airway procedures dominated pediatric inpatient outliers.This is the first large-scale study of high-cost otolaryngology care across multiple subspecialties. Specific procedures and subspecialties and increased comorbidities predicted high-cost care. Contrary to previous studies, patient sex, race, and ethnicity did not.

    View details for DOI 10.1177/0194599819838843

    View details for Web of Science ID 000478631500011

    View details for PubMedID 30909852

  • Impact of a Formal Patient Safety and Quality Improvement Curriculum: A Prospective, Controlled Trial LARYNGOSCOPE Jamal, N., Bowe, S. N., Brenner, M. J., Balakrishnan, K., Bent, J. P. 2019; 129 (5): 1100–1106


    To assess the impact of implementing a dedicated Patient Safety and Quality Improvement (PSQI) curriculum for otolaryngology residents.Residents in two otolaryngology residency programs were recruited to participate in the study. Residents at institution A (intervention group) participated in a formal, newly developed, year-long PSQI curriculum. Residents at institution B (control group) participated in traditional, morbidity, and mortality conference-based PSQI education, with no formal curriculum in place. Curriculum participants completed anonymous surveys to assess learner satisfaction. Validated instruments were administered to assess for changes in resident confidence in the ability to develop PSQI projects, their attitudes toward patient safety, and PSQI-related knowledge. The number and quality of PSQI-related resident projects were also assessed.Survey responses demonstrated excellent learner satisfaction with the curriculum. Based on validated instrument-based responses, both programs demonstrated similar confidence scores (P = 0.05), safety attitudes (P = 0.82), and PSQI knowledge (P = 0.29) at the beginning of the year. The residents of institution A demonstrated significant improvement in confidence (P = 0.00009) and knowledge (P = 0.0006) after completing the curriculum, with no improvement noted for residents at institution B in either confidence (P = 0.06) or knowledge (P = 0.79). Neither program demonstrated improvement in attitudes toward patient safety at the end of the year-long curriculum.Implementing a formal curriculum dedicated to PSQI led to an improvement in PSQI-related project development confidence and PSQI knowledge. Attitudes toward safety did not improve over the course of a year. Longer-term studies involving multiple institutions and other interventions are needed to evaluate the impact and duration of changes that occur.1b Laryngoscope, 129:1100-1106, 2019.

    View details for DOI 10.1002/lary.27527

    View details for Web of Science ID 000467083900029

    View details for PubMedID 30443935

  • Identification of aggressive Gardner syndrome phenotype associated with a de novo APC variant, c.4666dup COLD SPRING HARBOR MOLECULAR CASE STUDIES Kiessling, P., Dowling, E., Huang, Y., Ho, M., Balakrishnan, K., Weigel, B. J., Highsmith, W., Niu, Z., Schimmenti, L. A. 2019; 5 (2)


    Gardner syndrome describes a variant phenotype of familial adenomatous polyposis (FAP), primarily characterized by extracolonic lesions including osteomas, dental abnormalities, epidermal cysts, and soft tissue tumors. We describe a 2-yr-old boy presenting with a 2-cm soft tissue mass of the forehead. Pathologic evaluation revealed a nuchal-type/Gardner-associated fibroma. Sequencing of the APC gene revealed a pathologic variant c.4666dupA. Parental sequencing of both blood and buccal tissue supported the de novo occurrence of this pathologic variant. Further imaging revealed a number of additional lesions including a large lumbar paraspinal desmoid, a 1-cm palpable lesion posterior to the left knee, firm lesions on bilateral heels, and multiple subdermal lesions. Colonoscopy was negative. This case illustrates a genetic variant of Gardner syndrome resulting in an aggressive early childhood phenotype and highlights the need for an individualized approach to treatment.

    View details for DOI 10.1101/mcs.a003640

    View details for Web of Science ID 000462938400004

    View details for PubMedID 30696621

    View details for PubMedCentralID PMC6549566

  • Medialization laryngoplasty/arytenoid adduction: US outcomes, discharge status, and utilization trends LARYNGOSCOPE Ekbom, D. C., Orbelo, D. M., Sangaralingham, L. R., Mwangi, R., Van Houten, H. K., Balakrishnan, K. 2019; 129 (4): 952–60


    To evaluate trends, outcomes, and healthcare utilization following medialization laryngoplasty (ML) with or without arytenoid adduction (AA) over 10 years.Retrospective observational study.Using OptumLabs Data Warehouse, trends, outcomes, and healthcare utilization from 2006 to 2015 were examined with a focus on discharge type (same day or not). Predictors of postoperative emergency department (ED) use and hospitalization were determined by multivariable logistic regression.Overall rate of ML was 1.09 per 100 thousand enrollees per year. Of these, 7.8% ML were combined with an AA. Outpatient same-day discharge represented 62.0% (1,142 of 1,843) of total patients, steadily increasing over the 10-year period (P < 0.01). There was a 5.9% revision ML rate and 1.0% rate of tracheotomy within 1 day of ML. A total of 5.6% visited an ED, and 5.4% were admitted to a hospital following initial discharge within 30 days. Same-day discharge was found to be a predictor of hospitalization within 30 days after ML (odds ratio [OR] 1.74, P = 0.0452), along with Elixhauser comorbidity index of 4 + (OR 5.74, P = 0.0001). Pulmonary embolism, pulmonary hypertension, and weight loss were top predictors of ED visit or hospitalization.To our knowledge, this is the first search evaluating national claims data for ML with or without AA. Overall rate of ML is low, and same-day discharge has become more common over a 10-year period, with an associated higher 30-day hospital admission risk. Correct patient selection criteria for disposition status cannot be fully determined based on current data, but a high Elixhauser comorbidity index clearly carries increased risk for hospitalization after initial discharge.4 Laryngoscope, 129:952-960, 2019.

    View details for DOI 10.1002/lary.27538

    View details for Web of Science ID 000462650400043

    View details for PubMedID 30467860

  • Tracheal Submucosal Lymphovenous Malformation AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Bourne, M. H., Kern, R. M., White, D., Balakrishnan, K. 2019; 199 (4): E26–E27

    View details for DOI 10.1164/rccm.201803-0496IM

    View details for Web of Science ID 000458886800001

    View details for PubMedID 30281321

  • The Impact of Cognitive and Implicit Bias on Patient Safety and Quality OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Balakrishnan, K., Arjmand, E. M. 2019; 52 (1): 35–46


    Humans use cognitive shortcuts, or heuristics, to quickly assess and respond to situations and data. When applied inappropriately, heuristics have the potential to redirect analysis of available information in consistent ways, creating systematic biases resulting in decision errors. Heuristics have greater effect in high-pressure, high-stakes decisions, particularly when dealing with incomplete information, in other words, daily medical and surgical practice. This article discusses 2 major categories: cognitive biases, which affect how we perceive and interpret clinical data; and implicit biases, which affect how we perceive and respond to other individuals, and also discusses approaches to recognize and alleviate bias effects.

