Interdisciplinary assessment of tracheostomy care knowledge: An opportunity for quality improvement.

PURPOSE: A 2013 AAOHNS consensus statement called for reduced variation in tracheostomy care. Multidisciplinary approaches and standardized protocols have been shown to improve tracheostomy outcomes. This study aims to identify inconsistencies in knowledge in order to design standardized education targeting these areas to improve quality of care. MATERIALS AND METHODS: An online, multiple-choice tracheostomy care knowledge assessment was administered to nurses and respiratory therapists in ICUs, stepdown units, and regular nursing floors, as well as residents in otolaryngology, general surgery, and thoracic surgery. The survey was administered and data were recorded using the Select Survey online platform. RESULTS: 173 nurses, respiratory therapists, and residents participated in this study. Over 75 % of respondents identified correct answers to questions addressing basic tracheostomy care, such as suctioning and humidification. Significant variation was observed in identification and management of tracheostomy emergencies, and appropriate use of speaking valves. Only 47 % of all respondents identified all potential signs of tracheostomy tube displacement. Respiratory therapists with over 20 years of experience (p = 0.001), were more likely to answer correctly than those with less. Nurses were less likely than respiratory therapists to have received standardized tracheostomy education (p = 0.006) and were less likely than others to choose the appropriate scenario for speaking valve use (p = 0.042), highlighting the need for interdisciplinary education. CONCLUSIONS: An interdisciplinary assessment of tracheostomy care knowledge demonstrates variation, especially in identification and management of tracheostomy emergencies and appropriate use of speaking valves. Design of a standardized educational program targeting these areas is underway.

Utility of the finance-electronic medical record digital dashboard in pediatric otolaryngology.

BACKGROUND: The time and cost of data collection via chart review of the electronic medical record (EMR) is a research barrier. This study describes the development of a digital dashboard conjoining EMR and finance data and its application in a pediatric otolaryngology practice. METHODS: The dashboard creates a common language crosswalk between surgeries via the EMR, financial data, and national Vizient database. First, all Otolaryngology procedures billed via ICD-10 or CPT codes were categorized into Procedure Groups, which constitute the common language that links all data sources. The joined dataset was inputted into a Tableau workbook supporting dynamic filtering and custom real-time analysis. RESULTS: The dashboard includes 84 Procedure Groups within Otolaryngology. Examples for pediatrics include Sistrunk procedure and supraglottoplasty. User-friendly dynamic filtering by Procedure Group, surgery date range, age, insurance, hospital, surgeon, and discharge status were developed. Outcomes include length of stay, telephone callbacks, postoperative hemorrhage, reoperations, return to Emergency Department, readmissions, and mortality. National comparisons can be analyzed via embedded Vizient data. The usability of the dashboard was tested by evaluating pediatric tonsillectomy outcomes, which revealed a significantly higher rate of postoperative hemorrhages and reoperations during the COVID-19 pandemic. CONCLUSION: The hybrid finance/EMR dashboard creates a crosswalk between data sources and shows utility for use in evaluating patient outcomes via real-time data analysis and dynamic filtering. This innovative dashboard expedites data extraction, promoting efficient implementation of quality improvement initiatives and surgical outcomes research.

Auditory testing outcomes with hearing aids in patients with auditory neuropathy spectrum disorder.

OBJECTIVE: The objective of this study is to evaluate the audiologic outcomes with hearing aids in pediatric patients with auditory neuropathy spectrum disorder (ANSD) using the Infant Toddler-Meaningful Auditory Integration Scale (IT-MAIS), and the Ling 6 Sound Test (Ling 6). STUDY DESIGN: Case series. SETTING: Single tertiary care academic medical center. SUBJECTS AND METHODS: All pediatric patients with a confirmed diagnosis of ANSD on Auditory Brainstem Response (ABR) testing who presented to a single tertiary medical center between September 2008 and September 2018 were included. Only patients that underwent Infant Toddler-Meaningful Auditory Integration Scale (IT-MAIS) and/or Ling 6 Sound Test (Ling 6) were included in the study. Audiologic testing performed after cochlear implantation was excluded. RESULTS: 60 pediatric patients with ANSD were analyzed. There were 10 patients included in the study with documented hearing aid use who underwent IT-MAIS and/or Ling 6 testing. Average IT-MAIS score improved by 20.4% after initial or extended trial of amplification. Similarly, average Ling 6 score improved from 3.6 to 4.8 after initial or extended trial of amplification. The four patients who did not receive amplification had higher average IT-MAIS and Ling 6 scores. CONCLUSION: In most children with ANSD, IT-MAIS and Ling 6 Sound Test scores improved with initial hearing aid use and over time with extended hearing aid use. Long-term prospective, multi-institutional studies are needed to determine the impact of the natural history of ANSD, comorbidities, and socioeconomic variables on auditory function testing results in children with ANSD using hearing aids.

