Improving Operating Room Efficiency in Otolaryngology-Head and Neck Surgery: A Scoping Review.

OBJECTIVE: One minute of operating room (OR) time costs $36 to 37. However, ORs are notoriously inefficient. There is growing literature on improving OR efficiency, but no formal review of this topic within otolaryngology has been performed. This study reviews and synthesizes the current literature on improving OR efficiency within otolaryngology. DATA SOURCES: MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, preprints.org, and medRxiv were searched on November 4, 2022. REVIEW METHODS: Published English studies were included if they reported on metrics for improving OR efficiency within otolaryngology. There were no publication date restrictions. Articles were screened by 2 reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analysis reporting for scoping reviews was followed. RESULTS: The search yielded 9316 no-duplicate articles; 129 articles were included. Most of the studies reported on head and neck procedures (n = 52/129). The main tactics included surgical considerations: hemostatic devices, techniques, and team/simultaneous approaches; anesthetic considerations: local anesthetic and laryngeal mask airways; procedure location considerations: procedures outside of the OR and remote technologies; standardization: equipment, checklists, and personnel; scheduling considerations: use of machine learning for booking, considering patient/surgeon factors, and utilizing dedicated OR time/multidisciplinary teams for on-call cases. CONCLUSION: The current literature brings to attention numerous strategies for improving OR efficiency within otolaryngology. Applying these strategies and implementing novel techniques to manage surgical cases may assist in offloading overloaded health care systems and improving access to care while facilitating patient safety and outcomes. Anticipated barriers to implementation include resistance to change, funding, and the current strain on health care systems and providers.

Evaluating implicit gender bias at Canadian otolaryngology meetings through use of professional title.

Objectives: Increasing numbers of women enter medical school annually. The number of female physicians in leadership positions has been much slower to equalize. There are also well-documented differences in the treatment of women as compared to men in professional settings. Female presenters are less likely to be introduced by their professional title ("Doctor") for grand rounds and conferences, especially with a man performing the introduction. This study reviewed the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS) meetings from 2017 to 2020 to determine the proportion of presenters introduced by their professional title and whether this varied by gender. Methods: Recordings from CSOHNS meetings were reviewed and coded for introducer and presenter demographics, including leadership positions and gender. Chi-squared tests of proportion and multivariate logistic regression was used to compare genders and identify factors associated with professional versus unprofessional forms of address. Results: No significant association was found between professional title use and introducer or presenter gender. Female presenters were introduced with professional title 69.6% of the time, while male presenters were introduced with professional title 67.6% of the time (P = 0.69). Residents were introduced with a professional title with the most frequency (75.8%), while attending staff were introduced with a professional title with the least frequency (63.0%) (P = 0.02). Conclusions: The lack of gender bias in speaker introductions at recent CSOHNS meetings demonstrates progress in achieving gender equity in medicine. Research efforts should continue to define additional forms of unconscious bias that may be contributing to gender inequity in leadership positions.

The Use of Ipratropium Bromide for the Treatment of Pediatric Sialorrhea: A Retrospective Clinical Case Series.

OBJECTIVE: This retrospective review documents the experience of ipratropium bromide use among pediatric patients with sialorrhea at our multidisciplinary sialorrhea clinic at Children's Hospital at London Health Sciences Centre (LHSC). METHODS: A retrospective chart review of patients diagnosed with sialorrhea at our multidisciplinary clinic between January 2015 and June 2021 was completed. Data on patient demographics, comorbidities, clinical presentation, previous interventions, quality of life, and medication adverse side effects was collected. Drooling Frequency and Severity Scale (DFSS) scores were reviewed to compare sialorrhea management pre- and post-treatment with topical 0.03% ipratropium bromide nasal solution. A descriptive analysis and Wilcoxon signed rank tests were conducted to compare pre- versus post-treatment DFSS scores. RESULTS: A total of 12 patients presented for follow-up and were included in the final analysis. At the pre-treatment visit, the median DFSS score was 4 for frequency and 5 for severity. Post-treatment, median DFSS score was 3 for frequency and 4.5 for severity, (P = .020 and .129, respectively). Minimal adverse effects were encountered. CONCLUSIONS: Ipratropium bromide provided a statistically significant benefit for drooling frequency in the patients studied and may present an additional topical medical option for pediatric sialorrhea with limited adverse effects.

Feeding outcomes in tracheostomy-dependent infants - can we predict future gastrostomy tube use?

