Animated Videos as a Tool for Teaching Uncommon ENT Diagnoses.

OBJECTIVE: The purpose of this study was to evaluate the knowledge of healthcare professionals and learners regarding the diagnosis and management of nasal septal hematomas (NSH). The secondary objective was to evaluate the effectiveness of a short-form animated video as an educational tool.  Methods: A cross-sectional survey study of healthcare professionals and medical students in the United States was undertaken from October 2022 to June 2023. A pre-test survey was distributed to assess participants' baseline knowledge of NSH management. An educational video on nasal septal hematoma management was presented, followed by a post-test survey to measure the effectiveness of the video.  Results: A total of 142 participant results were collected, 62 (43.7%) of which were attending physicians. There was a significant improvement in knowledge scores across the sample, with a median pre-test score of 83.0% (interquartile range (IQR) 33) and a median post-test score of 100.0% (IQR 17, p<0.001). Additionally, on a visual analog scale (VAS), comfort levels in managing NSH improved from 3.20 to 4.82 (p<0.001) for the entire sample.  Conclusion: NSH is a rare yet potentially devastating otolaryngologic emergency that requires prompt diagnosis and management. A short-form animated video can be an effective tool for educating emergency professionals on diagnosing and managing NSH.

Adverse events related to suction electrocautery devices in adenotonsillectomy: Analysis of the MAUDE database.

OBJECTIVE: To identify adverse events (AEs) related to suction electrocautery use during adenotonsillectomy. METHODS: The US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was searched using the terms "suction cautery," "suction electrocautery," "suction Bovie," and "suction coagulator" from January 2014 to December 2023. RESULTS: 165 AE reports were gathered from the MAUDE database medical device reports (MDRs). 36 met inclusion criteria. Patient injuries were found in 22 (61.1 %) reports and device malfunction events were found in 14 (38.9 %) reports. All patient injuries were thermal burns (N = 22, 100 %). Location of burn injuries included the lip (N = 6, 27.3 %), oral commissure (N = 5, 22.7 %), and tongue (N = 4, 18.2 %). The most common cause of an AE was inadequate device insulation (N = 7, 19.4 %). CONCLUSION: The suction electrocautery apparatus may malfunction and cause patient burn injuries. Device failures mainly result from inadequate device insulation, coagulation problems, and detachment of device components. Surgeons must be aware of these potential complications and counsel parents and patients regarding AEs.

Decreasing the Size of Bottle Caps: Helping or Hurting Children?

OBJECTIVE: Our study aims to assess if decreasing bottle cap size was associated with more ingestions and injuries nationally. STUDY DESIGN: Retrospective chart review. SETTING: The National Electronic Injury Surveillance System (NEISS) database. METHODS: The NEISS was queried for bottle cap ingestions in children 0 to 18 years old between 2002 and 2021. Demographic factors including age, race, and sex of the patient were recorded. The location where the ingestion took place and the disposition of the patient were also analyzed. Data were excluded if the narrative did not specify the ingestion of a cap of a drinking bottle. RESULTS: A total of 415 bottle cap ingestion injuries were identified, for a national estimate of 11,683 injuries. The mean age at the time of ingestion was 10.3 ± 5.2 years and the majority of the injuries occurred in males (N = 9129, 78.4%). 46.4% (N = 5398) were Caucasian, 17.6% (N = 2046) were Black or African American, and 2.7% (N = 311) were Hispanic. 55.0% (N = 6405) of injuries occurred at an unknown location, 41.4% (N = 4781) occurred at home, and 2.8% (N = 326) occurred at school. 82.3% (N = 9584) of patients were treated in the emergency department and released, 6.9% (N = 808) were treated and admitted, 6.7% (N = 783) were treated and transferred, and 0.9% (N = 110) were held for observation. From 2002 (N = 6) to 2021 (N = 2291), there was a statistically significant increase in bottle cap ingestions (P < .001). CONCLUSION: Plastic bottle cap ingestions have increased in children over the last 20 years, coincident with the change to smaller bottle caps.

Laryngeal Foreign Body Aspiration in Infancy: A Diagnostic Challenge.

Foreign body aspiration (FBA) is a significant cause of accidental death among children, with laryngeal FBA being relatively rare but potentially fatal due to airway obstruction. This report highlights a case of laryngeal FBA in an 11-month-old child, initially misdiagnosed as viral croup. Otolaryngological evaluation, particularly in the case of laryngeal FBA, may facilitate management. An 11-month-old male was brought to the emergency department, presenting with inspiratory stridor following a choking episode. A chest radiograph and CT scan of the chest were read as normal. He was suspected of having croup and treated with dexamethasone and racemic nebulized epinephrine, which led to temporary clinical improvement.  The child returned with persistent stridor to the emergency department eight days after his initial visit, prompting an otolaryngological consultation. Flexible laryngoscopy ultimately identified a star-shaped sequin lodged in the glottis. The foreign body was successfully removed via direct laryngoscopy and bronchoscopy (DLB). Following the removal, the patient demonstrated significant improvement and eventually made a full recovery. This case emphasizes the difficulty in diagnosing laryngeal FBA due to its non-specific symptoms and the limitations of imaging techniques. The importance of a thorough clinical history, physical examination, and proper imaging combined with a high index of suspicion is crucial for early diagnosis and treatment. Additionally, the report discusses the potential for severe complications if diagnosis and treatment are delayed, highlighting the need for awareness and prompt intervention in suspected laryngeal FBA cases.

Post-Tonsillectomy Bleeding and Analgesic Use Before and After the FDA Boxed Warning Against Codeine.

OBJECTIVE: The aim of this study was to investigate the trends in post-tonsillectomy analgesic utility and incidence of post-tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy. METHODS: A retrospective study was conducted using TriNetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD-10 codes were used to identify children who experienced post-tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013. RESULTS: Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post-tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone. CONCLUSION: Analgesics used post-tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post-tonsillectomy bleeding. LEVEL OF EVIDENCE: IV Laryngoscope, 2024.

Feeding Issues in Infants Referred for Frenotomy.

INTRODUCTION: The diagnosis of ankyloglossia has increased significantly around the world over the last decade. Frenotomy is indicated in infants with ankyloglossia to improve breastfeeding, although there is little scientific evidence of its efficacy. The purpose of this study is to evaluate whether infants being referred for frenotomy had feeding issues prior to the procedure. METHODS: A retrospective chart review was undertaken for all infants under one year of age referred with ankyloglossia to a pediatric otolaryngology practice or a pediatric hospital between 2018 and 2020. Data included age at referral, gender, comorbidities, feeding issues, whether ankyloglossia was diagnosed, and whether frenotomy was done. Frequencies and non-parametric comparisons were calculated. RESULTS: Of the 646 consultations made for tongue tie, a diagnosis of ankyloglossia was made in 94.7% (N=612) of the patients based on clinical judgment. The most common feeding complaints were poor latch (57.1%, N=369) and painful latch (50.3%, N=325). Eighty one (12.5%) patients did not have a reported feeding difficulty. Most patients had an anterior tongue tie (85.8%, N=554), with some showing signs of restricted tongue movement (30.1%, N=184). Ankyloglossia was 4.03 times more likely to be diagnosed (p<.001) and frenotomy was 1.76 times more likely to be performed (p<.001) in the hospital setting compared to the clinic setting.  Conclusion: Children under the age of one referred to otolaryngology for ankyloglossia were often diagnosed concordantly, although some lacked feeding issues that would indicate frenotomy. There are still knowledge gaps about infantile ankyloglossia in referring medical personnel.

White noise use among children undergoing sound field audiometry: A preliminary study.