Spontaneous cervical chyle fistula: A case report.

BACKGROUND: Cervical chylous fistulae are rare complications usually occurring from iatrogenic injury to the thoracic duct. There have been no reported cases of spontaneous chyle leaks in surgical naïve necks. METHODS: Case report. RESULTS: A 50 year-old female presented with progressive left neck swelling without fever, dyspnea, or dysphagia. Imaging demonstrated extensive infiltrative changes of the left neck with retropharyngeal fluid extending into strap musculature and the mediastinum. Flexible laryngoscopy revealed posterior pharyngeal wall edema. Differential diagnosis included abscess versus necrotizing fasciitis. Broad-spectrum antibiotics were initiated and she was taken to the OR for neck exploration. Intra-operatively, milky fluid was present around the carotid sheath and in the retropharyngeal space. Fluid analysis demonstrated chylomicrons and triglycerides >2400 mg/dL. Repeat imaging of the neck, chest, and abdomen did not reveal malignancy or obstructive masses. A lymphangiogram showed dilated lymphatic vessels near the cervical thoracic duct. On post-operative day four, the patient was taken back to the OR for thoracic duct ligation and biopsy of nearby tissue. Pathology demonstrated benign lymph nodes with dilated sinusoids. A low-fat diet was started and she was discharged home on hospital day nine. She has followed up regularly with no signs of recurrence. CONCLUSION: A cervical chylous fistula usually results from iatrogenic injury to the thoracic duct. To our knowledge, this is the first reported case of a spontaneous cervical chyle leak.

Non-nuclear estrogen receptor alpha activation in endothelium reduces cardiac ischemia-reperfusion injury in mice.

Steroid hormone receptors including estrogen receptors (ER) classically function as ligand-regulated transcription factors. However, estrogens also elicit cellular effects through binding to extra-nuclear ER (ERα, ERß, and G protein-coupled ER or GPER) that are coupled to kinases. How extra-nuclear ER actions impact cardiac ischemia-reperfusion (I/R) injury is unknown. We treated ovariectomized wild-type female mice with estradiol or an estrogen-dendrimer conjugate (EDC), which selectively activates extra-nuclear ER, or vehicle interventions for two weeks. I/R injury was then evaluated in isolated Langendorff perfused hearts. Two weeks of treatment with estradiol significantly decreased infarct size and improved post-ischemic contractile function. Similarly, EDC treatment significantly decreased infarct size and increased post-ischemic functional recovery compared to vehicle-treated hearts. EDC also caused an increase in myocardial protein S-nitrosylation, consistent with previous studies showing a role for this post-translational modification in cardioprotection. In further support of a role for S-nitrosylation, inhibition of nitric oxide synthase, but not soluble guanylyl cyclase blocked the EDC mediated protection. The administration of ICI182,780, which is an agonist of G-protein coupled estrogen receptor (GPER) and an antagonist of ERα and ERß, did not result in protection; however, ICI182,780 significantly blocked EDC-mediated cardioprotection, indicating participation of ERα and/or ERß. In studies determining the specific ER subtype and cellular target involved, EDC decreased infarct size and improved functional recovery in mice lacking ERα in cardiomyocytes. In contrast, protection was lost in mice deficient in endothelial cell ERα. Thus, extra-nuclear ERα activation in endothelium reduces cardiac I/R injury in mice, and this likely entails increased protein S-nitrosylation. Since EDC does not stimulate uterine growth, in the clinical setting EDC-like compounds may provide myocardial protection without undesired uterotrophic and cancer-promoting effects.

Association of Discharge Location Following Pediatric Tracheostomy with Social Determinants of Health: A National Analysis.

OBJECTIVE: To evaluate the breakdown of discharge locations among pediatric tracheostomy patients and determine the impact of demographic variables and social determinants of health. STUDY DESIGN: Retrospective review of the 2016 and 2019 Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP KID). SETTING: A total of 4000 United States community hospitals, defined as short-term, non-Federal, general, and specialty hospitals. METHODS: ICD-10-PCS, ICD-10 CM codes, and HCUP data elements were selected for patients and variables of interest. Bivariate comparisons were performed using Rao-Scott Chi-square tests; significance levels in post hoc pairwise testing were adjusted using Bonferroni adjustment. Multinomial generalized logistic regression models were used to determine the average annual odds ratio (OR) of 3 dispositions at discharge relative to discharge home for self-care. RESULTS: Patients aged 11-17, patients from large metropolitan areas, and patients of "Other" race have an increased odds of discharge to a short- or long-term care facility (all P < .001). Weekend admissions, nonelective admissions, patients in Northeast hospitals, and patients at urban nonteaching hospitals are also more likely to be discharged to a short- or long-term care facility (all P < .001). Mean and median total costs of admission were $424,387 and $243,479, respectively, with a median total charge of $854,499. CONCLUSION: Among pediatric tracheostomy patients, demographic factors that affect discharge disposition include age, community type, and race, and significant hospital factors include day and type of admission, geographic region, and hospital type. Hospitalizations are associated with high overall costs and charges to the patient, which are increasing over time.

Auditory Outcomes Following Cochlear Implantation in Children with Unilateral Hearing Loss.

OBJECTIVE: Unilateral hearing loss (UHL) in children is associated with speech and language delays. Cochlear implantation (CI) is currently the only rehabilitative option that restores binaural hearing. This study aims to describe auditory outcomes in children who underwent CI for UHL and to determine the association between duration of hearing loss and auditory outcomes. STUDY DESIGN: Retrospective case series. SETTING: Three tertiary-level, academic institutions. PATIENTS: Children <18 years with UHL who underwent CI between 2018 and 2021. INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURES: Speech perception and Speech, Spatial and Qualities of Hearing Scale (SSQ) were assessed postimplantation. Scores >50% on speech perception and SSQ scores >8 points were considered satisfactory. Associations between duration of UHL and implantation age and outcomes were assessed using Spearman's rank correlation. RESULTS: Of the 38 children included, mean age at CI was 7.9 ± 3.2 years and mean UHL duration was 5.0 ± 2.8 years. Mean datalogging was 8.1 ± 3.1 hours/day. Mean auditory testing scores were SSQ, 7.9 ± 1.2; BABY BIO, 68.1 ± 30.2%; CNC, 38.4 ± 28.4%; WIPI, 52.5 ± 23.1%. Scores >50% on CNC testing were achieved by 40% of patients. SSQ scores >8 points were reported by 78% (7/9) of patients. There were no significant correlations between UHL duration and auditory outcomes. CONCLUSION: Overall, children with UHL who undergo CI can achieve satisfactory speech perception scores and SSQ scores. There were no associations between duration of hearing loss and age at implantation with auditory outcomes. Multiple variables may impact auditory outcomes, including motivation, family support, access to technology, and consistent isolated auditory training postactivation and should be taken into consideration in addition to age at implantation and duration of UHL in determination of CI candidacy.

'Adiposopathy' and cardiovascular disease: the benefits of bariatric surgery.

PURPOSE OF REVIEW: Obesity is an independent risk factor for cardiovascular disease (CVD) and promotes CVD risk factors. Bariatric surgery has gained much favor because it ameliorates CVD. This review examines the current evidence for the mechanism behind this, which is currently thought to occur in part by reduction of adiposopathy, or dysfunctional adipose tissue, through modulation of adipokine secretion. RECENT FINDINGS: Increased visceral fat in obesity leads to adiposopathy, due to the chronic inflammation present in this tissue. Bariatric surgery causes weight loss as well as reduction in insulin resistance, hypertension, dyslipidemia, cardiac hypertrophy, and mortality. It also causes changes in the adipokines adiponectin, leptin, and C-reactive protein, but not in tumor necrosis factor-α. These changes contribute to improved CVD risk, possibly through decrease of chronic inflammation. SUMMARY: The modulations in adipokine secretion that occur after bariatric surgery are involved with reduction in CVD risk factors, CVD, and CV mortality. On the basis of the known anti-inflammatory effects of adiponectin and the pro-inflammatory effects of leptin and CRP, reduction in chronic inflammation associated with less visceral fat after surgery may contribute to the reduction in CVD. This may promote improvement of endothelial dysfunction and insulin resistance. Further work is necessary to explore these relationships.

Voice outcomes following surgical treatment for pediatric vocal fold nodules: A systematic review and meta-analysis.

OBJECTIVES: This study aimed to systematically review the literature to determine outcomes following surgical treatment of pediatric vocal fold nodules. METHODS: Studies with patients ≤18 years with nodules who underwent surgery were reviewed for dysphonia improvement and recurrence in PubMed, EMBASE, Medline, CINAHL, Cochrane, Scopus, and Web of Science databases, searched from inception to November 1, 2022 using PRISMA guidelines. Non-English studies and case reports were excluded. Two evaluators independently reviewed each abstract and article. Heterogeneity and bias across studies were evaluated and meta-analysis was performed. RESULTS: The literature search yielded 655 articles; 145 underwent full-text screening and eight were selected for systematic review and meta-analysis. There were 311 children with nodules, aged 2-18 years, with male-to-female ratio of 3.6:1. There were no surgical complications. Voice therapy was inconsistently reported. Follow-up time ranged from 1 month to 10 years. One study concluded that neither surgery nor voice therapy was effective, while five studies concluded that dysphonia improved with surgery. Voice grading by GRBAS, objective voice measures, and lesion size were improved following surgery, when reported. Meta-analysis of six studies demonstrated improvement in dysphonia in 90% of children post-operatively (95% CI: 74-99%). Meta-analysis of four studies showed that recurrence occurred in 19% of children (95% CI: 13-23%). CONCLUSION: This systematic review suggests possible post-operative improvement in dysphonia for pediatric patients with vocal fold nodules; however, study measures, methods, and surgery utilized were heterogeneous and results should be interpreted cautiously. In order to better understand surgical outcomes, future studies should include standardized definition of nodules and objective measures of voice.

Refractory tympanostomy tube otorrhea: Outcomes with otowick placement.

OBJECTIVE: To evaluate rates of resolution of and antibiotic use in refractory otorrhea (otorrhea ≥2 weeks with no more than 2 days of otorrhea resolution during the episode) with otowick placement in comparison to medical therapy and tube removals with or without replacements. STUDY DESIGN: Retrospective cohort study of pediatric patients with a history of tympanostomy tube placement and refractory otorrhea between 2017 and 2022. SETTING: Cleveland Clinic Foundation (CCF) pediatric otolaryngology group. METHODS: Demographic data (sex, race, and age at tympanostomy tube placement) were collected. Outcome measures included number of oral and topical antibiotic treatments, duration of otorrhea episode, and resolution of otorrhea at 1 and 3 months follow-up. Wilcoxon rank sum and Kruskal-Wallis tests were used to compare number of antibiotics treatments. An ANOVA test and linear regression model using log-transformed data were used to compare duration of otorrhea. Fisher's exact test was used to compare rates of otorrhea recurrence. RESULTS: 70 patients met inclusion criteria: 37 male (52.9%), 33 female (47.1%), with an average age at tube placement of 29.66 months. There was a statistically significant decrease in total duration of otorrhea (in days) with otowicks (17.29 ± 13.13), compared to patients receiving medical therapy (27.09 ± 22.02) and tube removals and replacements (29.63 ± 19.95) (p = 0.025). There was no significant difference between the follow-up rates of resolution at 1 month (p = 1) and 3 months (p = 0.12). CONCLUSION: Otowick use is associated with shorter duration of otorrhea and can be considered as a first-line treatment for refractory otorrhea. Otowicks and medical therapy alone can reduce need for tube removals and the associated risk of anesthesia.