    View details for DOI 10.1016/j.otc.2018.08.016

    View details for Web of Science ID 000452819100006

    View details for PubMedID 30245040

  • Outcome measures for pediatric laryngotracheal reconstruction: International consensus statement LARYNGOSCOPE Balakrishnan, K., Sidell, D. R., Bauman, N. M., Bellia-Munzon, G. F., Boesch, R., Bromwich, M., Cofer, S. A., Daines, C., de Alarcon, A., Garabedian, N., Hart, C. K., Ida, J. B., Leboulanger, N., Manning, P. B., Mehta, D. K., Monnier, P., Myer, C. M., Prager, J. D., Preciado, D., Propst, E. J., Rahbar, R., Russell, J., Rutter, M. J., Thierry, B., Thompson, D. M., Torre, M., Varela, P., Vijayasekaran, S., White, D. R., Wineland, A. M., Wood, R. E., Wootten, C. T., Zur, K., Cotton, R. T. 2019; 129 (1): 244–55


    Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies.Standard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site-specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria.Thirty-three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative-/intraoperative-/procedure-related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site-specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable.This consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta-analyses, quality improvement, transfer of information, and surgeon self-assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient.5 Laryngoscope, 129:244-255, 2019.

    View details for PubMedID 30152166

  • International Pediatric Otolaryngology Group (IPOG): Juvenile-onset recurrent respiratory papillomatosis consensus recommendations. International journal of pediatric otorhinolaryngology Lawlor, C. n., Balakrishnan, K. n., Bottero, S. n., Boudewyns, A. n., Campisi, P. n., Carter, J. n., Cheng, A. n., Cocciaglia, A. n., DeAlarcon, A. n., Derkay, C. n., Fayoux, P. n., Hart, C. n., Hartnick, C. n., LeBoulanger, N. n., Moreddu, E. n., Muntz, H. n., Nicollas, R. n., Peer, S. n., Pransky, S. n., Rahbar, R. n., Russell, J. n., Rutter, M. n., Seedat, R. n., Sidell, D. n., Smith, R. n., Soma, M. n., Strychowsky, J. n., Thompson, D. n., Triglia, J. M., Trozzi, M. n., Wyatt, M. n., Zalzal, G. n., Zur, K. B., Nuss, R. n. 2019; 128: 109697


    To develop consensus recommendations for the evaluation and management of juvenile-onset recurrent respiratory papillomatosis (JORRP) in pediatric patients.Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.Consensus recommendations including diagnostic considerations, surgical management, systemic adjuvant therapies, postoperative management, surveillance, and voice evaluation. These recommendations are based on the collective opinion of the IPOG members and are targeted for otolaryngologists, primary care providers, pulmonologists, infectious disease specialists, and any other health care providers that manage patients with JORRP.Pediatric JORRP consensus recommendations are aimed at improving care and outcomes in this patient population.

    View details for DOI 10.1016/j.ijporl.2019.109697

    View details for PubMedID 31698245

  • International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Diagnosis, pre-operative, operative and post-operative pediatric choanal atresia care. International journal of pediatric otorhinolaryngology Moreddu, E. n., Rizzi, M. n., Adil, E. n., Balakrishnan, K. n., Chan, K. n., Cheng, A. n., Daniel, S. J., de Alarcon, A. n., Hart, C. n., Hartnick, C. n., Inglis, A. n., Leboulanger, N. n., Pransky, S. n., Rahbar, R. n., Russell, J. n., Rutter, M. n., Sidell, D. n., Smith, R. J., Soma, M. n., Spratley, J. n., Thompson, D. n., Trozzi, M. n., Ward, R. n., Wyatt, M. n., Yeung, J. n., Zalzal, G. n., Zur, K. n., Nicollas, R. n. 2019; 123: 151–55


    To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia.A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations.Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging.Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.

    View details for DOI 10.1016/j.ijporl.2019.05.010

    View details for PubMedID 31103745

  • Interdisciplinary aerodigestive care model improves risk, cost, and efficiency INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Boesch, R., Balakrishnan, K., Grothe, R. M., Driscoll, S. W., Knoebel, E. E., Visscher, S. L., Cofer, S. A. 2018; 113: 119–23


    This study sought to evaluate the impact of an interdisciplinary care model for pediatric aerodigestive patients in terms of efficiency, risk exposure, and cost.Patients meeting a standard clinical inclusion definition were studied before and after implementation of the aerodigestive program.Aerodigestive patients seen in the interdisciplinary clinic structure achieved a reduction in time to diagnosis (6 vs 150 days) with fewer required specialist consultations (5 vs 11) as compared to those seen in the same institution prior. Post-implementation patients also experienced a significant reduction in risk, with fewer radiation exposures (2 vs 4) and fewer anesthetic episodes (1 vs 2). Total cost associated with the diagnostic evaluation was significantly reduced from a median of $10,374 to $6055.This is the first study to utilize a pre-post cohort to evaluate the reduction in diagnostic time, risk exposure, and cost attributable to the reorganization of existing resources into an interdisciplinary care model. This suggests that such a model yields improvements in care quality and value for aerodigestive patients, and likely for other pediatric patients with chronic complex conditions.

    View details for DOI 10.1016/j.ijporl.2018.07.038

    View details for Web of Science ID 000444666100027

    View details for PubMedID 30173969

  • Revision Thoracic Slide Tracheoplasty: Outcomes Following Unsuccessful Tracheal Reconstruction LARYNGOSCOPE Sidell, D. R., Hart, C. K., Tabangin, M. E., Bryant, R., Rutter, M. J., Manning, P. B., Meinzen-Derr, J., Balakrishnan, K., Yang, C., de Alarcon, A. 2018; 128 (9): 2181–86

    View details for DOI 10.1002/lary.27145

    View details for Web of Science ID 000446523700040

  • Cost comparison and safety of emergency department conscious sedation for the removal of ear foreign bodies INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Olson, M. D., Saw, J., Visscher, S. L., Balakrishnan, K. 2018; 110: 140–43


    The purpose of this study is to investigate the relative cost and safety of ear foreign body (FB) removal via conscious sedation in the emergency department.A retrospective review of patients presenting from 2000 to 2015 to the emergency department at Mayo Clinic, Rochester, Minnesota was performed. 63 patients requiring sedation for ear foreign body removal were identified. Descriptive data, safety data, and costs were obtained for the study.There were no appreciable differences in patient safety outcomes and otologic outcomes in patients who received sedation in the emergency department or anesthesia in the operating room for FB removal. Cost analysis demonstrated increased cost associated with operating room utilization verses conscious sedation in the emergency department, with the greatest cost increase being in patients evaluated first in the emergency department and then sent to the operating room.Ear foreign body removal in the emergency department is shows a similar safety profile to removal in the operating room, but at a markedly lower cost. Emergency department conscious sedation should be considered a viable option in appropriately selected patients with this common problem given these results.

