Quantitative impact of frenotomy on breastfeeding: a systematic review and meta-analysis.

BACKGROUND: Symptoms related to infant ankyloglossia/tongue-tie may deter mothers from breastfeeding, yet frenotomy is controversial. METHODS: Databases included PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar from 1961-2023. Controlled trials and cohort studies with validated measures of surgical efficacy for breastfeeding outcomes were eligible. Meta-analyses synthesized data with inverse-variance weighting to determine standardized mean differences (SMD) between pre-/postoperative scores. RESULTS: Twenty-one of 1568 screened studies were included. Breastfeeding self-efficacy improved significantly post-frenotomy: medium effect after 5-10 days (SMD 0.60 [95% CI: 0.48, 0.71; P < 0.001]), large effect after 1 month (SMD 0.91 [CI: 0.79, 1.04; P < 0.001]). Nipple pain decreased significantly post-frenotomy: large effect after 5-15 days (SMD -1.10 [CI: -1.49, -0.70; P < 0.001]) and 1 month (SMD -1.23 [CI: -1.79, -0.67; P = 0.002]). Frenotomy had a medium effect on infant gastroesophageal reflux severity at 1-week follow-up (SMD -0.63 [CI: -0.95, -0.31; P = 0.008]), with continued improvement at 1 month (SMD -0.41 [CI: -0.78, -0.05; P = 0.04]). From LATCH scores, breastfeeding quality improved after 5-7 days by a large SMD of 1.28 (CI: 0.56, 2.00; P = 0.01). CONCLUSIONS: Providers should offer frenotomy to improve outcomes in dyads with ankyloglossia-associated breastfeeding difficulties. PROTOCOL REGISTRATION: PROSPERO identifier CRD42022303838 . IMPACT: This systematic review and meta-analysis showed that breastfeeding self-efficacy, maternal pain, infant latch, and infant gastroesophageal reflux significantly improve after frenotomy in mother-infant dyads with breastfeeding difficulties and ankyloglossia. Providers should offer frenotomy to improve breastfeeding outcomes in symptomatic mother-infant dyads who face challenges associated with ankyloglossia.

Severity and prevalence of ankyloglossia-associated breastfeeding symptoms: A systematic review and meta-analysis.

AIM: To evaluate breastfeeding symptoms associated with ankyloglossia/tongue-tie. METHODS: Databases included PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar. Eligible studies reported baseline breastfeeding symptoms/severity from tongue-tied infants. Two reviewers independently screened studies, extracted data, and assessed quality. Low-quality studies were excluded. Main outcomes were weighted mean severity scores for dyads with ankyloglossia relative to reference values for successful breastfeeding. Meta-analyses used inverse-variance-weighted random-effects models. RESULTS: Of 1328 screened studies, 39 were included (5730 infants with ankyloglossia). The mean LATCH score for patients with untreated ankyloglossia, 7.1 (95% CI: 6.7-7.4), was significantly below the good-breastfeeding threshold. The mean Infant Breastfeeding Assessment Tool score, 10.0 (8.2-11.7), was not significantly below the good-breastfeeding threshold. The mean Infant-Gastroesophageal Reflux Questionnaire-Revised score, 18.2 (10.5-26.0), was consistent with gastroesophageal reflux disease. The mean Breastfeeding Self-Efficacy Scale-Short Form score, 43.7 (39.3-48.1), indicated significant risk of cessation of exclusive breastfeeding within 1-3 months. Mean nipple pain was 4.9 (4.1-5.7) on a 0-10 scale, greater than typical scores for breastfeeding mothers without nipple damage. Total prevalence of breastfeeding difficulties was 49.3% (95% CI: 47.3-51.4%). Early, undesired weaning occurred in 20.3% (18.5-22.2%) of cases before intervention. CONCLUSION: Ankyloglossia is adversely associated with breastfeeding success and maternal well-being.

The utility of preoperative echocardiography in pediatric obstructive sleep apnea.

