Review of the enhanced recovery pathway for children: perioperative anesthetic considerations.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways. SOURCE: A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths. PRINCIPAL FINDINGS: The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking. CONCLUSION: Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement.

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, 131:E1941-E1949, 2021.

Patient Engagement in Otolaryngology.

Patient engagement, which involves incorporating the patient and family as partners in their care, is a growing focus in otolaryngology and surgery. Attention to patient and family centeredness, shared decision making, and patient experience together improves the overall tenor of patient engagement. Patient engagement promotes safety through improving quality of electronic health record data, error detection, and treatment decisions and adherence. In this article, we review specific areas of importance for patient engagement in otolaryngology as well as areas needing more research and development.

Health literacy in pediatric otolaryngology: A scoping review.

OBJECTIVE: To review research on status and outcomes of health literacy in pediatric otolaryngology and identify opportunities for quality improvement. METHODS: We performed a scoping review, adhering to methodologic standards. A combination of MeSH terms and keywords related to health literacy in otolaryngology was used to conduct a search. Relevant studies were identified using PubMed, Ovid MEDLINE, and Google Scholar databases. Studies were selected for inclusion by two authors if they addressed the domains of pediatric otolaryngology as well as health literacy. Data were abstracted from each study on the number of participants, the setting, the study design, the outcome measure, the intervention used, and the overall theme. Authors identified prominent overarching themes and grouped studies accordingly. Results were then tabulated for further review and to discern implications for future practice and research. RESULTS: Of 1046 articles identified, 20 articles were included. Studies fell into three major themes: readability of patient materials, patient recall after informed consent, and optimal patient education. Prominent findings included the following: 1. Much of the printed and electronic educational material in otolaryngology is above the recommended reading level for public health information; 2. Parents do not easily recall information provided verbally or in written form; and 3. Adding visual and multimodal components improves the success of parental education. CONCLUSION: Health literacy in pediatric otolaryngology may influence comprehension of educational materials and adequacy of informed consent. Future research may address whether patient health literacy affects clinical outcomes.

Safety and postoperative adverse events in pediatric airway reconstruction: Analysis of ACS-NSQIP-P 30-day outcomes.

OBJECTIVES: Prior research has shown that airway reconstructive procedures comprise significant composite morbidity compared to the whole of pediatric otolaryngologic cases evaluated in the American College of Surgeon's National Surgery Quality Improvement Program-Pediatric (ACS-NSQIP-P) platform. We describe postoperative sequelae of pediatric airway reconstructive procedures and identify predictive factors for adverse events. METHODS: Current procedural terminology (CPT) codes were used to identify children undergoing included procedures in the 2012 to 2014 ACS-NSQIP-P public use files (PUF). Targeted variables included patient demographics and 30-day postoperative events (reoperation, readmission, and complications). Event rates were determined and compared within subgroups. Multivariate logistic regression was performed to identify predictive factors for major adverse events. RESULTS: In 3 years of PUF data (183,283 total cases), 198 cases (0.11%) were airway reconstructive procedures. The most common was laryngoplasty (CPT 31580, 31582; n = 111, 56.1%), followed by cervical tracheoplasty (CPT 31750; n = 47, 23.7%), tracheal resection (CPT 31780; n = 24, 12.1%), and cricoid split (CPT 31587, n = 16, 8.1%). There were 131 premature children (66.2%) and 94 children (47.5%) with history of bronchopulmonary dysplasia. Thirty-day postoperative sequelae included readmissions (n = 42, 21.2%), complications (n = 27, 13.6%), and reoperations (n = 14, 7.1%). On univariate analysis, children less than 3 years of age were more likely to undergo an unplanned reoperation. There were no significant predictive factors for readmission or complication. On multivariate analysis, there was a trend toward higher rates of unplanned reoperations in children less than 3 years of age. CONCLUSION: The 30-day adverse event rate in pediatric airway surgery is high, with no identifiable predictors noted in the analysis of these data. Findings imply that systematic collection of variables and outcomes specific to pediatric airway surgery, in addition to standard NSQIP workflow, will be essential for NSQIP-P to truly effect quality improvement in these high-risk procedures. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:504-508, 2017.

Treatment and outcomes of chronic rhinosinusitis in children with primary ciliary dyskinesia: where is the evidence? A qualitative systematic review.