    View details for DOI 10.1016/j.ijporl.2018.05.001

    View details for Web of Science ID 000442844700029

    View details for PubMedID 29859576

  • Fetoscopic Therapy for Severe Pulmonary Hypoplasia in Congenital Diaphragmatic Hernia: A First in Prenatal Regenerative Medicine at Mayo Clinic MAYO CLINIC PROCEEDINGS Ruano, R., Klinkner, D. B., Balakrishnan, K., Novoa, V., Davies, N., Potter, D. D., Carey, W. A., Colby, C. E., Kolbe, A. B., Arendt, K. W., Segura, L., Sviggum, H. P., Lemens, M. A., Famuyide, A., Terzic, A. 2018; 93 (6): 693–700


    To introduce the prenatal regenerative medicine service at Mayo Clinic for fetal endoscopic tracheal occlusion (FETO) care for severe congenital diaphragmatic hernia (CDH).Two cases of prenatal management of severe CDH with FETO between January and August 2017 are reported. Per protocol, FETO was offered for life-threatening severe CDH at between 26 and 29 weeks' gestation. Regenerative outcome end point was fetal lung growth. Gestational age at procedure and maternal and perinatal outcomes were additional monitored parameters.Diagnosis by ultrasonography of severe CDH was based on extremely reduced lung size (observed-to-expected lung area to head circumference ratio [o/e-LHR], eg, o/e-LHR of 20.3% for fetus 1 and 23.0% for fetus 2) along with greater than one-third of the liver herniated into the chest in both fetuses. Both patients underwent successful FETO at 28 weeks. At the time of intervention, no maternal or fetal complications were observed. Postintervention, fetal lung growth was observed in both fetuses, reaching an o/e-LHR of 62.7% at 36 weeks in fetus 1 and 52.4% at 32 weeks in fetus 2. The balloons were removed successfully at 35 weeks and 4 days by ultrasound-guided puncture in the first patient and at 32 weeks and 3 days by ex utero intrapartum therapy-to-airway procedure in the second patient. Postnatal management followed standard of care with patch CDH therapy. At discharge, one patient was breathing normally, whereas the other required minimal nasal cannula oxygen support.The successful launch of the first fetoscopic therapy for CDH at Mayo Clinic reveals its feasibility and safety, with early signs of benefit documented by fetal lung growth and reversal of severe pulmonary Identifier: G170062.

    View details for DOI 10.1016/j.mayocp.2018.02.026

    View details for Web of Science ID 000434290600009

    View details for PubMedID 29803315

  • Revision thoracic slide tracheoplasty: Outcomes following unsuccessful tracheal reconstruction. The Laryngoscope Sidell, D. R., Hart, C. K., Tabangin, M. E., Bryant, R. 3., Rutter, M. J., Manning, P. B., Meinzen-Derr, J., Balakrishnan, K., Yang, C., de Alarcon, A. 2018


    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, 2018.

    View details for PubMedID 29729016

  • Indirect management of full-thickness tracheal erosion in a complex pediatric patient INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Trousdale, W. H., Boesch, R., Orvidas, L. J., Balakrishnan, K. 2018; 107: 155–59


    Prolonged tracheostomy dependence in pediatric patients can be associated with significant complications, including damage to the tracheal wall requiring reconstruction. We present a case of an 8 year-old female with full-thickness tracheal erosion secondary to the presence of a tracheostomy tube combined with a narrow thoracic inlet. A direct tracheal reconstruction was considered but eliminated due to the poor tissue quality of the trachea. Instead, a multi-disciplinary surgical team conceived of a novel indirect approach to manage the patient's tracheal defect. To our knowledge the use of indirect repair of a full-thickness tracheal defect has not been reported in the literature.

    View details for DOI 10.1016/j.ijporl.2018.02.011

    View details for Web of Science ID 000428492100030

    View details for PubMedID 29501299

  • Structure and Functions of Pediatric Aerodigestive Programs: A Consensus Statement PEDIATRICS Boesch, R., Balakrishnan, K., Acra, S., Benscoter, D. T., Cofer, S. A., Collaco, J. M., Dahl, J. P., Daines, C. L., DeAlarcon, A., DeBoer, E. M., Deterding, R. R., Friedlander, J. A., Gold, B. D., Grothe, R. M., Hart, C. K., Kazachkov, M., Lefton-Greif, M. A., Miller, C., Moore, P. E., Pentiuk, S., Peterson-Carmichael, S., Piccione, J., Prager, J. D., Putnam, P. E., Rosen, R., Rutter, M. J., Ryan, M. J., Skinner, M. L., Torres-Silva, C., Wootten, C. T., Zur, K. B., Cotton, R. T., Wood, R. E. 2018; 141 (3)


    Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.

    View details for DOI 10.1542/peds.2017-1701

    View details for Web of Science ID 000426361800035

    View details for PubMedID 29437862

  • Trans-nasal flexible bronchoscopy in wheezing children: Diagnostic yield, impact on therapy, and prevalence of laryngeal cleft PEDIATRIC PULMONOLOGY Boesch, R. P., Baughn, J. M., Cofer, S. A., Balakrishnan, K. 2018; 53 (3): 310–15


    Persistent or recurrent wheezing is a common indication for flexible bronchoscopy, as anatomic and infectious or inflammatory changes are highly prevalent. We sought to evaluate the prevalence of anatomic, infectious, and inflammatory disease in a cohort of children undergoing flexible bronchoscopy for wheezing or poorly controlled asthma.We retrospectively reviewed all children <18 years old who underwent flexible bronchoscopy at our center from October 29, 2012-December 31, 2016 for the primary or secondary indication of wheezing (persistent, frequently recurring, or atypical) or poorly controlled asthma.A total of 101 procedures were identified in 94 patients, aged 3 months to 18 years. Potential anatomic causes for wheezing identified in 45.7% of patients and inflammatory changes in 49.5% of procedures. This included the identification of a laryngeal cleft in 17% for which half required medical or surgical management. Tracheobronchomalacia was the most commonly identified anatomic lesion. Thirty children from this cohort had poorly controlled asthma. Among this subgroup, 54% had increased neutrophils on BAL and 30% had an anatomic contributor to wheezing, including one with a laryngeal cleft. Based on findings from flexible bronchoscopy, management changes made in 63.8% of patients. This included medication changes in 54 and surgical intervention in 9.We conclude that transnasal flexible bronchoscopy has high yield in children with recurrent, persistent, or atypical wheezing and those with poorly controlled asthma. Laryngeal cleft has a reasonably high prevalence that warrants specific evaluation in this population.