PURPOSE: The purpose of this study was to determine the associations between cardiac function and postoperative adverse events in pediatric patients with obstructive sleep apnea (OSA). METHODS: Patients between birth and 18 years of age diagnosed with OSA between January 1, 2015, and December 31, 2018, who underwent echocardiographic evaluation within 6 months of surgery at a tertiary care children's hospital were evaluated. Exclusion criteria included history of neuromuscular disorders, tracheostomy placement, or a predominance of central apneic events recorded during polysomnography (PSG). Patients were grouped by OSA severity. Chi-squared analysis and logistic regression were utilized to determine associations between demographic characteristics, OSA severity, preoperative echocardiographic abnormalities, and postoperative adverse events. RESULTS: One hundred ten children met inclusion criteria for the study, including 22 with mild OSA, 22 with moderate OSA, and 66 with severe OSA. Race and the presence of congenital heart disease (CHD) were significantly associated with differences in OSA severity. Echocardiographic abnormalities were found in 45 patients, but exclusion of patients with CHD revealed no significant associations with differences in OSA severity. Postoperative adverse events were identified in 18 (16%) patients, and only O2 saturation nadir was found to be a significant predictor of these complications. CONCLUSION: Preoperative echocardiogram abnormalities are not commonly found in children with OSA and presence of abnormalities does not predict postoperative adverse events. O2 saturation nadir measured on preoperative PSG is a significant predictor of postoperative adverse events and should be examined as a clinical indicator of OSA severity.

Bullying, Peer Victimization, and Quality of Life in Pediatric Hearing Loss Patients: A Pilot Study.

OBJECTIVE: The primary objective of this pilot study is to describe the impacts of bullying and peer victimization (BPV) in children with hearing loss. STUDY DESIGN: Prospective clinical survey study. METHODS: This pilot study enrolled children between 8 and 18 years who were administered validated surveys at an outpatient clinic between July 2020 and March 2022. Surveys included health-related quality of life questionnaires (PedsQL and EQ-5D-Y), along with bullying and peer victimization questionnaires ("My Life in School" and the multidimensional peer victimization scale). Responses were scored with multivariate analysis. Clinical histories and active ICD-10 codes were also collected. RESULTS: About 105 patients were recruited with a mean age of 13.1 years (SD = 3.15) and hearing loss (n = 30) among the top otolaryngological diagnoses. When surveying patients with hearing loss, 50.0% (n = 15) actively used a hearing aid device. Children (ages 8-12 years) with hearing loss reported a significantly lower psychosocial health-related quality of life than their peers without hearing loss (P = .007), though this was not the case for adolescents (ages 13-18 years) with hearing loss (P = .099). These trends did not change significantly before or after students resumed in-person classes. Children who wore hearing aids did not report a different BPV level than their peers. CONCLUSION: In this small sample of school-aged children, any hearing loss, even with mild severity, was associated with diminished health-related quality of life; however, this was unrelated to hearing aid use. Wearing a hearing aid did not appear to be linked to higher bullying and peer victimization rates. Along with further studies on BPV with larger sample sizes, the findings in this study may help physicians counsel parents and children on the psychosocial aspects of hearing loss treatment and guide care decisions. LEVEL OF EVIDENCE: 3.

Neuropathological features of pediatric laryngomalacia.

OBJECTIVE: Laryngomalacia is the most common pediatric laryngeal anomaly. The pathophysiology of laryngomalacia is not well defined; the leading hypothesis suggests weak laryngeal tone and neuromuscular discoordination. Only a few studies explored the histopathology of the laryngeal submucosal nerves, with reported nerve hypertrophy. Our study aims to describe the histopathology of submucosal nerves in specimens obtained from children with severe laryngomalacia compared to pediatric cadaveric controls. STUDY DESIGN: Prospective study. SETTINGS: Tertiary care children's hospital. METHODS: Histologic and immunohistochemical sections of supraglottic tissue from 26 children with severe laryngomalacia and six pediatric autopsies were digitally scanned and assessed with image analysis software (QuPath), resulting in the identification and measurement of 4561 peripheral nerves and over 100,000 foci of neurofilaments. RESULTS: Chronic inflammation was noted in all patients. Eosinophils were rare. The mean nerve area and perimeter were significantly smaller for patients with laryngomalacia compared to the control group (1594.0 ± 593.2 µm^2 vs. 2612.1 ± 2824.0 µm^2, p < 0.0001, and 158.8 ± 30.3 µm vs. 217.6 ± 165.0 µm, p < 0.0001). Nerve-per-area unit was significantly greater for patients with laryngomalacia compared to controls (1.39E-05 vs. 6.19 E-06, p = 0.009). The mean area and the number of neurofilaments per total nerve area were similar. Immunohistochemistry for calretinin, a marker for intestinal ganglion cells in Hirschsprung disease, was absent from all specimens. CONCLUSIONS: This series includes a comparison of all identifiable nerve fibers obtained from children with severe laryngomalacia and shows that the mucosal nerves are smaller on average than controls. These findings fail to provide support for significant morphologic peripheral nerve pathology in laryngomalacia.

