Efficacy of inferior turbinate reduction in pediatric patients: a prospective analysis.

BACKGROUND: Chronic nasal congestion is a common presentation in the pediatric setting. For patients who fail to respond to maximal medical therapy and adenoidectomy, inferior turbinate reduction (ITR) may be a reasonable adjuvant surgical approach. Our objective was to prospectively evaluate nasal congestion symptoms and daily medication use in the year following ITR in children with and without allergic rhinitis (AR). METHODS: Patients younger than 18 years undergoing ITR alone or in combination with nonsinonasal procedures were enrolled. Scores from the Nasal Obstruction Symptom Evaluation (NOSE) survey were collected preoperatively and at 3, 6, and 12 months postoperatively from 96 patients. Number and type of pertinent daily medications utilized were also analyzed using Wilcoxon signed-rank and McNemar's tests. Patients with and without comorbid AR were then compared using Wilcoxon rank-sum tests. RESULTS: Median (range) NOSE sum scores significantly improved from preoperative median of 65 out of 100 points (0-100) to 20 (0-100), (z = 7.12, p < 0.001) at 12 months postoperatively. The median number of daily medications was significantly reduced from 1 (range, 0-4) preoperatively to 0 (range, 0-5) postoperatively (z = 2.38, p = 0.017). Fifty-six (58.3%) patients had AR. AR patients received more medications preoperatively and postoperatively compared with those without AR (z = -2.96, p = 0.003; z = -2.23, p = 0.024). At 12 months, NOSE scores remained significantly greater in patients with AR compared with those without AR (ß = 11.6; 95% confidence interval [CI], 0.676-22.5; p = 0.038). CONCLUSION: Our data highlight the need for a multimodal approach to chronic nasal congestion, particularly in children with AR.

Can Ophthalmologic Examination Predict Abducens Nerve Recovery After Endoscopic Skull Base Surgery?

OBJECTIVES: While abducens nerve palsy (ANP) is a known risk in the setting of some endoscopic endonasal skull base surgery (ESBS), frequency and prognosis of post-operative palsy remain unknown. Our goals were to determine the frequency and prognosis of ANP after high-risk ESBS, and identify factors associated with recovery. METHODS: Retrospective case series of all patients with pathology at highest risk for abducens nerve injury (pituitary adenoma, chordoma, meningioma, chondrosarcoma, cholesterol granuloma) generated a list of patients with abducens nerve palsy after ESBS performed from 2011-2016. A validated ophthalmologic clinical grading scale measuring lateral rectus duction from 0 to -5 (full motion to inability to reach midline) was measured at multiple time points to assess recovery of ANP. RESULTS: Of 655 patients who underwent ESBS with increased risk of abducens injury, 40 (6.1%) post-operative palsies were identified and 39 patients with dedicated examination at multiple time points were included in subsequent analysis. Complete resolution was noted in 25 patients (64%) within 12 months. While 19 of 23 (83%) with a partial palsy had complete resolution, only six of 16 (38%) with a complete palsy resolved entirely (P = .005; Fisher's exact test). All six patients with delayed onset of palsy resolved (P = .070; Fisher's exact test). Meningioma and chordoma had higher rates of both temporary and permanent post-operative ANP (P < .0001; Fisher's exact). CONCLUSIONS: The frequency of post-operative ANP following ESBS is low, even in high-risk tumors. While only a minority of complete abducens nerve palsies recover, patients with partial or delayed palsy post-operatively are likely to recover function without intervention. LEVEL OF EVIDENCE: IV Laryngoscope, 131:513-517, 2021.

Tympanostomy Tube Innovation: Advances in Device Material, Design, and Office-Based Technology.

