INTRODUCTION Post tracheostomy hemorrhage is a potentially life-threatening complication that occurs in approximately 1% of cases and requires immediate intervention. Iatrogenic vascular injury to the jugular and carotid vessels and branches of the neck during surgery is usually the cause for major bleedings during the immediate postoperative period, lasting up to 3 days. Delayed bleeding is usually the result of a tracheal erosion by a major artery, leading to pseudoaneurysms or fistulae. In most cases, the innominate artery is involved, resulting in trachea-innominate artery fistula (TIAF), with mortality rates reaching 100%. In some cases, sentinel bleeding, hemoptysis, or pulsation around the cannula may precede. In the past, the only treatment options for acute and delayed bleeding were open surgery to repair, ligate or resect the damaged vessels. Once the bleeding is controlled, repair of the tracheal fistula is indicated. Reported success rates following surgical repairs are low, with high morbidity and mortality of more than 75%. In recent years, an endovascular approach is replacing the need for surgery, with higher survival rates of over 70% and fewer complications. Objectives To describe our experience with endovascular treatments for immediate and delayed post-tracheostomy hemorrhage.

Unilateral vocal cord paralysis (UVCP) is a known complication of thyroid surgery, due to iatrogenic recurrent laryngeal nerve injury, with reported rates of 2-5% in children. The gold standard for assessing vocal cord function in flexible nasendoscopy (FNE) examination, which is considered high-risk for contraction of the COVID-19 virus. Intraoperative ultrasonographic assessment (IUA) of vocal cord function is a non-invasive and relatively simple procedure, performed in a supine position under general anesthesia. Objectives: To evaluate the validity of IUA modality in children undergoing thyroidectomy, and to compare it to the standard FNE. Design: A prospective double-blind study covering 24 months (March 2019-March 2021). Twenty thyroid lobectomies were performed, during 15 surgeries. Vocal cord function was assessed three times: Preoperatively by FNE, intraoperative (IUA) following extubation, and a second FNE on the first post-operative day. Settings: A tertiary pediatric hospital. Results: The overall accuracy of IUA results in our study was 92%. IUA sensitivity, specificity, positive and negative predictive values were 100%, 89%, 33%, and 100% respectively. Patient’s age demonstrated borderline significance (p= 0.08). The resident’s experience was associated with a better correlation between IUA and FNE results (p<0.05). Conclusions: IUA of vocal cord motion has a high accuracy rate for detection of iatrogenic vocal cord paralysis, similar to FNE. It is easily learned by residents, well tolerated by children, and it provides a safe and valid alternative modality while ensuring the safety of the medical staff in treating patients, especially in times of COVID-19 pandemic.

Objective: To describe the occurrence, clinical presentation and management, of pediatric nasal foreign bodies, and to assess various risk factors for complications. Methods: A retrospective analysis of a computerized patient directory of 562 children admitted to the emergency department (ED) in a tertiary pediatric hospital during a 10-year period (Jan 2010-Dec 2019), with a witnessed NFB upon physical examination. Results: Upon admittance to the ED, most of the children (82%) were asymptomatic. Among the symptomatic children (18%), the primary symptoms were nasal discharge (10%), epistaxis (8%) and pain (4%). Younger children (under age 4 years) were more likely to insert organic materials, compared to older children. Younger children were also admitted sooner to the ED and were more likely to present with nasal discharge. The overall complication rate was 5%. None of the children had aspirated the NFB. Complications included infection (2%), necrosis (0.7%), septal perforation (0.5%), deep mucosal laceration (1.5%) and loss of NFB (1.9%). Significantly higher rates of symptoms and complications were associated with button batteries. Increased risk for complications were observed according to NFB-type, multiple attempts to remove NFB, posterior insertion of NFB and left-side insertion. Conclusions: NFB in children are common. Mostly, patients are asymptomatic, therefore a high index of suspicion is required, for quick diagnosis and safe removal, without complications.