Intraoperative and postoperative findings in children with myringotomy tubes (MT) undergoing cochlear implantation (CI).

OBJECTIVE: To evaluate and compare children undergoing cochlear implantation (CI) with myringotomy tubes (MT) placed preoperatively or intraoperatively to those without MT . METHODS: This was a retrospective review of pediatric patients undergoing CI between 2015 to 2020 at a tertiary care pediatric hospital. CI patients with and without MT were reviewed for the following outcomes: intraoperative findings, intraoperative and postoperative complications, and surgical time. Descriptive and bivariable statistical analysis was performed. RESULTS: 192 cochlear implant surgeries were included: 116 without MT tubes and 76 with a history of MT. Twenty-six patients had MT present at the time of CI surgery. No statistical difference existed between patients with MT (CI + MT group) and those without MT (CI - MT group) with regard to intraoperative complications (P = 0.760) and intraoperative findings (P = 0.545). MT association with total post-operative complications (GEE) showed no statistical significance (OR 2.45, 95% CI 0.83-7.22, P-value 0.105). CI + MT patients were significantly more likely to have inflamed middle ear mucosa at time of surgery (P = 0.003). CI + MT patients did not have a longer length of surgery compared to the CI - MT group (3.47 h vs 3.3 h, respectively, P = 0.342). CONCLUSION: Our data confirms it is safe to perform CI in ears with myringotomy tubes, although the surgeon should be aware of possibly encountering increased middle ear inflammation during the surgery.

Congenital Cytomegalovirus Infection and Hearing Outcomes in Twins: A Systematic Review of Reported Cases.

OBJECTIVE: Congenital cytomegalovirus infection is the leading nonhereditary cause of pediatric sensorineural hearing loss. This systematic review evaluated infection concordance and comparative hearing abilities in twins/multiple births to model infection patterns. DATABASES REVIEWED: PubMed, Embase, Web of Science, and Google Scholar. METHODS: Studies that reported hearing outcomes of congenital cytomegalovirus infection in at least one multiple birth were eligible. Concordant infections (both twins) and discordant infections (single twin) were included. Multiple reviewers performed data extraction and quality assessment. Analyses involved relative risk of infection concordance by zygosity and chorionicity and odds of hearing loss by infection concordance. Hearing outcomes were compared between siblings. RESULTS: Of 247 studies screened, 31 were included (74.2% high quality). The review captured 40 eligible multiple births. Among infected patients, 42.9% (95% confidence interval, 31.2-55.2%) demonstrated hearing loss. All uninfected twins had normal hearing. Most infections were concordant, and infected patients experienced 4.11 (1.18-14.36) times greater odds of hearing loss if their twin was also infected ( p = .02). Yet siblings' hearing outcomes diverged in over 40% of concordant cases. If either twin is infected, infection risk in the second twin is 3.25 (1.83-5.79) times greater in monozygotic than dizygotic twins and 2.50 (1.61-3.88) times greater in monochorionic than dichorionic twins (both p < .001). We describe a case from our practice. CONCLUSION: Congenital cytomegalovirus infection patterns and hearing outcomes can vary widely even within a shared fetal and postnatal environment. Suspected infection in a twin indicates that both should receive testing and continued monitoring for late-onset sequelae.

The Impact of Ankyloglossia Beyond Breastfeeding: A Scoping Review of Potential Symptoms.