OBJECTIVES: To identify characteristics of infants with tracheostomy that require gastrostomy tube insertion versus those likely to orally feed to predict which patients may benefit from insertion of gastrostomy at the time of tracheostomy placement. METHODS: Retrospective review of infants undergoing tracheostomy from birth to 18 months of age. The primary outcome was to identify pre-operative factors predictive of future gastrostomy tube use. Univariate and multivariate analyses evaluated association between pre-operative patient characteristics and feeding outcomes. RESULTS: Of 103 patients identified, 73 met inclusion criteria. Upper airway anomaly was the indication for tracheostomy in 70.4 %. Gastrostomy tube was required in 52 patients (75.4 %), with 7 (13.5 %) placed concurrently with tracheostomy. Infants with birth complications, a neurologic diagnosis, multiple co-morbidities, or identified with aspiration risk were more likely to require a gastrostomy tube (p < 0.05). CONCLUSIONS: Most infants who require tracheostomy placement from birth until 18 months of age will require nutritional support. Tracheostomy and gastrostomy are uncommonly placed concurrently. Coordination of placement would theoretically minimize the risk of general anesthetic exposure while potentially reducing hospital length of stay and healthcare related costs.

Understanding Gender Differences in Research Productivity of Canadian Otolaryngologists-A Comprehensive National Audit.

Objective: To understand the factors contributing to gender disparities in the research productivity of Canadian academic otolaryngologist-head and neck surgeons. Methods: Publicly available sources including departmental websites, SCOPUS, and the Royal College of Physicians and Surgeons of Canada were accessed between February and April 2022 to analyze gender differences in the academic productivity of otolaryngologist-head and neck surgeons across Canada. Gender differences in research productivity metrics, including h-index, i10-index, publication number, and number of first and senior authorships were assessed. Demographic data, including gender, institution, years in practice, and leadership roles were assessed for correlation with increased research productivity. Subgroup analyses were used to evaluate gender differences in productivity metrics, and univariable and multivariable regression analyses were used to evaluate predictors of research productivity. Results: Data were collected for 316 academic otolaryngologists (252 men, 64 women, P < .001). Men had significantly more years of publishing [mean (standard deviation, SD), 15.64 (9.45) vs 12.44 (8.28), P = .014], higher h-indices [12.22 (11.47) vs 7.33 (5.36), P < .001], i10-indices [22.61 (37.88) vs 8.17 (9.14), P > .001], publication numbers [46.63 (65.18) vs 19.59 (23.40), P < .001], and first [8.18 (9.95) vs 4.89 (6.18), P = .001] and senior authorships [12.98 (22.72) vs 3.83 (6.89), P < .001]. Gender differences were most pronounced in head and neck oncology, pediatrics, and the late career stage. Gender disparities in productivity were absent in the early career stage. Multivariate analysis identified only the number publications and number of senior author publications as being significantly influenced by gender. Conclusion: Canadian female otolaryngologist-head and neck surgeons appear to have equivalent research productivity to their male counterparts in the early career stage. This mirrors the recent findings in the United States, and demonstrates progress compared to earlier studies that found women to have lower research productivity in the early career stage.

Changes in operative otolaryngology infections related to the COVID19 pandemic: A retrospective cohort study.

BACKGROUND: Pediatric emergency admissions fell significantly during the COVID-19 pandemic. This study investigated the changes in severe infectious complications managed by otolaryngology between the pre-pandemic period and the first year of the pandemic to determine if COVID-19 or related public health measures influenced the rate or severity of presentations managed in otolaryngology. METHODS: A retrospective chart review was conducted on pediatric patients who presented with severe infectious otolaryngology presentations (acute mastoiditis, deep neck space abscesses, and orbital complications of sinusitis) over the pre-pandemic (March 2018-February 2020) and early pandemic (March 2020-February 2021) periods. Patient characteristics, details of presentation, treatment, and outcomes were extracted from patients' charts. Independent samples t-tests/Mann-Whitney U-tests for continuous variables and Pearson chi-squared tests/Fisher's exact test for categorical variables were conducted to compare the pre vs early pandemic groups. RESULTS: There were 93 pre-pandemic and 28 early pandemic presentations. The monthly case average was significantly lower during the early pandemic period than the 2 years prior [3.58 (2.80) vs 2.00 (2.00), P = .045]. The average monthly frequency of presentations for deep neck space abscess and mastoiditis were significantly higher in the pre-pandemic group when compared to the early pandemic group [1.96 (±0.33) vs 1.33 (±0.48), P = .049; .71 (±0.26) vs 0.17 (±0.41), P = .01, respectively]. The early pandemic group was significantly younger (3.81 vs 6.04 years, P = .005), however there were no differences in gender, length of admission, and days from symptom onset to presentation between the two groups (P > .05). The early pandemic group had significantly elevated inflammatory markers on presentation [CRP, WBC, neutrophils (P = .02, P = .02, P = .04, respectively)] compared to the pre-pandemic group. CONCLUSION: The COVID-19 pandemic has had an effect on severe infectious complications of ENT pathologies, including decreased average monthly cases during the early pandemic, younger age at presentation, and elevated inflammatory markers.