    View details for DOI 10.1002/ppul.23829

    View details for Web of Science ID 000425450000009

    View details for PubMedID 28910519

  • Definitive airway management after prehospital supraglottic rescue airway in pediatric trauma Hernandez, M. C., Antiel, R. M., Balakrishnan, K., Zielinski, M. D., Klinkner, D. B. W B SAUNDERS CO-ELSEVIER INC. 2018: 352–56


    Supraglottic airway (SGA) use and outcomes in pediatric trauma are poorly understood. We compared outcomes between patients receiving prehospital SGA versus bag mask ventilation (BVM).We reviewed pediatric multisystem trauma patients (2005-2016), comparing SGA and BVM. Primary outcome was adequacy of oxygenation and ventilation. Additional measures included tracheostomy, mortality and abbreviated injury scores (AIS).Ninety patients were included (SGA, n=17 and BVM, n=73). SGA patients displayed increased median head AIS (5 [4-5] vs 2 [0-4], p=0.001) and facial AIS (1 [0-2] vs 0 [0-0], p=0.03). SGA indications were multiple failed intubation attempts (n=12) and multiple failed attempts with poor visualization (n=5). Median intubation attempts were 2 [1-3] whereas BVM patients had none. Compared to BVM, SGA patients demonstrated inadequate oxygenation/ventilation (75% vs 41%), increased tracheostomy rates (31% vs 8.1%), and increased 24-h (38% vs 10.8%) and overall mortality (75% vs 14%) (all p<0.05).Escalating intubation attempts and severe facial AIS were associated with tracheostomy. Inadequacy of oxygenation/ventilation was more frequent in SGA compared to BVM patients. SGA patients demonstrate poor clinical outcomes; however, SGAs may be necessary in increased craniofacial injury patterns. These factors may be incorporated into a management algorithm to improve definitive airway management after SGA.

    View details for DOI 10.1016/j.jpedsurg.2017.10.004

    View details for Web of Science ID 000425899500038

    View details for PubMedID 29096887

  • National Multispecialty Survey Results: Comparing Morbidity and Mortality Conference Practices within and outside Otolaryngology OTOLARYNGOLOGY-HEAD AND NECK SURGERY Balakrishnan, K., Arjmand, E. M., Nussenbaum, B., Snyderman, C. 2018; 158 (2): 273–79


    Objective The objective is to describe variations in the otolaryngology morbidity and mortality (M&M) conference and to compare with other specialties. Design Cross-sectional survey. Setting The setting included otolaryngology departments across the United States and nonotolaryngology medical and surgical departments at 4 academic medical centers. Subjects and Methods Participants were members of a national otolaryngology quality/safety network and nonotolaryngology quality leaders at 4 large academic hospitals. Surveys were administered January 2017. Respondents described M&M conference practices, goals, and educational role. Results Twenty-eight of 39 individuals representing 28 institutions completed the otolaryngology survey (72% response rate). Of 197 individuals, 60 (30% response rate) representing 11 surgical and 20 nonsurgical specialties completed the comparison survey. Twenty-seven of 28 otolaryngologists (46 of 60 nonotolaryngologists) worked in academic settings. All otolaryngology programs conducted an M&M conference: 54% discussed all adverse events and errors; 32% used standard case selection processes; 70% used structured discussion, usually root cause analysis (64%); and 32% classified harm level. In comparison with other specialties, otolaryngology programs were more likely to discuss all adverse events and errors ( P = .01). Most conferences led to quality projects and intrainstitutional communication: 22% communicated to patients and families; 73% of respondents thought that M&M conferences should be standardized or use "best practices." In both surveys, improving patient care was rated the conference's most important function, followed by trainee education and culture change. Patient care and practice-based learning were rated the most relevant Accreditation Council for Graduate Medical Education Core Competencies in both surveys. Conclusions Academic otolaryngology M&M practices generally align with other specialties, but specifics vary widely, making collaborative quality improvement challenging. Educational and administrative priorities cross specialties. Most respondents thought that standardization and best practices are worthwhile. Nonacademic practice data are needed.

    View details for DOI 10.1177/0194599817737993

    View details for Web of Science ID 000424058700012

    View details for PubMedID 29064313

  • Primary cervical leiomyoma: A rare cause of a posterior neck mass in a pediatric patient INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Oliver, J. D., Anzalone, C., Balakrishnan, K. 2018; 104: 166–69


    A 13-year-old male presents for evaluation of a right-sided posterolateral neck mass, first noted four years prior to presentation; incisional biopsy two years ago suggested a benign lymph node. Recent growth and increased pain prompted referral to our tertiary care center. MR imaging revealed a densely calcified mass in the right posterior paraspinous muscles with intense enhancement with gadolinium contrast, approximately 5 cm × 2.8 cm x 4.6 cm. Incisional biopsy showed leiomyoma with extensive dystrophic calcifications. This case describes a rare finding of extraesophageal leiomyoma of the neck; this is only the second such case reported in a pediatric patient.

    View details for DOI 10.1016/j.ijporl.2017.11.015

    View details for Web of Science ID 000423646800034

    View details for PubMedID 29287860

  • International Pediatric Otolaryngology Group: Consensus guidelines on the diagnosis and management of type I laryngeal clefts INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Yeung, J. C., Balakrishnan, K., Cheng, A. L., Daniel, S. J., Garabedian, E., Hart, C. K., Inglis, A. F., Leboulanger, N., Liming, B. J., Moreddu, E., Nicollas, R., Russell, J. D., Rutter, M. J., Sidell, D. R., Spratley, J., Soma, M., Thierry, B., Thompson, D. M., Triglia, J., Watters, K., Wyatt, M., Zalzal, G. H., Zur, K. B., Rahbar, R. 2017; 101: 51–56


    The diagnosis and management of type I laryngeal clefts can be controversial and varies across centers and surgeons. Using existing peer-reviewed literature to develop an expert-based consensus will help guide physicians in the treatment of these patients as well as develop research hypotheses to further study this condition.To provide recommendations for the diagnosis and management of type I laryngeal clefts.Determination of current expert- and literature-based recommendations, via a survey of the International Pediatric Otolaryngology Group, using a modified Delphi method.Multinational, multi-institutional, tertiary pediatric hospitals.Consensus recommendations include diagnostic workup, medical management, pre-operative, intra-operative and post-operative considerations for type I laryngeal clefts.This guide on the diagnosis and management of patients with type I laryngeal clefts is aimed at improving patient care and promoting future hypothesis generation and research to validate the recommendations made here.