OBJECTIVE: The purpose of this study was to evaluate the spectrum of pediatric quality-of-life sequelae associated with ankyloglossia that may affect children who do not undergo tongue-tie release (frenotomy) during infancy. DATA SOURCES: This study contains data from PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar (1961-January 2023). REVIEW METHOD: The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews reporting guidelines. Experimental and observational studies were eligible if they reported baseline outcomes associated with ankyloglossia in children above a year of age. Two reviewers independently screened studies, extracted data, and assessed quality. Low-quality studies were excluded. CONCLUSIONS: Twenty-six of 1,568 screened studies (> 1,228 patients) were included. Six studies were high quality and 20 were medium quality. Studies identified various symptoms that may be partially attributable to ankyloglossia after infancy, including speech/articulation difficulties, eating difficulties, dysphagia, sleep-disordered breathing symptoms, dental malocclusion, and social embarrassment such as oral hygiene issues. Multiple comparative studies found associations between ankyloglossia and risk factors for obstructive sleep apnea; a randomized controlled trial found that frenotomy may attenuate apnea severity. Ankyloglossia may also promote dental crowding. IMPLICATIONS FOR PRACTICE: Ankyloglossia may be associated with myriad effects on children's quality of life that extend beyond breastfeeding, but current data regarding the impact are inconclusive. This review provides a map of symptoms that providers may want to evaluate as we continue to debate the decision to proceed with frenotomy or nonsurgical therapies in children with ankyloglossia. A continuing need exists for controlled efficacy research on frenotomy for symptoms in older children and on possible longitudinal benefits of early frenotomy for maxillofacial development. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.23900199.

Pediatric cochlear implants and myringotomy tubes: a systematic review.

OBJECTIVE: To evaluate the intraoperative findings and post-operative complications associated with patients who have current or history of myringotomy tubes undergoing a cochlear implantation. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were followed. Studies from Pubmed, Cochrane, Embase, Web of Science, and Scopus were included. Studies were independently screened and analyzed by 2 reviewers. Publications assessing pediatric patients with current or history of myringotomy tubes at time of cochlear implantation were reviewed. Discrepancies were resolved by a team of 4 reviewers. RESULTS: 172 studies were screened, 15 met inclusion criteria, and 12 were incorporated into the study. All 12 of the studies were retrospective cohort studies. Meta-analysis showed no significant relationship between intraoperative findings at time of cochlear implantation (presence of effusion, granulation tissue, edematous middle ear tissue) and myringotomy tube insertion (p = 0.63). Additionally, there was no significant relationship between current or history of myringotomy tube and acute otitis media episode after CI (p = 0.25). CONCLUSION: There was no association noted between perioperative outcomes of pediatric cochlear implantation and myringotomy tube. This information will be helpful for surgeons planning to perform cochlear implantation in the pediatric population.

Opioid stewardship and perioperative management of pediatric tympanoplasty.

OBJECTIVE: To provide insight into the intraoperative management, admission course, pain management, and graft success of microscope- and endoscope-assisted tympanoplasty. STUDY DESIGN: Retrospective Chart Review. METHODS: This study included children 18 years and younger who underwent ambulatory tympanoplasty at a tertiary pediatric hospital between January 2018 and December 2020. Medical records were reviewed and information about intraoperative factors, surgical approach, laterality, complications, and post-operative perforation closure success rates was collected. Multivariate analysis was performed to compare and contrast the two surgical approaches. RESULTS: The review included 321 pediatric patients who underwent a tympanoplasty. Endoscopic tympanoplasty accounted for 17.4%, while microscopic tympanoplasty accounted for 82.6%. In both approaches, the rate of intraoperative complications, postoperative complications, audiological improvements, and perforation closure success rates were statistically similar. However, patients who underwent endoscopic tympanoplasty were 3.96 times less likely to require opioids in the post-anesthesia care unit (PACU) and had a shorter post-operative admission length. This pattern emerged regardless of the type of graft used. Obtaining an autograft was not associated with a higher opioid requirement in the PACU. CONCLUSION: While both approaches are viable, our findings demonstrate the reduced need for opioids with similar success rates following an endoscopic tympanoplasty. Ultimately, the trade-off for the minimally invasive endoscopic approach appears to be a less painful experience for the child while promoting clinically appropriate opioid stewardship in the perioperative setting.