Exploring Diversity in Otolaryngology-Head and Neck Surgery Journal Editorial Boards.

OBJECTIVE: Despite increasing diversity in medical school entrants, disparities exist in academic leadership. This study sought to examine the proportion of women and visible minorities (VMs) among editorial board members (EBMs) of otolaryngology journals. METHODS: Two reviewers collected journal, editorial board, and editor-in-chief characteristics using journal mastheads or official websites. Gender and VM representation on editorial boards and factors associated with increased representation were investigated. RESULTS: Forty-one journals were explored, from January to April 2022. Of 2128 EBMs, 663 (31.3%) were VMs and 551 (25.9%) were women. Editor-in-chief roles were held by 12 (25%) VM individuals and 3 (6.2%) women. Gender differences in the distribution of editorial board positions were found (P < .001); women had higher representation as associate editors (24.5%, n = 551 vs 15.4, n = 1577%) and deputy/managing editors (2.2%, n = 551 vs 0.4%, n = 1577), while men were more represented as editor-in-chief (2.9%, n = 1577 vs 0.5%, n = 551). Similar VM representation existed between genders (31.0% male; 31.6% women) (P = .80). Journal impact factor quartile and gender were significantly correlated (P < .001); a higher proportion of women were represented in the first (27.0% vs 24.5%) and fourth (12.0% vs 4.9%) quartile. No significant factors were identified for higher women's editorial board representation. Larger editorial board size (P = .002) and Asian/South American journals (P = .003 to P < .001) had significantly higher representation of VMs. CONCLUSION: Women and VMs are underrepresented in high-ranking editorial positions. Diversity in editorial boards is needed to ensure fair and balanced journal reviews and equity within otolaryngology.

Auto-Substitutions to Optimize Perioperative Antimicrobial Prophylaxis: Pre-Post Intervention Study.

BACKGROUND: Appropriate administration of perioperative antibiotics can prevent antimicrobial resistance, adverse drug events, surgical site infections, and increased costs to the health care system for many surgeries in Otolaryngology-Head and Neck Surgery (OHNS). OBJECTIVE: The objective of the study is to achieve 90% compliance with evidence-based perioperative antibiotic prophylaxis guidelines among elective surgical procedures in OHNS. METHODS: The pre-intervention group consisted of patients undergoing elective surgical procedures in the 13 months prior to the interventions (September 2019-2020) whereas the post-intervention group comprised patients undergoing elective procedures during the 8 months following the implementation (October 2020-May 2021). The 4 Es of knowledge translation and the Donabedian framework were used to frame the study. Components of the intervention included educational grand rounds and automatic substitutions in electronic health records. In June 2021, a survey of staff and residents assessed the self-reported perception of following evidence-based guidelines. RESULTS: Compliance with antimicrobial prophylaxis guidelines were evaluated based on agent and dose. The overall compliance improved from 38.8% pre-intervention to 59.0% post-intervention (p < 0.001). Agent compliance did not improve from pre- to post-intervention, that is, 60.7% to 62.8%, respectively, (p = 0.68), whereas dose compliance improved from 39.6% to 89.2% (p < 0.001). Approximately 78.5% of survey respondents felt that they strongly agreed or agreed with always following evidence-based antimicrobial prophylaxis guidelines. CONCLUSION: Compliance with antimicrobial prophylaxis guidelines improved, primarily due to increased dosing compliance. Future interventions will target agent compliance and selected procedures with lower compliance rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:3403-3408, 2023.

Gender representation in leadership & research: a 13-year review of the Annual Canadian Society of Otolaryngology Meetings.