OBJECTIVES: With tympanostomy tube insertion remaining the most common procedure performed in children to date, growing interests in minimizing both procedural costs and anesthetic exposure in the pediatric population have inspired innovation with respect to tympanostomy tubes. As such, we aim to discuss the current state of tympanostomy tube innovation including insertion devices, tube material, and design. METHODS: Computerized literature review. RESULTS: (1) Numerous single-use devices consisting of a myringotomy knife and preloaded tympanostomy tube offer potential advantages of decreasing or eliminating operating room time and may be performed under moderate instead of a general anesthetic. (2) Innovation with respect to tympanostomy tube material and design may offer enhanced ototopical drug delivery, decreased rates of tube occlusion, and/or the ability to dissolve "on-command" with application of a novel ototopical material. (3) These technologies currently remain in various phases of preclinical and clinical testing. CONCLUSIONS: While clinical testing for a number of new technologies is preliminary and ongoing, tympanostomy tube-related innovations hold exciting promise to supplement or potentially replace the present-day armamentarium of tympanostomy tube design and insertion moving forward.

Opioid prescription and postoperative outcomes in pediatric patients.

OBJECTIVES/HYPOTHESIS: To determine if the amount of opioid prescribed and postoperative outcomes after adenotonsillectomy changed following implementation of mandated opioid consent forms. STUDY DESIGN: Retrospective cohort study. METHODS: Patients undergoing adenotonsillectomy 6 months before and after implementation of mandated opioid consent forms at a tertiary-care pediatric hospital were studied. Demographics, operative data, weight-based opioid dosage, and postoperative outcome measures, including nursing calls, emergency department (ED) visits, hospital readmission, and bleed rates, were collected and analyzed. RESULTS: Of 300 patients, opioid prescription was provided for 211 patients (70.3%), 112 preconsent (74.7%) and 99 postconsent (66.0%). Mean (standard deviation) total opioid prescribed (milligrams/kilogram) was significantly higher preconsent 4.8 (5.6) than postconsent 3.2 (4.7), (P = .003). There were no differences between number of nursing calls (P = .134) or ED visits (P = .083). Interestingly, preconsent patients had more hospital readmission for pain/dehydration (odds ratio OR: 368, P = .016) and bleeding concerns (OR: 244, P = .003). CONCLUSIONS: A mandated consent form prior to opioid prescription was associated with decreased overall opioid prescription without resultant increase in postoperative complications in pediatric patients. These data provide support for minimizing opioid prescription on a systems-based level. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1477-1481, 2019.

Reducing rates of operative intervention for pediatric post-tonsillectomy hemorrhage.

OBJECTIVES/HYPOTHESIS: The aims of this study were to determine the frequency of rebleeding in patients admitted for observation after presentation for nonactive hemorrhage in the post-tonsillectomy period, compare rebleeding rates between patients managed with observation versus initial operative control, and describe the complication profile associated with observation as a management strategy for post-tonsillectomy bleeding. STUDY DESIGN: Case series with retrospective review of patients. METHODS: Patients presenting from September 1, 2013 to August 31, 2015 for post-tonsillectomy hemorrhage to a tertiary pediatric care center were evaluated for inclusion in the study. Inclusion criteria included patients ≤18 years of age without active bleeding at the time of the initial examination. Proportions were compared using χ2 and Fisher exact tests, whereas continuous data were compared using the Wilcoxon rank sum test. RESULTS: Of 3,866 tonsillectomy patients, 285 (7.4%) presented with concern for oropharyngeal bleeding in the postoperative period, of whom 224 were admitted for nonactive bleeding. Of patients with nonactive bleeding, 203 (90.6%) were managed with observation and 21 (9.4%) with operative intervention. Rate of rebleeding was 26/203 (12.8%) after inpatient observation and 3/21 (14.3%) after operative intervention (P = 1.000). Frequency of rebleeding requiring operative control in patients undergoing initial observation was 14/203 (6.9%). CONCLUSIONS: In our pilot study, rates of rebleeding in patients observed for nonactive post-tonsillectomy hemorrhage was not statistically different than those managed with initial operative exploration. Although preliminary in nature, our data suggest observation may have comparable safety and efficacy when compared to operative management for pediatric patients presenting with nonactive post-tonsillectomy bleeding. Further data collection to establish an optimal management algorithm is ongoing. LEVEL OF EVIDENCE: 4 Laryngoscope, 1958-1962, 2018.