    View details for DOI 10.1016/j.ijporl.2017.07.016

    View details for Web of Science ID 000413713100010

    View details for PubMedID 28964310

  • Three-dimensional printed models in multidisciplinary planning of complex tracheal reconstruction LARYNGOSCOPE Balakrishnan, K., Cofer, S., Matsumoto, J. M., Dearani, J. A., Boesch, R. 2017; 127 (4): 967–70


    Three-dimensional printed models are increasingly used in medicine and surgery, but applications of these models in the planning of operative procedures is not well described. In particular, their benefits have not been documented in complex, multiservice, high-risk operations. We describe five cases of complex pediatric tracheal reconstruction for which three-dimensional models had specific benefits in planning as well as in education of trainees, operating room staff, and patient families. We also describe our method for producing models so that others can adopt the technology if desired. Laryngoscope, 127:967-970, 2017.

    View details for DOI 10.1002/lary.26353

    View details for Web of Science ID 000397572700040

    View details for PubMedID 27753107

  • Endoscopic anterior-posterior cricoid split for pediatric bilateral vocal fold paralysis. Laryngoscope Rutter, M. J., Hart, C. K., Alarcon, A. d., Daniel, S., Parikh, S. R., Balakrishnan, K., Lam, D., Johnson, K., Sidell, D. R. 2017


    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.Multicenter review.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.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.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.4 Laryngoscope, 2017.

    View details for DOI 10.1002/lary.26547

    View details for PubMedID 28271539

  • Education on, Exposure to, and Management of Vascular Anomalies During Otolaryngology Residency and Pediatric Otolaryngology Fellowship JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY Chun, R., Jabbour, N., Balakrishnan, K., Bauman, N., Darrow, D. H., Elluru, R., Grimmer, J., Perkins, J., Richter, G., Shin, J. 2016; 142 (7): 648–51


    The field of vascular anomalies presents diverse challenges in diagnosis and management. Although many lesions involve the head and neck, training in vascular anomalies is not universally included in otolaryngology residencies and pediatric otolaryngology (POTO) fellowships.To explore the education in, exposure to, and comfort level of otolaryngology trainees with vascular anomalies.A survey was distributed to 39 POTO fellows and 44 residents in postgraduate year 5 who matched into POTO fellowships from April 22 through June 16, 2014.Survey responses from trainees on exposure to, education on, and comfort with vascular anomalies.Forty-four residents in postgraduate year 5 who applied to POTO fellowships and 39 POTO fellows were emailed the survey. Fourteen respondents were unable to be contacted owing to lack of a current email address. Thirty-six of 69 residents and fellows (18 fellows and 18 residents [52%]) responded to the survey. Twenty-seven trainees (75%) reported no participation in a vascular anomalies clinic during residency; 6 of these 27 individuals (22%) trained at institutions with a vascular anomalies clinic but did not participate in the clinic, and 28 of the 36 respondents (78%) reported that they had less than adequate or no exposure to vascular anomalies in residency. Among POTO fellows, 11 of 17 (65%) did not participate in a vascular anomalies clinic during fellowship, even though 8 of the 11 had a vascular anomalies clinic at their fellowship program. During fellowship training, 12 of 18 fellows (67%) reported that they had adequate exposure to vascular anomalies. Only 20 respondents (56%) felt comfortable distinguishing among diagnoses of vascular anomalies, and only 4 residents (22%) and 9 fellows (50%) felt comfortable treating patients with vascular anomalies. All fellows believed that training in vascular anomalies was important in fellowship, and 100% of respondents indicated that increased exposure to diagnosis and management of vascular anomalies would have been beneficial to their ability to care for patients.These data indicate that most otolaryngology trainees do not receive formal training in vascular anomalies in residency and that such training is valued among graduating trainees. Conversely, most POTO fellows felt their exposure was adequate and 50% of fellows felt comfortable treating vascular anomalies. However, 65% of POTO fellows had no participation in a vascular anomalies clinic, where many patients are managed by a multidisciplinary team. This finding may indicate that POTO fellows may have a false sense of confidence in managing patients with vascular anomalies and that residency and fellowship programs may consider changes in didactic and clinical programs.

    View details for DOI 10.1001/jamaoto.2016.0605

    View details for Web of Science ID 000380264600006

    View details for PubMedID 27124736

  • Predicting CPAP Use and Treatment Outcomes Using Composite Indices of Sleep Apnea Severity JOURNAL OF CLINICAL SLEEP MEDICINE Balakrishnan, K., James, K. T., Weaver, E. M. 2016; 12 (6): 849–54


    Measures of baseline sleep apnea disease burden (apnea-hypopnea index, Epworth Sleepiness Scale) predict continuous positive airway pressure (CPAP) adherence, but composite indices of sleep apnea severity (Sleep Apnea Severity Index, Modified Sleep Apnea Severity Index) may be more robust measures of disease burden. We tested the relative prognostic ability of each measure of sleep apnea disease burden to predict subsequent CPAP adherence and subjective sleep outcomes.Prospective cohort study at a tertiary academic sleep center. Patients (n = 323) underwent initial diagnostic polysomnography for suspected obstructive sleep apnea and 6 mo of subsequent CPAP therapy.Baseline apnea-hypopnea index and both composite indices predicted adherence to CPAP therapy at 6 mo in multivariate analyses (all p ≤ 0.001). Baseline Epworth Sleepiness Scale did not predict CPAP adherence (p = 0.22). Both composite indices were statistically stronger predictors of CPAP adherence at 6 mo than apnea-hypopnea index (p < 0.001). In multivariate analyses, baseline apnea-hypopnea index (p < 0.05) and both composite indices (both p < 0.04) predicted change in Pittsburgh Sleep Quality Index, whereas only the composite indices predicted changes in Sleep Apnea Quality of Life Index (both p < 0.001). Adjustment for treatment adherence did not affect the relationship of the composite indices with change in Sleep Apnea Quality of Life Index (both p ≤ 0.005).Composite indices of baseline sleep apnea severity better predict objective CPAP adherence and subjective treatment outcomes than baseline apnea-hypopnea index and baseline Epworth Sleepiness Scale.

    View details for DOI 10.5664/jcsm.5884

    View details for Web of Science ID 000378334500011

    View details for PubMedID 26857052

    View details for PubMedCentralID PMC4877317

  • The Lymphatic Malformation Function (LMF) Instrument OTOLARYNGOLOGY-HEAD AND NECK SURGERY Kirkham, E. M., Edwards, T. C., Weaver, E. M., Balakrishnan, K., Perkins, J. A. 2015; 153 (4): 656–62


    The Lymphatic Malformation Function (LMF) instrument is a preliminary parent-report assessment designed to measure outcomes in children with cervicofacial lymphatic malformation (LM). This study aimed to assess the measurement properties of the LMF, refine it, test criterion validity, and evaluate the test-retest reliability.Cross-sectional.Two pediatric tertiary referral centers.Parents of 60 children from 6 months to 15 years old with cervicofacial LM.Parents were recruited via mail and online. The LMF was administered on paper or online initially and again within 21 days. Response distributions and interitem correlations were examined for item reduction. Exploratory factor analysis was conducted on retained items. Cronbach's α, Spearman correlation, and intraclass correlation (ICC) coefficients were calculated to test internal consistency, criterion validity (compared to stage), and test-retest reliability, respectively.One item was removed due to a floor effect. The response scale was collapsed from a 5-point scale to a 3-point scale due to skewness. Six items were discarded due to redundancy (interitem correlations >0.7); 2 items were discarded due to factor loadings <0.4. Exploratory factor analysis revealed a 2-factor structure explaining 84% of variance, and the domains Signs and Impacts had good internal consistency (all Cronbach's α >0.80 and <0.90), significant association with stage (P < .05), and good overall test-retest reliability (ICC, 0.82).The LMF has been refined into a 12-item, 2-domain instrument measuring LM-specific signs and impacts with internal consistency, criterion validity, and test-retest reliability.

    View details for DOI 10.1177/0194599815594776

    View details for Web of Science ID 000362445800031

    View details for PubMedID 26195574

    View details for PubMedCentralID PMC5938064

  • Outcomes and Resource Utilization of Endoscopic Mass-Closure Technique for Laryngeal Clefts OTOLARYNGOLOGY-HEAD AND NECK SURGERY Balakrishnan, K., Cheng, E., de Alarcon, A., Sidell, D. R., Hart, C. K., Rutter, M. J. 2015; 153 (1): 119-123


    To compare resource utilization and clinical outcomes between endoscopic mass-closure and open techniques for laryngeal cleft repair.Case series with chart review.Tertiary academic children's hospital.Pediatric patients undergoing repair for Benjamin-Inglis type 1-3 laryngeal clefts over a 15-year period. All 20 patients undergoing endoscopic repair were included. Eight control patients undergoing open repair were selected using matching by age and cleft type. Demographic, clinical, and resource utilization data were collected.Twenty-eight patients were included (20 endoscopic, 8 open). Mean age, rates of tracheostomy and vocal fold immobility, and distribution of cleft types were not different between the 2 groups (all P > .2). Mean operative time (P = .004) and duration of hospital stay (P < .001) were significantly shorter in the endoscopic group. All repairs were intact in both groups at final postoperative endoscopy. Rates of persistent laryngeal penetration or aspiration on swallow study were not different between groups (P = 1.000), although results were available for only 11 patients.Endoscopic laryngeal cleft repair using a mass-closure technique provides a durable result while requiring significantly shorter operative times and hospital stays than open repair and avoiding the potential morbidity of laryngofissure. However, open repair may allow the simultaneous performance of other airway reconstructive procedures and may be a useful salvage technique when endoscopic repair fails. Postoperative swallowing results require further study.

    View details for DOI 10.1177/0194599815576718

    View details for Web of Science ID 000357297000019

    View details for PubMedID 25782984

  • Standardized Outcome and Reporting Measures in Pediatric Head and Neck Lymphatic Malformations OTOLARYNGOLOGY-HEAD AND NECK SURGERY Balakrishnan, K., Bauman, N., Chun, R. H., Darrow, D. H., Grimmer, J. F., Perkins, J. A., Richter, G. T., Shin, J. J., Shivaram, G. M., Sidell, D. R., Elluru, R. G. 2015; 152 (5): 948-953


    To develop general and site-specific treatment effect and outcome measures to standardize the reporting of head and neck lymphatic malformation (HNLM) treatments.Consensus statement/expert opinion.Multiple tertiary academic institutions.The modified Delphi method is an iterative process of collecting expert opinions, refining opinions through discussion and feedback, statistically aggregating opinions, and using these aggregates to generate consensus opinion in the absence of other data. The modified Delphi method was used by a multi-institutional group of otolaryngology and interventional radiology experts in the field of vascular anomalies to formulate a list of recommended reporting outcomes for the study and treatment of head and neck lymphatic malformations.Through 3 rounds of iteration, 10 expert panelists refined 98 proposed outcome measures and 9 outcome categories to a final consensus set of 50 recommended outcome measures in 3 global categories (general, demographics, and treatment complications) and 5 site-specific categories (orbit, oral cavity, pharynx, larynx, and neck).We propose the first consensus set of standardized reporting measures for clinical and treatment outcomes in studies of HNLMs. Consistent outcome measures across future studies will facilitate comparison of treatment options and allow systematic review. We hope that these guidelines facilitate the design and reporting of subsequent HNLM studies.

    View details for DOI 10.1177/0194599815577602

    View details for Web of Science ID 000354261400029

    View details for PubMedID 25829389

  • Applying Cost Accounting to Operating Room Staffing in Otolaryngology: Time-Driven Activity-Based Costing and Outpatient Adenotonsillectomy OTOLARYNGOLOGY-HEAD AND NECK SURGERY Balakrishnan, K., Goico, B., Arjmand, E. M. 2015; 152 (4): 684–90


    (1) To describe the application of a detailed cost-accounting method (time-driven activity-cased costing) to operating room personnel costs, avoiding the proxy use of hospital and provider charges. (2) To model potential cost efficiencies using different staffing models with the case study of outpatient adenotonsillectomy.Prospective cost analysis case study.Tertiary pediatric hospital.All otolaryngology providers and otolaryngology operating room staff at our institution.Time-driven activity-based costing demonstrated precise per-case and per-minute calculation of personnel costs. We identified several areas of unused personnel capacity in a basic staffing model. Per-case personnel costs decreased by 23.2% by allowing a surgeon to run 2 operating rooms, despite doubling all other staff. Further cost reductions up to a total of 26.4% were predicted with additional staffing rearrangements.Time-driven activity-based costing allows detailed understanding of not only personnel costs but also how personnel time is used. This in turn allows testing of alternative staffing models to decrease unused personnel capacity and increase efficiency.