BACKGROUND: The gender disparity in surgical disciplines, specifically in speakers across North American medical and surgical specialty conferences, has been highlighted in recent literature. Improving gender diversity at society meetings and panels may provide many benefits. Our aim was to determine the state of gender diversity amongst presenters and speakers at the annual Canadian Society of Otolaryngology-Head and Neck Surgery (CSO) meetings. METHODS: Scientific programs for the CSO annual meetings from 2008 to 2020 were obtained from the national society website. Participant name, role, gender, location, and subspecialty topic were recorded for all roles other than poster presenter. Gender (male or female) was determined using an online search. The total number of opportunity spots and proportion of women was then calculated. Gender differences were analyzed using chi-square test and logistic regression with odds ratios. Four categories were analyzed: Society Leadership, Invited Speaker Opportunities, Workshop Composition (male-only panels or "manels", female-only panels, or with at least one female speaker), and Oral Paper Presenters (first authors). RESULTS: There were 1874 leadership opportunity spots from 2008 to 2020, of which 18.6% were filled by women. Among elected leadership positions in the society, only 92 unique women filled 738 leadership opportunity spots. 13.2% of workshop chairs, 20.8% of panelists and 22.7% of paper session chairs were female. There was an overall increase in the proportion of leadership positions held by women, from 13.9% of leadership spots in 2008 to 30.1% in 2020. Of the 368 workshops, 61.1% were led by men only, 36.4% by at least 1 female surgeon, and 2.5% by women only. "Manels" have comprised at least 37.5% of workshops each year. CONCLUSIONS: The proportion of women in speaking roles at the annual CSO meetings has generally increased over time, particularly among panelists, leading to fewer male-only speaking panels. However, there has been a slower rate of growth in the proportion of unique women in speaker roles. There remains an opportunity to increase gender/sex diversity at the major Canadian otolaryngology meeting.

Canadian women in otolaryngology: head and neck surgery part 2-challenges in family planning, fertility, and lactation.

BACKGROUND: Previous literature demonstrates that female surgeons face difficulties in family planning, meeting breastfeeding goals, leadership and advancement opportunities. These issues have received limited attention in Canadian surgeons despite different maternity leave patterns compared to the general Canadian population. We sought to describe the experience of otolaryngologist-head and neck surgeons in family planning, fertility, and lactation and to identify the role of gender and career stage in these experiences. METHODS: A RedCAP® survey was disseminated to Canadian otolaryngology-head and neck surgeons and residents from March to May of 2021 through social media and the national listserv. This survey examined fertility, pregnancy losses, and infant feeding. Major independent variables include gender and career stage (faculty and resident). Dependent variables include respondent experiences with fertility, number of children, and length of parental leave. Responses were tabulated and presented descriptively to communicate the experience of Canadian otolaryngologists. Further, statistical comparisons such as chi-square and t-tests were employed to identify relationships between these variables. Thematic analysis was conducted for narrative comments. RESULTS: We received 183 completed surveys (22% response rate). 54% of females versus 13% of males agreed that career influenced their ability to have children (p = 0.002). 74% of female respondents without children have concerns about future fertility compared to 4% of men (p < 0.001). Furthermore, 80% of women versus 20% of men have concerns about future family planning (p < 0.001). The average maternity leave was 11.5 weeks for residents, and 22.2 weeks for staff. Additionally, significantly more women than men stated that maternity leave impacted advancement opportunities (32% vs. 7%) and salary/remuneration (71% vs. 24%) (p < 0.001). Over 60% of those choosing to pump breastmilk at work reported having inadequate time, space, and breastmilk storage. In total, 62% of breastfed infants were receiving breastmilk at 1 year. CONCLUSION: Canadian female otolaryngologists-head and neck surgeons face challenges in family planning, ability to conceive, and breastfeeding. Focused effort is required to provide an inclusive environment that helps all otolaryngologists-head and neck surgeons achieve both their career and family goals, regardless of gender or career stage.

Canadian Women in Otolaryngology-Head and Neck Surgery part 1: the relationship of gender identity to career trajectory and experiences of harassment.

INTRODUCTION: Women in surgical specialties face different challenges than their male peers. However, there is a paucity of literature exploring these challenges and their effects on a Canadian surgeon's career. METHODS: A REDCap® survey was distributed to Canadian Otolaryngology-Head and Neck Surgery (OHNS) staff and residents in March 2021 using the national society listserv and social media. Questions examined practice patterns, leadership positions, advancement, and experiences of harassment. Gender differences in survey responses were explored. RESULTS: 183 completed surveys were obtained, representing 21.8% of the Canadian society membership [838 members with 205 (24.4%) women]. 83 respondents self-identified as female (40% response rate) and 100 as male (16% response rate). Female respondents reported significantly fewer residency peers and colleagues identifying as their gender (p < .001). Female respondents were significantly less likely to agree with the statement "My department had the same expectations of residents regardless of gender" (p < .001). Similar results were observed in questions about fair evaluation, equal treatment, and leadership opportunities (all p < .001). Male respondents held the majority of department chair (p = .028), site chief (p = .011), and division chief positions (p = .005). Women reported experiencing significantly more verbal sexual harassment during residency (p < .001), and more verbal non-sexual harassment as staff (p = .03) than their male colleagues. In both female residents and staff, this was more likely to originate from patients or family members (p < .03). DISCUSSION: There is a gender difference in the experience and treatment of OHNS residents and staff. By shedding light on this topic, as a specialty we can and must move towards greater diversity and equality.