OBJECTIVE: To describe the prevalence of routine white noise exposure in children who undergo sound field audiometry. METHODS: A retrospective cohort study was conducted at a pediatric otolaryngology clinic affiliated with an academic tertiary care hospital. The medical records of children who underwent sound field audiometry were reviewed and data was collected regarding demographics and audiogram results. The group was divided into two cohorts based on routine exposure to white noise. Children exposed to white noise were tested with warble tones, while those not exposed were tested with narrow-band noise. RESULTS: 127 patients underwent sound field audiometry testing, of which 96 (75.6%) were reported by their parents to use white noise for sleep. The mean age at time of testing was 1.6 years (95% Confidence Interval [CI] 1.5-1.7). 104 (81.9%) children were able to respond to at least four of the sound field thresholds, and there was no significant difference between the children exposed to white noise and those who were not (P = 0.459). Mean pure tone average (PTA) was 26.2 dB (95% CI 25.2-27.2) and mean speech reception threshold (SRT) was 19.2 dB (95% CI 18.2-20.2). The sound field response rate, PTA, and SRT were similar between these two groups. CONCLUSIONS: The routine use of white noise therapy was extremely common in this pediatric population. The use of warble tones as the audiometric stimuli for children exposed to white noise resulted in similar testing success compared to the use of narrow-band noise in children not exposed to white noise.

Second opinions: Do otolaryngologist demographics matter?

OBJECTIVE: Pediatric patients and their caregivers may receive information from their primary care physician (PCP) that does not match current American Academy of Otolaryngology (AAO) guidelines. The purpose of this study is to evaluate the frequency of parents deciding to seek a second opinion based on the demographics of pediatric otolaryngologists who deliver guideline supported advice, contrary to advice from their child's PCP. METHODS: A survey was distributed to parents in a pediatric otolaryngology clinic between June 2021 and July 2023. Demographics included parent age category, gender, race, and age of youngest child. The survey included a scenario depicting recurrent otitis media with clear ears and a suggestion to defer tympanostomy tube insertion per AAO guidelines after their child's PCP recommended tubes. Thirteen variations of otolaryngologist photos were used in the case, including a control case with no picture. RESULTS: Of the 658 participants, 460 (69.9 %) were female. 551 (83.7 %) were aged 30-49 years, 70 (10.7 %) were younger, and 37 (5.6 %) were older. 545 (82.8 %) were White, 30 (4.6 %) were Black, 20 (3.0 %) were Asian, and 31 (4.7 %) were Hispanic. 39.9 % of parents would seek a second opinion if an otolaryngologist recommended watchful waiting following evaluation of their child's otitis media. Participants given the control case were 2.23 times more likely to listen to the otolaryngologist's advice (p = .025). If a picture was provided, respondents were more likely to follow advice given if the pictured otolaryngologist was female (p = .025, OR = 1.47) or Asian (p = .042, OR = 1.53). CONCLUSION: In this group, there is evidence that physician race and gender may influence decision making when considering action versus monitoring in the context of recurrent otitis media.

A Comparison of Drug-Induced Sleep Endoscopy Findings in Infants and Toddlers.

OBJECTIVE: To compare patterns of obstruction in infants and toddlers with obstructive sleep apnea (OSA) by analyzing drug-induced sleep endoscopy (DISE) examinations. STUDY DESIGN: Retrospective chart review. SETTING: An academic tertiary care pediatric hospital at a single institution. METHODS: Children aged ≤3 years who underwent DISE with propofol titration from 2020 to 2022 were included in the study. Data extracted included age, body mass index, comorbidities, and polysomnography parameters. The sites of anatomic obstruction during DISE were recorded using a validated 10-site scoring system. RESULTS: A total of 86 children underwent DISE, including 15 infants (<1 year) and 71 toddlers (>1≤3 years). Sixty-two percent were male and 37% were female. The mean age of the infant group was 9.6 months (95% confidence interval [CI]: 7.92, 11.28 months), and the mean age of the toddler group was 2.3 years (95% CI: 2.06, 2.50 years). The mean total number of sites of obstruction was not significantly different between infants (N = 2.5) and toddlers (N = 3.2, P = .086). The most common subsite of significant obstruction in both infants and toddlers was the aryepiglottic folds (46.7% and 36.8%, respectively; P = .578). The sites of obstruction and frequency of their occurrence were not significantly different between the 2 groups. CONCLUSION: Multisite airway obstruction is common among children with OSA, especially at the epiglottis, aryepiglottic folds, and tongue base. There is no difference in sites of obstruction and their frequency between toddlers and infants.

Gender distribution of Top Doctors in otolaryngology-head and neck surgery.

INTRODUCTION: Our study seeks to understand the profiles of otolaryngologists selected by Castle Connolly's Top Doctor list and how this compares to the entire field of otolaryngology. METHODS: Top Doctor lists published in Castle Connolly affiliated magazines were analyzed for Otolaryngology, Otolaryngology/Facial Plastic Surgery, or Pediatric Otolaryngology physicians. Only lists published in 2021 or representing the 2021 Top Doctor lists were analyzed. Of the total 39 partnered magazines, 27 met our criteria. Information on the physician was analyzed from the Castle Connolly website and included: gender, education, faculty position, years as a Top Doctor, and certifications of each physician. RESULTS: 879 doctors, 742 (84%) men and 137 women (16%), were included in our analysis. 509 physicians completed a fellowship, 85 (62%) women and 424 (57%) men. The fellowship type varied significantly between gender (p = .002). 122 (14%) Top Doctors completed facial and plastic reconstructive surgery and 111 (91%) were men. Of the women Top Doctors completing a fellowship, 29 (34%) completed a fellowship in pediatric otolaryngology. A logistic regression found that men have an increased odds of being on the Top Doctors list for more years than females (OR: 1.36, p < .001). CONCLUSION: The percentage of women named as Top Doctors was less than the proportion of women in otolaryngology. This may be attributed to gender differences we found in fellowship type and certification. Further research into the role of otolaryngology subspecialties in selection of Top Doctors is needed to better understand gender differences.

Does resident involvement in tonsillectomy affect outcomes?

OBJECTIVE: Tonsillectomy is essentially a solo surgery with a well-described complication profile. It may serve as a good benchmark to evaluate the resident-as-surgeon. This study examined complications such as post-tonsillectomy bleeding in children undergoing tonsillectomy by attending surgeons (AS) or pediatric otolaryngologist-supervised residents. METHODS: Charts were reviewed of all children aged 12 and under who had tonsillectomy +/- adenoidectomy at a children's hospital between Jan 2019 and Dec 2020. Patient age, gender, BMI, indication for surgery, surgical technique, presence of a resident surgeon, primary bleeding, secondary bleeding, treatment of bleeding, other Emergency Room (ER) visits, and clinic phone calls were recorded. Binary logistic regression was performed. RESULTS: 2051 total children (1092 (53.2 %) males and 956 (46.6 %) females) with a mean age of 6.1 years (95 % CI 6.0-6.2) were included. 1910 (93.0 %) underwent surgery for tonsillar obstruction. 1557 (75.9 %) underwent monopolar cautery tonsillectomy. 661 (32.2 %) had a resident surgeon. 274 (13.4 %) had a related ER visit within 15 days. 18 (0.9 %) had a primary bleed and 155 (7.6 %) had a secondary bleed. Binary logistic regression showed that significant predictors of postoperative ER visits were patient age (OR = 1.101, 95 % CI = 1.050-1.154, p < .001) and resident involvement (OR = 0.585, 95 % CI = 0.429-,797, p < .001). Only age was associated with overall postoperative bleeding incidence (OR = 1.131, 95 % CI = 1.068-1.197, p < .001), as well as secondary bleeding (OR = 1.128, 95 % CI = 1.063-1.197, p < .001). There were no significant predictors of primary bleeding. CONCLUSION: Resident involvement in pediatric tonsillectomy is associated with decreased postoperative ER utilization and does not appear to increase common postoperative complications including bleeding and dehydration.

Comparison of Epworth Sleepiness Scale and OSA-18 Scores With Polysomnography in Children.

OBJECTIVE: Our goal is to determine if there is a correlation between Modified Epworth Sleepiness Scale (M-ESS) scores, obstructive sleep apnea (OSA)-18 scores, and polysomnography (PSG) outcomes in children. STUDY DESIGN: Retrospective chart review. SETTING: Pediatric otolaryngology clinic. METHODS: Charts of consecutive children presenting from July 2021 to July 2023 were reviewed. Demographics, body mass index (BMI), BMI Z score, M-ESS score, OSA-18 score, PSG results, and sleep apnea severity were included. One-way analysis of variance and Pearson/Spearman correlation coefficients were calculated. RESULTS: Three hundred sixty-seven children were included, 162 (44.1%) girls and 205 (55.9%) boys. Mean patient age was 7.8 (95% confidence interval [CI]: 7.3-8.3) years. M-ESS score was 6.3 (n = 348, 95% CI: 5.8-6.8), mean OSA-18 score was 56.2 (n = 129, 95% CI: 53.0-59.4). Mean apnea-hypopnea index (AHI) was 10.1 (95% CI: 8.7-11.4) events/h, obstructive AHI 9.3 (95% CI: 8.0-12.7) events/h, respiratory distress index 14.6 (95% CI: 8.4-20.8) events/h, and oxygen saturation nadir 89.8% (95% CI: 89.1-90.4). Sixty-two children (17.2%) had mild, 192 (53.5%) moderate, and 105 (29.2%) severe sleep apnea. M-ESS score correlated weakly to AHI (r = .19, P = <.001), and OSA-18 score to oxygen saturation nadir (r = -.16, P = .002). After logistic regression adjusted for age and BMI, neither clinical scores were independently associated with AHI. CONCLUSION: M-ESS and OSA-18 scores have a weak correlation with OSA severity in children. More reliable, age-appropriate screening tools are needed in pediatric sleep apnea.

Comparison of Surgical Techniques for the Treatment of Congenital Nasal Pyriform Aperture Stenosis: A Systematic Review.

INTRODUCTION: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare condition that results in neonatal respiratory difficulty. The purpose of this systematic review was to compare surgical outcomes of drilling versus dilation techniques in the treatment of CNPAS. METHODS: Pubmed, Embase, and Cochrane Clinical Trials databases were searched for terms "congenital nasal pyriform aperture stenosis" or "pyriform aperture stenosis" from 2010 to 2021. Twenty-five studies were included that evaluated pediatric patients treated surgically for CNPAS with available outcomes data including complications, revisions, and length of stay. RESULTS: A total of 51 patients with CNPAS were pooled from included studies. The median age was 29 days, 56.9% were female, and 54.9% were born full-term. The median pyriform aperture width before surgery was 5.00 mm (IQR = 4.10, 6.45). Forty (78.4%) patients underwent sublabial drilling, while 6 had a dilation procedure performed with hegar cervical dilators, 2 had a balloon dilation, and 3 were dilated with either an acrylic device, endotracheal tube, or bougie. There were no post-operative complications for 76.5% of patients, while a second surgery was required in 9 (17.6%) patients. The median length of stay was 11 days (IQR = 4, 26). No statistically significant difference was observed between sublabial drilling and surgical dilation techniques with respect to complications, need for revision surgery, or length of stay. CONCLUSION: Current literature is insufficient to determine if drilling or dilation is more effective in the treatment of CNPAS.

Acute Intratonsillar Abscess in an Adult: A Case Report and Literature Review.

Intratonsillar abscess (ITA) is rarely reported. Here, we present an uncommon case of acute ITA in an adult, discuss the evaluation and treatment plan, and review the ITA literature.  The abscess reported in the present study was diagnosed through a combination of clinical findings and computed tomography imaging, and treatment included drainage, intravenous (IV) clindamycin, and IV dexamethasone. The literature reports 72 ITA cases with specified treatments: 21 (29.2%) in adults, 19 (26.4%) in children, and 32 (44.4%) in patients of unspecified ages. Among them, 25 (34.7%) responded to antibiotics alone, 11 (15.3%) to needle aspiration and antibiotics, and 36 (50.0%) needed further intervention. Based on the presented case and literature review, we suggest the use of IV antibiotics with needle aspiration as the primary treatment for acute ITA. Incision and drainage (I&D) with antibiotics should be reserved for cases unresponsive to initial measures, and tonsillectomy is recommended for recurrent post-I&D cases.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea.