BACKGROUND: Consensus on treatment of chronic rhinosinusitis (CRS) in children with primary ciliary dyskinesia (PCD) is limited. We sought to synthesize the best available evidence pertaining to treatment and outcomes of CRS in children with PCD. METHODS: This work is a systematic review of PubMed and EMBASE for studies pertaining to treatment and outcomes of CRS in children with PCD in a 20-year period. Two reviewers independently extracted information on study design, setting, medical or surgical therapy for CRS, and treatment outcomes. RESULTS: Twelve studies from 8 countries were included for analysis: (3 retrospective cohorts, 2 prospective cohorts, 2 cross-sectional, 1 case series, and 4 case reports). The number of patients with PCD ranged from 1 to 78. Medical treatment included oral antibiotics, intranasal steroids, and oral steroids. Surgical treatment was mentioned in 8 studies, with endoscopic sinus surgery (ESS) described in 3 of 8. Outcome measures were rarely defined but included the 20-item Sino-Nasal Outcome Test (SNOT-20) questionnaire (1/12), symptom questionnaire (1/12), decreased recurrent pneumonia (1/12), and subjective report of CRS symptoms. No randomized, controlled, or long-term prospective cohort studies were identified, and no study employed a disease-specific, pediatric-validated instrument to measure outcomes of therapy. CONCLUSION: There is a paucity of evidence pertaining to CRS treatment or outcomes in children with PCD. Given the rare prevalence of PCD and the insufficient evidence pertaining to treatment effectiveness for CRS, we propose an international, multicenter database to prospectively track data pertaining to diagnosis, treatment, and outcomes of CRS for children with PCD. This effort would encourage implementation of validated and standardized outcome measures.

Ex utero intrapartum treatment procedure for management of congenital high airway obstruction syndrome in a vertex/breech twin gestation.

Congenital high airway obstruction syndrome (CHAOS) is one indication for the ex utero intrapartum treatment (EXIT), which is used to secure the fetal airway, while fetal oxygenation is maintained by uteroplacental circulation. We report a successful EXIT procedure in a twin gestation in which one child had CHAOS while the other was a healthy child without any congenital abnormalities. After version of Twin B to allow for delivery of Twin A, Twin B underwent airway evaluation and tracheostomy for laryngeal atresia prior to delivery.

Racial/ethnic and socioeconomic disparities in the diagnosis and treatment of sleep-disordered breathing in children.

OBJECTIVE: Although racial/ethnic and socioeconomic healthcare disparities in pediatric primary care are widely documented, little is known regarding health disparities for common otolaryngic conditions. Pediatric sleep-disordered breathing (SDB) is highly prevalent, associated with significant physical and neurocognitive sequelae, and a common reason for pediatric otolaryngology referral. We sought to synthesize information from published findings related to racial/ethnic and socioeconomic disparities in children with SDB. METHODS: Qualitative systematic review of MEDLINE database for articles reporting on racial/ethnic or socioeconomic differences in prevalence, diagnosis or surgical treatment of SDB in children over 30 years. RESULTS: Of 210 abstracts identified, 33 met inclusion criteria. 24 articles directly addressed differences in race/ethnicity and socioeconomic status, and 10 had findings which identified a disparity. Differences were identified in prevalence, sleep patterns, and sequelae of pediatric SDB (24/33) and in access to care and utilization of adenotonsillectomy (10/33). Black children (12/33) and children with socioeconomic deprivation (17/33) were the most common minority groups studied. Although conclusions were broad, common study findings showed: (1) children in racial/ethnic and socioeconomic minorities may have higher prevalence and greater risk for SDB, and (2) In the U.S., white children or children with private insurance are more likely to undergo adenotonsillectomy. CONCLUSIONS: Racial/ethnic and socioeconomic disparities are prevalent among children with SDB. Disparities in multiracial populations and disparities in access to care, treatment, and utilization of services for pediatric SDB require more detailed investigation. Given the potential negative impact of SDB in children, as well as its economic consequences, the evaluation of disparities should be prioritized in health policy research.

Socioeconomic disparities for hearing-impaired children in the United States.

OBJECTIVES: This study aims to evaluate disparities in socioeconomic status and healthcare utilization in hearing-impaired children using a nationally representative sample. STUDY DESIGN: Cross-sectional analysis of stacked data from the 1997 to 2003 National Health Interview Survey, a voluntary U.S. household survey of the National Center for Health Statistics. METHODS: Children were grouped according to three levels of hearing ability based on parental response to perceived hearing status. χ(2) and analysis of variance (ANOVA) models tested the association of individual sociodemographic variables with hearing status. Multivariate regression analyses examined the association of hearing impairment with family income, poverty status, and utilization of routine and specialty health services. RESULTS: The total sample consisted of 76,012 children, of whom 2.6% had some hearing loss and 0.43% had marked hearing loss. Families of hearing-impaired children were more likely to report poorer health status, have Medicaid, live in single-mother households, and live below the poverty level (P < .01). After adjusting for confounders, children with mild and marked hearing impairment were less likely to afford prescription medications (odds ratio [OR] = 1.89, 95% confidence interval [CI], 1.44-2.48 [mild]; OR = 2.72, 95% CI, 1.73-4.29 [marked]) and less likely to have access to mental health services (OR = 3.26, 95% CI, 2.41-4.69 [mild]; OR = 2.62, 95% CI, 1.34-5.12 [marked]) or dental services (OR = 1.65, 95% CI, 1.36-2.02 [mild]; OR = 1.62, 95% CI, 1.09-2.41 [marked]). No difference was identified for access to routine/sick health services. CONCLUSIONS: Compared with families of children without hearing loss, families of hearing-impaired children live closer to the poverty level and utilize some medical services with less frequency. Further identification of causal relationships between familial socioeconomic status and childhood hearing loss may help direct policy initiatives designed to mitigate healthcare disparities and improve access to services for hearing-impaired children.