Posterior pharyngeal wall augmentation is a useful technique in selected patients with velopharyngeal insufficiency who have a small central velopharyngeal gap. Options for augmenting this region include using posterior pharyngeal wall flaps to create bulk and implanting various materials to fill in the central deficiency. Autologous and nonautologous implant materials are available and may be implanted through an incision or directly injected into the posterior pharyngeal wall. Previously described materials for implantation include cartilage, fat, fascia, silicone, acellular dermis, polytetrafluoroethylene, and calcium hydroxyapatite. Patient evaluation and surgical techniques for posterior pharyngeal wall augmentation are described.

ObjectiveDifficult airway management is a key skill required by all pediatric physicians, yet training on multiple modalities is lacking. The objective of this study was to compare the rate of, and time to, successful advanced infant airway placement with direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult airway simulator. This study is the first to compare the success with 3 methods for difficult airway management among pediatric trainees.Study DesignRandomized crossover pilot study.SettingTertiary academic medical center.MethodsTwenty-two pediatric residents, interns, and medical students were tested. Participants were provided 1 training session by faculty using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of a Robin sequence. Success was defined as confirmed endotracheal intubation or correct LMA placement by the testing instructor in ≤120 seconds.ResultsDirect laryngoscopy demonstrated a significantly higher placement success rate (77.3%) than video-assisted laryngoscopy (36.4%, P = .0117) and LMA (31.8%, P = .0039). Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds; 95% CI, 59.4-110.1) versus direct laryngoscopy (44.9 seconds; 95% CI, 33.8-55.9) and LMA placement (36.6 seconds; 95% CI, 24.7-48.4).ConclusionsPediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway simulator model. However, given the potential lifesaving implications of advanced airway adjuncts, including video-assisted laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for trainees.

Blast-exposed individuals who sustained severe extremity injuries reported significantly fewer cognitive and vestibular symptoms. In the aftermath of a blast, those who can walk away may have still sustained a significant injury. Specifically, they may suffer more long-term cognitive and vestibular symptoms than those with severe physical injuries.

We present a method to create a tragus using the patient's conchal cartilage. It is a simplified, single-stage technique with well-hidden incisions, yet it maintains the rigidity of a natural tragus. This patient did not have a history of radiation to the area, which may compromise healing with this technique. The cosmetic importance of the tragus has been described, but its functionality in accommodating modern technology has not been previously discussed. The main treatment goal for this patient was to gain the ability to wear earphones (clinical question/level of evidence: therapeutic, V).

Objectives: Compare advanced airway placement (1) success rate and (2) time taken between direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult infant airway simulator. Methods: Prospective, randomized trial in an cademic, tertiary medical center. Twenty-two pediatric residents, interns, and medical students were tested between November 2013 and January 2014. Participants were provided a single training session by faculty from the subspecialties of pediatric otolaryngology, pediatric critical care medicine, and pediatric anesthesiology using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of Pierre-Robin sequence including features of micrognathia, glossoptosis, and cleft palate. Success was defined as a confirmed endotracheal intubation or correct LMA placement by the testing instructor in 120 seconds or less. Results: Direct laryngoscopy demonstrated significantly higher placement success rate (77.3%) than video-assisted laryngoscopy (36.4%, P = .0117) and LMA (31.8%, P = .0039). Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds, 95% confidence interval [CI] 59.4, 110.1), when compared with direct laryngoscopy (44.9 seconds, 95% CI 33.8, 55.9) and LMA placement (36.6 seconds, 95% CI 24.7, 48.4). Conclusions: Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway model of Pierre-Robin. Video-assisted laryngoscopy users took significantly more time to establish a successful advanced airway. Given the potential life-saving implications of advanced airway adjuncts including video laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for in this population.