Auditory Outcomes in Children Who Undergo Cochlear Implantation Before 12 Months of Age: A Systematic Review.

OBJECTIVE: To systematically review the literature to determine auditory outcomes of cochlear implantation in children ≤12 months old. DATA SOURCE: PubMed, EMBASE, Medline, CINAHL, Cochrane, Scopus, and Web of Science databases were searched from inception to 9/1/2021 using PRISMA guidelines. REVIEW METHODS: Studies analyzing auditory outcomes after cochlear implantation (CI) in children ≤12 months of age were included. Non-English studies and case reports were excluded. Outcome measures included functional and objective auditory results. Two independent reviewers evaluated each abstract and article. Heterogeneity and bias across studies were evaluated. RESULTS: Of 305 articles identified, 17 met inclusion criteria. There were 642 children ages 2 to 12 months at CI. The most common etiologies of hearing loss were congenital CMV, meningitis, idiopathic hearing loss, and GJB2 mutations and other genetic causes. All studies concluded that early CI was safe. Overall, outcomes improved following early CI: IT-MAIS (9 studies), LittlEARS (4 studies), PTA (3 studies), CAP (3 studies), GASP (3 studies), and LNT (3 studies). Nine studies compared outcomes to an older implantation group (>12 months); of these (n = 450 early CI, n = 1189 late CI), 8 studies showed earlier CI achieved comparable or better auditory outcomes than later implantation, whereas 1 study (n = 120) concluded no differences in speech perception improvement. CONCLUSION: Auditory outcomes were overall improved in children ≤12 months old undergoing CI. Studies that compared early to late CI demonstrated similar or better auditory outcomes in early implantation group. Given the comparable safety profile and critical time period of speech and language acquisition, earlier CI should be considered for infants with hearing loss.

An Analysis of Tracheostomy Complications in Pediatric Patients With Scoliosis.

OBJECTIVES/HYPOTHESIS: To analyze tracheostomy-related complications in pediatric patients with scoliosis. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review of all patients with tracheostomy and scoliosis was performed at a single institution. The charts were reviewed for variables including difficulties with tracheostomy tube changes, poor positioning of tube, abnormal appearance of trachea, and emergency room visits and admissions for complications. Decannulation rates were also identified. RESULTS: About 102 patients met inclusion criteria, 96 (94.1%) had scoliosis involving the thoracic spine, and 4 had scoliosis involving the cervical spine; 13 (12.8%) patients had documented poor positioning on tracheoscopy; 31 patients (30.3%) had at least one emergency room visit or admission for complications, such as accidental decannulation or bleeding from the tracheostomy; 19 (18.6%) patients required at least one tube change due to poor positioning, with 7 (6.9%) requiring multiple changes; 18 (17.7%) had reported difficulties with home tube changes. Custom length tubes were required in 9 patients (8.8%). The level of scoliosis was not associated with any of these complications. Abnormalities of the trachea, such as tortuosity, obstructive granulomas, or tracheomalacia, were seen in 35 patients (34.3%) on bronchoscopy. Scoliosis repair was performed in 18 patients (17.65%), of which two achieved decannulation. Ten patients (9.8%) overall were decannulated. CONCLUSION: A portion of patients with scoliosis who are tracheostomy-dependent have anatomical abnormalities of the trachea and poor positioning of the tracheostomy tube. Decannulation rates are also lower in this population compared to the literature. Further work is required to elucidate if scoliosis predisposes patients toward tracheostomy-related complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:944-948, 2022.

Cochlear Implantation in Pediatric Patients With Enlarged Vestibular Aqueduct: A Systematic Review.