The qualitative experiences of otolaryngologists with genetic services in pediatric hearing loss evaluation.

Genetic testing is one of the most high-yield diagnostic tests in the evaluation of pediatric sensorineural (SNHL) hearing loss, leading to a genetic diagnosis in 40-65% of patients. Previous research has focused on the utility of genetic testing in pediatric SNHL and otolaryngologists' general understanding of genetics. This qualitative study examines otolaryngologists' perceptions about facilitators and barriers when ordering genetic testing in the workup of pediatric hearing loss. Potential solutions for overcoming barriers are also explored. Eleven (N = 11) semi-structured interviews were conducted with otolaryngologists in the USA. Most participants were currently practicing in a southern, academic, urban setting and had completed a pediatric otolaryngology fellowship. Insurance was one of the main barriers to testing, and increased genetics provider accessibility was the most frequently cited solution to increase utilization of genetic services. Difficulty acquiring insurance coverage and unfamiliarity with the genetic testing process were the most common reasons otolaryngologists referred patients to genetics clinics for genetic testing, as opposed to ordering testing themselves. This study suggests that otolaryngologists recognize the importance and utility of genetic testing, but a lack of genetics-specific skills, knowledge, and resources makes it difficult for them to facilitate testing. Multidisciplinary hearing loss clinics that include genetics providers may increase the overall accessibility of genetic services.

Measuring the Impact of a Delay in Care on Pediatric Otolaryngologic Surgery Completion.

Objective: To determine if postponement of elective pediatric otorhinolaryngology surgeries results in a change in overall healthcare utilization and if there is any commensurate impact on disease progression. Methods: We identified patients ≤18 years of age whose surgeries were postponed at the onset of the COVID-19 pandemic-related shutdown. We then tracked patients' rate of and patterns of rescheduling surgery. Surveys were also sent to caregivers to better characterize his/her decision regarding moving forward with his/her child's surgery during COVID-19. Results: A total of 1915 pediatric patients had elective surgeries canceled, of which 992 (51.8%) were rescheduled within 4 months. No difference in rates of rescheduling was identified based on race or ethnicity. Patients who were scheduled for tonsillectomies and/or adenoidectomies were 1.22 times more likely to reschedule compared to those patients with other planned procedures (CI: 1.02-1.46). A total of 95 caregivers at two hospitals completed surveys: 44 (47.4%) rescheduled their child's surgery. Most caregivers who rescheduled were concerned their child's disease could impact their future (n = 14, 32%). Conclusions: Just over half of patients who had pediatric otolaryngologic surgery canceled during a period of social distancing went on to have surgery within a 4-month timeframe. This reflects the dependence of pediatric otolaryngologic surgery on environmental exposures and may represent a potential target for prevention and management of some pediatric otolaryngology diseases.

Radiologic Findings in Pediatric Sudden Sensorineural Hearing Loss.

OBJECTIVE: Pediatric sudden sensorineural hearing loss (pSSNHL) is a rare phenomenon. There is currently no consensus on the role of imaging in the work-up for this patient population. We aim to evaluate the efficacy of magnetic resonance imaging (MRI) and high-resolution computed tomography (CT) studies in determining the etiology of pSSNHL. STUDY DESIGN: Retrospective case review. SETTING: Tertiary Hospital and Ambulatory Otolaryngology Clinic. PATIENTS: Patients ≤18 years of age with sudden sensorineural hearing loss (SSNHL) and who had either MRI or CT imaging between January 2010 and May 2019 were included. INTERVENTION: Diagnostic imaging. MAIN OUTCOME MEASURES: Clinical characteristics and radiology impressions. RESULTS: A total of 11 patients were identified, and 10 had unilateral SSNHL. MRI was performed on all patients, five patients had additional CT imaging. Abnormal imaging findings relevant to SSNHL were observed in five patients (45.5%), which included enlarged endolymphatic duct and sac, labyrinthine ossification, apical petrositis, hypoplastic cochlear nerve, and arachnoid cyst in the internal auditory canal; one patient had unrelated findings (enlarged pituitary gland), all remaining imaging studies were normal. CONCLUSION: In our cohort, we found a higher imaging yield on pSSNHL than what has been reported for adult populations, indicating that the use of imaging in the diagnostic work-up is especially important in children.