STUDY OBJECTIVES: Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery. METHODS: A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes. RESULTS: A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005). CONCLUSIONS: This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%). CITATION: Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Do Children with Previous COVID Infection Have Hyposmia?

OBJECTIVE: Our goal was to see if children with a history of COVID infection had subclinical hyposmia. METHODS: Consecutive patients at a pediatric otolaryngology clinic aged 5-17 years were recruited. Demographics including gender, race, use of nasal topical medications (NTM), previous nasal surgery including adenoidectomy (NSA), and previous COVID-19 infection were collected. Each child performed a test of their sense of smell using the Pediatric Smell Wheel (PSW, Sensonics Intl, USA) under the direct supervision and scores were compared. RESULTS: 260 children were included; mean age 10.1 years (95% CI 9.7-10.5), 128 (49.2%) female and 132 (50.8%) male. 65 (25%) used steroid nasal sprays, 100 (38.5%) had undergone adenoidectomy, and 36 (13.8%) had other nasal surgery. 120 (46.2%) had a previous COVID-19 infection. The COVID+ and COVID- groups were the same for age, gender, race, use of NTMs, and previous NSA (p > 0.05). Mean PSW score was 7.8 (95% CI 7.6-8.0), median of 8, ranging from 2 to 11. The mean PSW score was 8.0 for the COVID- group and 7.6 for the COVID+ group (p = 0.005). There was no significant difference in total PSW scores based on gender, race, use of NTMs, previous NSA. Linear regression showed previous COVID infection was significantly negatively associated with total PSW score (Beta -0.636, p = 0.006) with age significantly positively associated (Beta 0.122, p < 0.001). CONCLUSION: Children with a history of COVID infection performed slightly worse when identifying odors than children without a COVID history. More study into the rates of pediatric anosmia related to COVID infection is needed. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:901-906, 2024.

Tracheotomy in children older than two years: Analysis of discharge trends from 2015 to 2020.

OBJECTIVE: In light of increasingly complex patients being discharged with tracheostomies, we aimed to evaluate discharge trends over time in pediatric tracheotomy patients. We hypothesized that there would be delays in discharge from increased focus on preparing families for at-home care of critically ill pediatric patients. MATERIALS AND METHODS: We conducted a cross-sectional analysis of pediatric patients who underwent tracheotomy (Current Procedural Terminology code 31600) between 2015 and 2020 using the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIP-P). Univariate and multivariate regression analyses were performed to assess patient demographics, comorbidities, perioperative factors, postoperative complications, and discharge information. Data were analyzed using Stata 15. RESULTS: A total of 1552 patients were identified. There were 868 (56 %) males and 684 (44 %) females with a mean age of 7.3 ± 5.7 years. At least one comorbidity was seen in 1282 (83 %) patients, with 907 (58 %) having impaired cognitive status or developmental delay. Thirty-six (2.3 %) patients experienced mortality within 30 days, while 710 (46 %) were still in the hospital at 30 days. The odds of remaining in the hospital after 30 days were positively correlated with the year (p=.001). Other factors associated with an increased likelihood of remaining in the hospital after 30 days included younger patient age (p <.001), any complication (p <.001), and a higher American Society of Anesthesiologists classification (p <.001). CONCLUSION: As years have progressed, fewer children were discharged from the hospital after 30 days following tracheotomy. Further research may identify socioeconomic factors contributing to the increasing length of hospital stays associated with a need for tracheotomy.

Age-related outcomes after pediatric branchial cleft cyst excision via NSQIP-P.

OBJECTIVE: Branchial cleft cysts present at varying ages; sometimes excision is delayed because of concern about operating in small children. Our goal was to determine if outcomes and complications differed among pediatric age groups. STUDY DESIGN: Retrospective, cross-sectional. SETTING: American College of Surgeons' National Surgical Quality Improvement Pediatric database. METHODS: Patients who underwent a branchial cleft cyst excision between 2016 and 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database. Patients with CPT code 42,815: 'excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx' as their primary procedure were included. Variables of interest included patient demographics, comorbidities, pre-operative risk factors and complications. RESULTS: 2267 patients with median age of 3.9 (IQR: 7.4, range: 0.04-17.9) years were included. The most common pre-operative risk factors were 149 (7 %) patients with prematurity, 136 (6 %) with developmental delay, 135 (6 %) with congenital malformation, and 128 (6 %) with open wound or wound infection. 68 (3 %) patients experienced at least one post-operative complication, with 73 post-operative complications documented in total. Surgical site infections were the most common complications with 49 (67.1 %) superficial infections, 11 (15.1 %) deep infections, and 4 (5.5 %) organ/space infections. Surgical site infections were the most common reason for related readmission. Duration of anesthesia and operative time increased significantly as patient age increased (p < .001 for both). There was no significant correlation between age and complication incidence. CONCLUSION: Branchial cleft cyst excision is a relatively safe operation with a low complication rate, even in young pediatric populations.

How Pediatric Sleep Disordered Breathing Impacts Parental Fatigue.

OBJECTIVE: Previous research has indicated that sleep disordered breathing (SDB) can lead to a decreased quality of life in children and their families as compared to children who do not have SDB. The purpose of this study was to examine fatigue levels in parents who had young children who were impacted by sleep symptoms as determined by the OSA-18 scale. STUDY DESIGN: Survey. SETTING: Three pediatric otolaryngology clinics associated with a tertiary care children's hospital in Buffalo, NY. METHODS: Fatigue levels for parents of children with OSA-18 ≥ 60 were assessed using the Fatigue Severity Scale and the Chalder Fatigue Scale. Consecutive parents with at least one child between the ages of 1 and 10 were recruited. Parents scored their youngest child on the OSA-18 scale. RESULTS: Of the 261 respondents included, 37 parents had a child with an OSA-18 score ≥60. The majority, 211 (82.1%), of participants reported 2 caregivers in the household while 30 (11.7%) had 1 caregiver in the household. Parents of children with OSA-18 ≥60 had a significantly higher mean fatigue score, 16.5 ± 5.8, compared to their counterparts, 11.9 ± 5.2, on the Chalder Fatigue Scale (P < .001). Similar results were reported for the total score on the Fatigue Severity Scale, 34.7 ± 10.8 compared to 28.9 ± 12.0 (P = .004). CONCLUSION: Parents of children with OSA-18 score ≥60 are significantly more fatigued than parents of children with lower scores. Recognition of this is important for the health care community as it impacts not just the child with OSA but also their family.

Factors Affecting Medical Residents' Decisions to Work After Call.

BACKGROUND: Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions (WHRs) are intended to improve patient safety by reducing resident fatigue. Compliance with ACGME WHRs is not universal. PURPOSE: The purpose of this study was to identify factors that influence residents' decisions to take a postcall day (PCD) off according to ACGME WHRs. METHODS: Residents (N = 433) at one university were emailed a link to a survey in 2019. The survey included demographic details and a Discrete Choice Experiment examining influences on resident decisions to take a PCD off. RESULTS: One hundred seventy-five residents (40.4%) responded to the survey; 113 residents (26%) completed the survey. Positive feedback from attending physicians about taking PCDs off in the past had the greatest impact on respondents' decisions to take a PCD off, increasing the probability by 27.3%, followed by chief resident comments about the resident looking tired (16.6% increase), and having never heard their attendings comment about PCDs off as either positive or negative (13.9% increase). Factors that had the largest effect on decreasing the probability of taking a PCD were negative feedback about taking PCDs off (14.3% decrease), continuity of care concerns (10.8% decrease), and whether the resident was looking forward to an assignment (7.9% decrease). CONCLUSIONS: The most important influencer of residents' decisions to take a PCD off was related to feedback from their attending physicians, suggesting that compliance with WHRs can be improved by focusing on the residency program's safety culture.