OBJECTIVE(S): To describe cochlear implantation (CI) outcomes, with speech perception, auditory, language, and parent-reported auditory and speech behaviors, in children with an enlarged vestibular aqueduct (EVA) and incomplete partition type 2 (IP-II) and compare to control children without inner ear malformations (IEMs) and to determine cerebrospinal fluid gusher rates and effect on outcomes. STUDY DESIGN: Systematic review and meta-analysis. METHODS: MEDLINE, Embase, Cochrane, and CINAHL databases were searched from inception to February 2020. Studies reporting relevant outcomes in children with EVA or EVA + IP-II and controls without IEMs undergoing CI were included. Mean differences in speech perception, auditory, and language scores between cases and controls were meta-analyzed. Gusher rates were determined by proportion meta-analyses. RESULTS: Of 214 identified articles, 42 met inclusion criteria, evaluating 775 cases and 2,191 controls. Of -cases, 578 (74.6%) had EVA and 197 (25.4%) had EVA + IP-II. Cases showed a significant improvement in speech perception, auditory and language performance, comparable to controls. Parent-reported auditory and speech production behaviors outcomes were positive among cases and comparable to controls. Pooled gusher proportions in EVA and EVA + IP-II cases were 27.7% (95% CI: 17.6-39.1) and 48.6% (95% CI: 28.6-69.0), respectively, with a proportion difference of 20.9% (95% CI: 11.0-30.1). Gusher occurrence did not impact speech perception or language outcomes. CONCLUSION: Outcomes in children with EVA or EVA + IP-II undergoing CI are favorable and largely comparable to outcomes in children with hearing loss undergoing CI without IEMs. Intraoperative gusher is more prevalent among children with EVA + IP-II as compared to iEVA. Gusher does not influence speech perception and language development outcomes. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1459-1472, 2022.

Safety of Cochlear Implantation in Children 12 Months or Younger: Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature to determine safety of cochlear implantation in pediatric patients 12 months and younger. DATA SOURCE: Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception to March 20, 2021. REVIEW METHODS: Studies that involved patients 12 months and younger with report of intraoperative or postoperative complication outcomes were included. Studies selected were reviewed for complications, explants, readmissions, and prolonged hospitalizations. Two independent reviewers screened all studies that were selected for the systematic review and meta-analysis. All studies included were assessed for quality and risk of bias. RESULTS: The literature search yielded 269 studies, of which 53 studies underwent full-text screening, and 18 studies were selected for the systematic review and meta-analysis. A total of 449 patients and 625 cochlear implants were assessed. Across all included studies, major complications were noted in 3.1% of patients (95% CI, 0.8-7.1) and 2.3% of cochlear implantations (95% CI, 0.6-5.2), whereas minor complications were noted in 2.4% of patients (95% CI, 0.4-6.0) and 1.8% of cochlear implantations (95% CI, 0.4-4.3). There were no anesthetic complications reported across all included studies. CONCLUSION: The results of this systematic review and meta-analysis suggest that cochlear implantation in patients 12 months and younger is safe with similar rates of complications to older cohorts.

Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study.

BACKGROUND: Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort. METHODS: Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models. RESULTS: Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival. CONCLUSIONS: Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.

Predictors of surgical management for paediatric orbital subperiosteal abscesses.

PURPOSE OF REVIEW: Many paediatric orbital subperiosteal abscesses (SPA) are effectively managed conservatively with systemic antibiotics, but surgical drainage is required in some patients. This review aims to summarize the current literature to determine predictors of surgical intervention. RECENT FINDINGS: Nearly all the data regarding this topic come from analysis of retrospective case series. There is consensus that large volume SPAs require surgical drainage; however, the cutoff for volume differs between studies. Proptosis more than 5 mm, superior location of SPA and patient age more than 9 years are also all factors that may predispose towards surgical treatment. SUMMARY: A conservative approach may be trialled in younger patients with medial, smaller volume SPAs. Larger volume SPA, presence of proptosis, superior location of SPA and patient age more than 9 years should lower the threshold for considering surgical intervention. Given that many studies have been retrospective, future studies should be prospective and specifically aim to determine a cutoff for SPA volume.

Craniofacial Interventions in Children.

Craniofacial interventions are common and the surgical options continue to grow. The issues encountered include micrognathia, macroglossia, midface hypoplasia, hearing loss, facial nerve palsy, hemifacial microsomia, and microtia. In addition, a unifying theme is complex upper airway obstruction. Throughout a child's life the focus of interventions may change from airway management to speech, hearing, and language optimization, and finally to decannulation and procedures aimed at social integration and self-esteem. Otolaryngologists play an important role is this arena and provide high-quality care while continuing to expand what can be done for our patients.