Attitudes and Perceptions of Canadian Otolaryngology-Head and Neck Surgeons and Residents on Environmental Sustainability.

Objective: Healthcare systems, specifically operating rooms, significantly contribute to greenhouse gas emissions. Addressing operating room environmental sustainability requires understanding current practices, opinions, and barriers. This is the first study assessing the attitudes and perceptions of otolaryngologists on environmental sustainability. Study Design: Cross-sectional virtual survey. Setting: Email survey to active members of the Canadian Society of Otolaryngology-Head and Neck Surgery. Methods: A 23-question survey was developed in REDCap. The questions focused on four themes: (1) demographics, (2) attitudes and beliefs, (3) institutional practices, and (4) education. A combination of multiple choice, Likert-scale, and open-ended questions were employed. Results: Response rate was 11% (n = 80/699). Most respondents strongly believed in climate change (86%). Only 20% strongly agree that operating rooms contribute to the climate crisis. Most agree environmental sustainability is very important at home (62%) and in their community (64%), only 46% said it was very important in the operating room. Barriers to environmental sustainability were incentives (68%), hospital supports (60%), information/knowledge (59%), cost (58%), and time (50%). Of those involved in residency programs, 89% (n = 49/55) reported there was no education on environmental sustainability or they were unsure if there was. Conclusion: Canadian otolaryngologists strongly believe in climate change, but there is more ambivalence regarding operating rooms as a significant contributor. There is a need for further education and a systemic reduction of barriers to facilitate eco-action in otolaryngology operating rooms.

Gender differences in publication rates at Canadian Society of Otolaryngology-Head and Neck Surgery annual meetings: an 11-year analysis.

BACKGROUND: Evaluating gender differences in publication rates after conference presentations is an avenue to assess women's contributions to academic medicine. The objective of this study was to assess gender differences in publication rates, time to publication, and subspeciality of publication of abstracts presented at Canadian otolaryngology conferences over an 11-year period. METHODS: Cross-sectional data was obtained from online conference schedules of annual Canadian Society of Otolaryngology-Head and Neck Surgery national meetings between 2009 and 2020. A total of 2111 abstract titles were searched in MedLine via PubMed. Gender of the first and senior author, publication status of presented work, and subspeciality of publication were extracted. RESULTS: Of 2111 scientific abstracts presented between 2009 and 2020, female first and senior authors accounted for 29.0% and 12.8% of published abstracts, respectively. There was a significant difference in the publication rate of senior authors by gender (p < 0.01). Male senior authors had a 9.70% higher rate of publication compared to female senior authors. Posters with a female first author were 33.0% (OR: 0.67; 95% CI 0.49-0.91) less likely to be published compared to posters with a male first author. Similarly, posters with a female senior author were 34.0% (OR: 0.66; 95% CI 0.45-0.96) less likely to be published. There was a significant difference in discipline of publication by gender of the senior author (p < 0.001). Male senior authors were more likely to supervise projects in otology while female senior authors were more likely to supervise projects in education and pediatrics. The time to publication and impact factor of the journal of publication did not differ by gender. CONCLUSION: Gender disparities exist in the publication rates of first and senior authors at Canadian otolaryngology meetings. Female senior authors have significantly lower publication rates compared to their male colleagues and differences exist in publication rates after poster presentations. Investigation of gender gaps in academic medicine, research productivity, and publications is essential for development of a diverse, equitable, and inclusive workforce in otolaryngology.

The Experiences of Motherhood in Female Surgeons: A Scoping Review.

OBJECTIVE: The objective of this study is to systematically synthesize the existing literature on the experiences of motherhood in female surgeons both during surgical training and as staff physicians, to identify knowledge gaps, and to provide recommendations for institutional changes to better support pregnant female surgeons. BACKGROUND: There are disproportionately fewer medical students pursuing surgical specialties, as surgery is often seen as incompatible with childbearing and pregnancy. However, no review has summarized the published literature on the collective experiences of female surgeons in navigating motherhood. METHODS: Four databases were searched and 1106 abstracts were identified. Forty-two studies were included and a thematic analysis was performed. RESULTS: Four themes were identified: path toward motherhood (n=18), realities of motherhood (n=25), medical culture and its impact on career and family life (n=24), and institutional reproductive wellness policies (n=21). Female surgeons are more likely to delay motherhood until after training and have high rates of assisted reproductive technology use. Pregnancy during surgical training is associated with negative perception from peers, pregnancy complications, and scheduling challenges. