Objective. This update of the 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation cerumen impaction clinical practice guideline provides evidencebased recommendations on managing cerumen impaction. Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. Changes from the prior guideline include• a consumer added to the development group;• new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials); • enhanced information on patient education and counseling; • a new algorithm to clarify action statement relationships;• expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion; • an enhanced external review process to include public comment and journal peer review; and • 3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.Purpose. The primary purpose of this guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention and to promote evidence-based management. Another purpose of the guideline is to highlight needs and management options in special populations or in patients who have modifying factors. The guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, and it applies to any setting in which cerumen impaction would be identified, monitored, or managed. The guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal.Key Action Statements. The panel made a strong recommendation that clinicians should treat, or refer to a clinician who can treat, cerumen impaction, defined as an accumulation of cerumen that is associated with symptoms, prevents needed assessment of the ear, or both.The panel made the following recommendations: (1) Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen. (2) Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents needed assessment of the ear, or both. (3) Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as ≥1 of the following: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, and nonintact tympanic membrane. (4) Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined. (5) Clinicians s...

Objective To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep. Methods Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized. Results The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research. Conclusion Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

ppropriate nutritional intake is essential for the rapid growth and development that occurs during infancy and childhood. 1 Feeding and swallowing dysfunction are diagnosed with increasing frequency, especially in children with a history of prematurity, neuromuscular disorders, cardiopulmonary disorders, anatomic anomalies of the upper aerodigestive tract, and gastrointestinal tract disorders. [2][3][4] Early diagnosis and intervention by a multidisciplinary team are essential to the management of swallowing disorders in children. 5 Physiologic Characteristics of SwallowingThe normal swallow is classically divided into 4 phases: the preparatory phase, the oral phase, the pharyngeal phase, and the esophageal phase. The preparatory phase is when food is taken into the oral cavity, moistened with saliva, chewed, and prepared into a bolus using the oral tongue and hard palate. This phase develops at approximately age 6 months. Before age 6 months, the preparatory phase consists of sucking from a nipple. The oral phase is the propulsion of the food bolus into the oropharynx by the oral tongue and the triggering of the swallow reflex. The soft palate elevates to prevent food from regurgitating into the nasopharynx. The pharyngeal phase is the passage of the food bolus through the oropharynx and hypopharynx toward the esophagus via coordinated muscle contraction. The velum approximates the pharyngeal musculature, the larynx elevates and the vocal folds adduct, and the tongue and pharyngeal muscles propel the bolus into the pharynx. 2,5,6 Respiration ceases during the pharyngeal phase; in fact, while eating, the respiratory rate becomes faster and more irregular than during tidal breathing. 7,8 The esophageal phase consists of cricopharyngeus relaxation, allowing the food bolus to enter the esophagus, and coordinated smooth muscle peristalsis passes the bolus into the stomach. 2,9 Development of the suck and swallow begins in utero as early as gestational week 10 or 11. Gestational age 34 to 38 weeks is typically when most children develop efficiency and tolerance of oral feeding. 5,10,11 In infants, all 4 phases are under involuntary reflex control. In children and adults, the preparatory and oral phases are under voluntary control, and the pharyngeal and esophageal phases remain involuntary. 2 A physiologic swallow is the result of the complex integration of more than 30 nerves and muscles and must progress with the child as their anatomy matures. 2 Dysphagia is defined as difficulty swallowing and must be distinguished from behavioral feeding disorders, such as oral aversion. 1 Dysphagia can be further categorized depending on the disordered phase of swallowing. Oral dysphagia can present as absent oral reflexes, immature or absent suck, uncoordinated biting/chewing, and poor handling of the food bolus. Pharyngeal dysphagia can present as laryngeal penetration, when the food bolus enters the laryngeal vestibule; aspiration, when the food enters the airway below the vocal folds; choking, when food obstructs the airway...

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