Analysis of Process-Related Quality Metrics and Survival of Patients with Oral Cavity Squamous Cell Carcinoma.

OBJECTIVE: To analyze the association of prior reported key quality metrics-neck dissection ≥18 nodes, radiation oncology referral for stage III/IV disease, unplanned surgery ≤14 days, and unplanned readmission ≤30 days-with disease-free survival (DFS) and overall survival (OS) in oral cavity cancer (OCC). STUDY DESIGN: A retrospective chart review. SETTING: A tertiary care center from 1995 to 2016. SUBJECTS AND METHODS: Data from patients with OCC who underwent primary surgery were studied. The association of quality metrics and pathology with DFS/OS was determined by Cox proportional hazards regression analysis. RESULTS: A total of 514 patients were included, and 398 (77.4%) underwent elective neck dissection. Key metrics were not associated with DFS on analysis, but higher pathologic stage and extracapsular extension (ECE) were. When stratified by stage, unplanned readmission within 30 days was associated with decreased survival on multivariate analysis (HR = 0.40; 95% CI, 0.20-0.85; P = .02) for patients with clinical stage III or IV disease. ECE was associated with decreased survival among these patients as well. Neck dissection with ≤18 nodes (HR = 0.62; 95% CI, 0.44-0.86; P = .004) and unplanned surgery within 14 days (HR = 0.56; 95% CI, 0.32-0.96; P = .03) were associated with decreased survival on univariate analysis but not on multivariate analysis. ECE and higher-stage disease were associated with decreased OS on multivariate analysis. CONCLUSION: In this study, aggressive pathology, rather than adherence to key quality metrics, was associated with lower DFS and OS among patients with OCC. More studies are needed to elucidate the association of quality metrics with survival.

Novel interferon-beta-induced gene expression in peripheral blood cells.

Type I IFNs are used for treating viral, neoplastic, and inflammatory disorders. The protein products encoded by IFN-stimulated genes (ISGs) likely mediate clinical effects of IFN in patients. Macroarray assays, used for studying ISG induction in IFN-treated patients, comprise genes identified predominantly through analysis of long-term cell lines. To discover genes induced selectively by IFN-beta in PBMC, we exposed whole blood to physiological concentrations of IFN-beta. PBMC were prepared, and RNA was extracted, reverse-transcribed, and hybridized to cDNA microarrays, and microarray analysis identified 39 ISGs and 20 IFN-repressed genes (IRGs). Thirty-three ISGs were known previously, and six ISGs were novel. New ISGs included GTP cyclohydrolase 1; hypothetical protein LOC129607; hypothetical protein FLJ38348; leucine aminopeptidase 3; squalene epoxidase; and GTP-binding protein overexpressed in skeletal muscle. Twenty IRGs included IL-1beta and CXCL8, which had been identified earlier. CXCL1 was a novel IRG identified in the current study. PCR analysis demonstrated the regulation of six novel ISGs and CXCL1 as an IRG in PBMC and astrocytoma cells. Results were validated using RNA obtained ex vivo from blood of patients after injection with IFN-beta. Identification of new ISGs and IRGs in primary PBMC will enhance macroarray assays for monitoring IFN responsiveness.

Metastasis of Ewing's sarcoma to the thyroid gland: A case report.

Ewing's sarcoma (ES) is an aggressive pediatric malignancy. We present a case of ES with thyroid metastasis. The patient was diagnosed with ES at age 8. Despite aggressive treatment, she suffered disease progression. Surveillance demonstrated a left thyroid lesion. This grew rapidly within 2 months, causing tracheal compression. She underwent hemi-thyroidectomy to prevent airway compromise. Due to her refractory ES, she was enrolled in the Vigil immunotherapy vaccine trial; thus, the specimen was used for vaccine development. This is the first reported case of skeletal ES with metastasis to the thyroid, requiring hemithyroidectomy to prevent airway compromise.