Echocardiographic findings in children with obstructive sleep apnea: A systematic review.

OBJECTIVE: To systematically review the incidence of cardiac abnormalities in pediatric patients with obstructive sleep apnea (OSA) in order to assess the utility of preoperative echocardiographic evaluation for patients undergoing surgery. STUDY DESIGN: A systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Data sources were searched from January 1, 1980 to March 25, 2020. Studies that examined echocardiographic findings and polysomnographic data for patients between birth and 18 years of age with polysomnogram-confirmed OSA were included. Studies that included patients with preexisting cardiac, metabolic, or hematologic disorders that could affect hemodynamic parameters were excluded. Included studies were assessed for quality and risk of bias using the U.S. National Institute of Health's Quality Assessment Tools. RESULTS: Thirteen studies met inclusion criteria. Five studies were categorized as high risk of bias, three were categorized as medium risk, and five were categorized as low risk. Study design varied considerably between studies, including heterogeneous classifications of OSA severity, discrepant reporting of echocardiographic parameters, and differing estimations of pulmonary hemodynamics. Significant disagreement regarding the effect of OSA on cardiac function was found between all included studies. CONCLUSION: Data demonstrating significant associations between OSA and cardiac abnormalities in children is inconsistent. Echocardiographic abnormalities are inconsistently found and, when present, their clinical significance remains poorly understood. Assessing the utility of preoperative echocardiography in children with OSA requires further investigation with prospective studies utilizing standardized classifications of OSA severity, reporting of echocardiographic parameters, and estimations of pulmonary hemodynamics.

Risk factors for return visits in children discharged with tracheostomy.

STUDY OBJECTIVES: To determine associations between demographic and clinical characteristics and rate of unplanned returns to system (RTS) in pediatric patients discharged with tracheostomy. METHODS: Medical records were examined for pediatric patients discharged after tracheostomy placement between January 1, 2011 and December 31, 2015. Exclusion criteria included death or decannulation prior to discharge and lack of follow-up through 180 days post-discharge. Readmissions were grouped by time interval after discharge (within 30 days or within 31-180 days). Chi-squared analysis and Fisher's Exact Test were utilized to determine associations between patient characteristics, rate and frequency of RTS, and type of admission (Emergency Department [ED] or inpatient [IP]). RESULTS: One hundred twenty-one patients were eligible for the study, and 80 (66.1 %) had an unanticipated RTS during the follow-up period. Patients with early RTS had a higher total number of RTS. Patients with two or more RTS were more likely to be younger, while patients with five or more RTS were more likely to have greater organ system involvement and cardiovascular (CV) disease in particular. Patients presenting with GI diagnoses were more likely to be discharged from the ED. The rate of RTS remained constant throughout the time period examined. CONCLUSION: Pediatric patients discharged with tracheostomy are medically complex and at high risk of RTS, especially for respiratory and GI problems. This risk does not decrease after the initial post-discharge period and long-term follow-up is warranted. Younger patients and patients with history of early RTS are at highest risk for repeat RTS and should be identified for closer outpatient care.

Bullying and Children who are Deaf or Hard-of-hearing: A Scoping Review.

OBJECTIVE/HYPOTHESIS: The goal of this scoping review is to evaluate and synthesize the published research regarding bullying and children who are deaf or hard-of-hearing (DHH). STUDY DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR) statement was used as the guideline for conducting this review. METHODS: This review included studies assessing pediatric (0-21 years) DHH children. Seventy records underwent the initial title-abstract screening, 33 underwent full-text review, and 23 studies met inclusion criteria. During the data extraction process, an additional six were excluded, resulting in a total of 17 evaluated studies. RESULTS: Of the 17 studies assessed, nine compared peer victimization of DHH children and their hearing peers. Of those, seven studies reported that hearing loss (HL) is significantly associated with increased victimization. Two studies found that HL is significantly associated with decreased bullying perpetration. Notably, bullying in DHH children was not associated with a visible sign of disability, such as a hearing assistive device. Rather, variables such as educational setting, parental, and peer support are more likely to mediate bullying in this population. CONCLUSIONS: DHH children have a higher risk of peer victimization and may bully others less often than their hearing peers. Studies described the health consequences of bullying in children who are DHH, including sleep issues and anxiety. These consequences may have implications for the patients' overall HL management. Additional research regarding bullying interventions and prevention in this population should be conducted. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1884-1892, 2021.