    View details for DOI 10.1177/0194599814568273

    View details for Web of Science ID 000352580000023

    View details for PubMedID 25623288

  • Prognostic Value of a Simplified Anatomically Based Nomenclature for Fetal Nuchal Lymphatic Anomalies OTOLARYNGOLOGY-HEAD AND NECK SURGERY Longstreet, B., Balakrishnan, K., Saltzman, B., Perkins, J. A., Dighe, M. 2015; 152 (2): 342–47


    To propose an anatomic classification for fetal nuchal lymphatic anomalies that will be clinically useful and to evaluate the classification's value in predicting chromosomal abnormalities, pregnancy outcomes, other associated fetal anomalies, and spontaneous resolution of these lesions.Retrospective cohort study.Tertiary academic hospital and affiliated tertiary children's hospital.Mother-baby pairs diagnosed with fetal nuchal lymphatic anomalies in a prenatal ultrasound database. Anomalies were classified as nuchal thickening, dorsal lymphatic malformation, or ventral lymphatic malformation. Pregnancy outcomes, prevalence of chromosomal and anatomic abnormalities, and rates of spontaneous lesion resolution were determined for each group.The study included 189 patients: 58 with nuchal thickening, 120 with dorsal lymphatic malformation, and 11 with ventral lymphatic malformation. In fetuses for whom chromosomal analysis was available, chromosomal abnormalities were strongly associated with dorsal lymphatic malformations (83%), less associated with nuchal thickening (29%), and not associated with ventral lymphatic malformations. Dorsal lymphatic malformation predicted high rates of elective (43%) and spontaneous (20%) termination of pregnancy and showed the strongest association with cardiac, renal, and skeletal anomalies. Nuchal thickening was more likely to resolve in utero than dorsal lymphatic malformations, while no ventral lymphatic malformation resolved spontaneously.Fetal nuchal anomalies demonstrate significant and clinically important prognostic differences depending on their anatomic location. The simple classification system proposed here therefore provides useful information to clinicians involved in the pre- and postnatal management of children with these anomalies.

    View details for DOI 10.1177/0194599814559190

    View details for Web of Science ID 000349468100027

    View details for PubMedID 25411310

    View details for PubMedCentralID PMC4672725

  • Primary Surgery vs Primary Sclerotherapy for Head and Neck Lymphatic Malformations JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY Balakrishnan, K., Menezes, M. D., Chen, B. S., Magit, A. E., Perkins, J. A. 2014; 140 (1): 41–45


    The optimal treatment for head and neck lymphatic malformations (LMs) is unknown. To our knowledge, this is the first head-to-head comparison of primary surgery and sclerotherapy for this condition.To compare surgery and sclerotherapy as initial treatment for head and neck LMs.Retrospective cohort study including patients in 2 pediatric vascular anomaly programs receiving treatment for head and neck LMs.Primary surgery or primary sclerotherapy and any subsequent therapy within 1 year.Treatment effectiveness was measured by (1) need for further therapy after first treatment and within 1 year and (2) change in Cologne Disease Score (CDS). Resource utilization was reflected by total intervention number, hospital and intensive care unit (ICU) days, and tracheostomy placement.A total of 174 patients were studied. Their mean (SD) age at presentation was 4.2 (4.7) years; 45.1% were female. The initial treatment was surgery in 55.8%, sclerotherapy in 35.1%, and other interventions in 9.1%. The LM stage ranged from 1 to 5, with similar distributions (P = .15) across initial treatment types; 31.2% of LMs were macrocystic, 34.8% were microcystic, and 33.9% were mixed, with similar distributions across treatment types. Patients receiving sclerotherapy had worse pretreatment CDS subscores for respiration, nutrition, and speech (all P ≤ .02). In univariate analysis, initial surgery and initial sclerotherapy had similar effectiveness after the first intervention (P = .21) and at 1 year (P = .30). In multivariate analysis controlling for lesion stage and type, initial surgery and sclerotherapy did not differ in effectiveness after the first intervention (P = .28) or at 1 year (P = .97). Total CDS and subscale changes were similar between treatment types except for the nutrition subscale. Treatment type did not predict total number of interventions (P = .64), total hospital days (P = .34), total ICU days (P = .59), or higher likelihood of subsequent tracheostomy (P = .36). Higher LM stage predicted more hospital and ICU days and higher likelihood of tracheostomy (all P ≤ .02).In this multisite comparison, initial surgery and sclerotherapy for head and neck LMs were similar in effectiveness and resource utilization. Higher stage predicted greater resource utilization.

    View details for DOI 10.1001/jamaoto.2013.5849

    View details for Web of Science ID 000331369700007

    View details for PubMedID 24288004

  • Composite Severity Indices Reflect Sleep Apnea Disease Burden More Comprehensively Than the Apnea-Hypopnea Index OTOLARYNGOLOGY-HEAD AND NECK SURGERY Balakrishnan, K., James, K. T., Weaver, E. M. 2013; 148 (2): 324–30


    To compare 2 composite indices of sleep apnea disease burden with the commonly used apnea-hypopnea index with regard to baseline measurement of subjective and objective disease burden.Cross-sectional study.Tertiary academic medical center sleep laboratory.Patients with suspected diagnosis of sleep apnea undergoing first diagnostic polysomnography. Subjective data were collected via validated questionnaires; objective data were obtained by standardized physical examination, chart extraction, and polysomnography. Four subjective (patient-reported) disease burden measures and 3 objective (anatomic and physiologic) disease burden measures were used for validation. Associations between composite indices or apnea-hypopnea index and these 7 construct validation measures were compared using bootstrapped correlation coefficients.Two hundred sixteen subjects were included in the final analysis. Both composite disease burden indices showed clinically important or nearly important associations with 3 of 4 subjective validation measures and all 3 objective validation measures, whereas the apnea-hypopnea index was associated only with the objective validation measures.Composite indices of sleep apnea disease burden may capture the breadth of baseline sleep apnea disease burden, particularly subjective disease burden, better than the apnea-hypopnea index.

    View details for DOI 10.1177/0194599812464468

    View details for Web of Science ID 000318361700023

    View details for PubMedID 23077154

    View details for PubMedCentralID PMC5940927

  • Management of Head and Neck Lymphatic Malformations FACIAL PLASTIC SURGERY Balakrishnan, K., Perkins, J. 2012; 28 (6): 596–602


    Lymphatic malformations are congenital vascular malformations most commonly found in the head and neck and typically presenting early in life. Although this disease entity has been recognized for more than a century, there is currently no standardization of disease staging or classification, of treatment paradigms, or of outcome measures. A wide variety of treatment modalities have been proposed. This article reviews diagnostic, evaluation, and treatment strategies for head and neck lymphatic malformations. It also provides the reader specific information to improve treatment outcomes in patients with these lesions. Finally, it advocates for standardization of LM assessment and treatment.

    View details for DOI 10.1055/s-0032-1329934

    View details for Web of Science ID 000311663000008

    View details for PubMedID 23188687

  • Applications and Outcomes of Orbital and Transorbital Endoscopic Surgery Balakrishnan, K., Moe, K. S. SAGE PUBLICATIONS LTD. 2011: 815–20


    To prospectively evaluate the safety, effectiveness, and utility of orbital and transorbital endoscopic surgery.Case series with planned data collection.Level 1 trauma center and tertiary academic hospital.Consecutive sample of 107 patients undergoing orbital or transorbital endoscopic operations.Ability to achieve intraoperative goals using endoscopic approach; occurrence of predetermined intraoperative or postoperative complications.One hundred seven patients (aged 6-83 years) underwent orbital or transorbital endoscopic surgery for 6 different indications. Seven incisions were used. Endoscopic orbitotomies were made through all 4 orbital walls to access surrounding structures. Intraoperative goals were achieved endoscopically in 106 patients. Mean follow-up was 3 months (mean ± SD, 3.0 ± 3.5). No complication was directly related to surgical approach or use of endoscopy. Seventeen complications were detected in 2 categories: persistent diplopia and persistent vision change. No patient had vision loss. No nonfracture patient suffered a complication. Subgroup analysis demonstrated no difference in surgical success rates when compared with transnasal and transantral medial orbital wall and orbital floor repair and cerebrospinal fluid leak repair. Endoscopic visualization was advantageous in several respects: superior visualization and lighting, particularly posterior to the equator of the globe; image magnification; and video monitoring for education and operating room staff involvement. It also facilitated surgical navigation and computer-aided reconstruction.Orbital and transorbital endoscopy are versatile, effective, and safe approaches useful for addressing diverse urgent and elective problems. In appropriate clinical situations, these procedures may offer better access and visualization than open or transnasal approaches.

    View details for DOI 10.1177/0194599810397285

    View details for Web of Science ID 000293998600027

    View details for PubMedID 21493355

  • Head and Neck Lymphatic Tumors and Bony Abnormalities: A Clinical and Molecular Review LYMPHATIC RESEARCH AND BIOLOGY Balakrishnan, K., Majesky, M., Perkins, J. A. 2011; 9 (4): 205–12


    Lymphatic malformations and lymphatic-derived tumors commonly involve the head and neck, where they may be associated with bony abnormalities and other systemic symptoms. The reasons for the association between these disorders and local skeletal changes are largely unknown, but such changes may cause significant disease-related morbidity. Ongoing work in molecular and developmental biology is beginning to uncover potential reasons for the bony abnormalities found in head and neck lymphatic disease; this article summarizes current knowledge on possible mechanisms underlying this association.

    View details for DOI 10.1089/lrb.2011.0018

    View details for Web of Science ID 000299009200007

    View details for PubMedID 22196287

    View details for PubMedCentralID PMC3391938

  • Management of airway hemangiomas. Expert review of respiratory medicine Balakrishnan, K., Perkins, J. A. 2010; 4 (4): 455–62


    Airway infantile hemangiomas can cause life-threatening airway compromise from the first year of life. Diagnosis, treatment protocols and outcome measures are not standardized for this condition, making systematic assessment of treatments and outcomes difficult. This article summarizes the treatment options in use and provides an overview of their benefits and drawbacks. It also emphasizes the need for further investigation in this field and discusses the standardization that is required for such research to proceed in a useful manner. The article is divided into discussions of airway infantile hemangioma in general, medical therapy and surgical therapy. It concludes with predictions about the near future of airway infantile hemangioma research and therapy.

    View details for DOI 10.1586/ers.10.46

    View details for PubMedID 20658907

  • Heat shock protein 70 binds its own messenger ribonucleic acid as part of a gene expression self-limiting mechanism CELL STRESS & CHAPERONES Balakrishnan, K., De Maio, A. 2006; 11 (1): 44–50


    Expression of heat shock proteins is a cellular response to a variety of stressors. HSP70, the major stress-induced heat shock protein, is involved in repair and protection after the insult. However, the prolonged presence of this protein is detrimental. Consequently, Hsp70 expression must be tightly regulated. We have previously shown an increase in the degradation of Hsp70 messenger ribonucleic acid (mRNA) paralleling the accumulation of HSP70. Incubation of cells with transcriptional and translational inhibitors after heat shock resulted in a significant reduction in Hsp70 mRNA degradation. These observations suggest that newly synthesized, stress-induced factors might be involved in the decay of Hsp70 mRNA. We found that HSP70 binds directly to Hsp70 mRNA, as demonstrated by immunoprecipitation. This observation was confirmed by RNA gel-shift assays. These results are evidence for a novel and likely direct interaction between HSP70 and Hsp70 mRNA in cells after stress. This interaction may be part of a self-limiting mechanism to reduce HSP70 production, thus avoiding potential toxic effects of this protein in the absence of stress.

    View details for DOI 10.1379/CSC-136R1.1

    View details for Web of Science ID 000236266000005

    View details for PubMedID 16572728

    View details for PubMedCentralID PMC1400612

  • Dendrite development regulated by CREST, a calcium-regulated transcriptional activator SCIENCE Aizawa, H., Hu, S. C., Bobb, K., Balakrishnan, K., Ince, G., Gurevich, Cowan, M., Ghosh, A. 2004; 303 (5655): 197–202


    The lasting effects of neuronal activity on brain development involve calcium-dependent gene expression. Using a strategy called transactivator trap, we cloned a calcium-responsive transactivator called CREST (for calcium-responsive transactivator). CREST is a SYT-related nuclear protein that interacts with adenosine 3',5'-monophosphate (cAMP) response element-binding protein (CREB)-binding protein (CBP) and is expressed in the developing brain. Mice that have a targeted disruption of the crest gene are viable but display defects in cortical and hippocampal dendrite development. Cortical neurons from crest mutant mice are compromised in calcium-dependent dendritic growth. Thus, calcium activation of CREST-mediated transcription helps regulate neuronal morphogenesis.

    View details for DOI 10.1126/science.1089845

    View details for Web of Science ID 000187908500039

    View details for PubMedID 14716005