The utility of handheld ultrasound as a point-of-care screening tool to assess vocal fold impairment following congenital heart surgery.

INTRODUCTION: Vocal fold motion impairment (VFMI) is a known potential complication of congenital heart surgery (CHS). Flexible nasolaryngoscopy (FNL) is the gold standard for evaluation of vocal fold movement but has risks, including epistaxis, desaturation, and changes in heart rate. Laryngeal ultrasound (LUS) has begun to emerge as a diagnostic tool and has been shown to have high accuracy in the evaluation of VFMI. We sought to assess the utility of hand-held LUS as a point-of-care screening tool to assess VFMI in pediatric patients following congenital heart surgery. METHODS: Using a prospective cohort design, children under 18 years who were undergoing congenital heart surgery at a tertiary care pediatric hospital were enrolled. All patients underwent postoperative LUS and FNL. All studies were reviewed by two otolaryngology reviewers blinded to the clinical diagnosis. Higher quality studies were reviewed by two cardiology reviewers also blinded to the clinical diagnosis. Accuracy and inter-rater reliability were calculated. RESULTS: Sixty-two children were screened. Fourteen children with VFMI were identified via FNL. When comparing LUS and FNL, both individual accuracy (90.3% and 75.8%) and interrater agreement (79% overall, 96% for high quality videos) were high for the otolaryngology reviewers. The cardiology reviewers were able to obtain 100% accuracy for high quality videos. CONCLUSION: Handheld LUS has utility as a point-of-care screening tool to assess VFMI. This may have benefit in low-resource settings, for universal screening in cardiac intensive care units, or in settings where otolaryngology consultation may be difficult to obtain.

Development and Validation of a Preference-Based Glaucoma Utility Instrument Using Discrete Choice Experiment.

IMPORTANCE: A glaucoma-specific instrument for estimating utilities across the spectrum of glaucoma severity is currently lacking, hindering the assessment of the cost-effectiveness of glaucoma treatments. OBJECTIVE: To develop and validate the preference-based Glaucoma Utility Instrument (Glau-U) and to ascertain the association between Glau-U utilities and severity of glaucoma and vision impairment. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted in 2 stages at the Singapore National Eye Centre glaucoma clinics. Stage 1 focused on the identification and pretesting of the Glau-U attributes and was carried out between June 2009 and May 2016. Stage 2 involved the development and administration of the discrete choice experiment (DCE) survey and tasks and was conducted between May 7, 2018, and December 11, 2019. Stage 2 participants were English- or Mandarin-speaking Singaporean citizens or permanent residents of Chinese, Malay, or Indian ethnicity who were 40 years or older and had a clinical diagnosis of glaucoma in at least 1 eye. EXPOSURES: Glau-U comprised 6 quality-of-life attributes: activities of daily living, lighting and glare, movement, eye discomfort, other effects of glaucoma, and social and emotional effects. The descriptions or response options for these attributes were no difficulty or never, some difficulty or sometimes, or severe difficulty or often. MAIN OUTCOMES AND MEASURES: Utility weights for Glau-U were developed using a DCE questionnaire, which was interviewer administered to participants. Mixed logit regression determined utility weights for each health state. Glau-U utility weights across better- or worse-eye glaucoma and vision impairment severity were calculated using 1-way analysis of variance. Correlations between Glau-U utilities and better- or worse-eye visual fields and EuroQol 5-Dimension utilities were ascertained to assess convergent and divergent validity. RESULTS: Of the 304 participants (mean [SD] age, 68.3 [8.7] years; 182 men [59.9%]), 281 (92.4%) had no vision impairment in the better eye, 13 (4.3%) had mild impairment, and 10 (3.3%) had moderate to severe vision impairment. Mean (SD) Glau-U utilities decreased as better-eye glaucoma severity increased (none: 0.73 [0.21]; mild: 0.66 [0.21]; moderate: 0.66 [0.20]; severe: 0.60 [0.28]; and advanced or end-stage: 0.22 [0.38]; P < .001), representing reductions of 20.7% to 76.1% in quality-adjusted life-years compared with a health state that included preperimetric glaucoma. Mean (SD) Glau-U utilities also decreased as better-eye vision impairment worsened from 0.67 (0.23) for none to 0.58 (0.32) for mild to 0.46 (0.29) for moderate to severe vision impairment. Glau-U utilities demonstrated moderate correlations with better-eye (r = 0.34; P < .001) and worse-eye (r = 0.33; P < .001) mean deviation scores and low correlations with EuroQol 5-Dimension utilities (r = 0.22; P < .001), supporting convergent and divergent validity. CONCLUSIONS AND RELEVANCE: Use of Glau-U revealed large decrements in utility that were associated with late-stage glaucoma, suggesting that this new instrument may be useful for cost-effectiveness analyses of interventions and informing resource allocation policies for glaucoma and vision loss.

Rapid telemedicine implementation in the context of the COVID-19 pandemic in an academic pediatric otolaryngology practice.

OBJECTIVE: To describe the implementation of telemedicine in a pediatric otolaryngology practice during the coronavirus disease 2019 (COVID-19) global pandemic. METHODS: A descriptive paper documenting the development and application of telemedicine in a tertiary academic pediatric otolaryngology practice. RESULTS: A total of 51 established patients were seen via telemedicine within the first 2 weeks of telemedicine implementation. Seven (7) patients were no shows to the appointment. The median patient age was 5 years old, with 55% male patients. Common diagnoses for the visits included sleep disordered breathing/obstructive sleep apnea (25%) and hearing loss (19.64%). Over half (50.98%) of visits were billed at level 4 visit code. DISCUSSION: The majority (88%) of visits during the first 2 weeks of telemedicine implementation in our practice were completed successfully. Reasons that patients did not schedule telemedicine appointments included preference for in person appointments, and lack of adequate device at home to complete telemedicine visit. Limitations to our telemedicine practice included offering telemedicine only to patients who had home internet service, were established patients, and English-speaking. Trainees were not involved in this initial implementation of telemedicine. CONCLUSIONS: COVID-19 has driven the rapid adoption of telemedicine in outpatient medicine. Our group was able to institute an effective telemedicine practice during this time.

Validation of a New Diabetic Retinopathy Knowledge and Attitudes Questionnaire in People with Diabetic Retinopathy and Diabetic Macular Edema.

Purpose: A validated questionnaire assessing diabetic retinopathy (DR)- and diabetic macular edema (DME)-related knowledge (K) and attitudes (A) is lacking. We developed and validated the Diabetic Retinopathy Knowledge and Attitudes (DRKA) questionnaire and explored the association between K and A and the self-reported difficulty accessing DR-related information (hereafter referred to as Access). Methods: In this mixed-methods study, eight focus groups with 36 people with DR or DME (mean age, 60.1 ± 8.0 years; 53% male) were conducted to develop content (phase 1). In phase 2, we conducted 10 cognitive interviews to refine item phrasing. In phase 3, we administered 28-item K and nine-item A pilot questionnaires to 200 purposively recruited DR/DME patients (mean age, 59.0 ± 10.6 years; 59% male). The psychometric properties of DRKA were assessed using Rasch and classical methods. The association between K and A and DR-related Access was assessed using univariable linear regression of mean K/A scores against Access. Results: Following Rasch-guided amendments, the final 22-item K and nine-item A scales demonstrated adequate psychometric properties, although precision remained borderline. The scales displayed excellent discriminant validity, with K/A scores increasing as education level increased. Compared to those with low scores, those with high K/A scores were more likely to report better access to DR-related information, with K scores of 0.99 ± 0.86 for no difficulty; 0.79 ± 1.05 for a little difficulty; and 0.24 ± 0.85 for moderate or worse difficulty (P < 0.001). Conclusions: The psychometrically robust 31-item DRKA questionnaire can measure DR- and DME-related knowledge and attitudes. Translational Relevance: The DRKA questionnaire may be useful for interventions to improve DR-related knowledge and attitudes and, in turn, optimize health behaviors and health literacy.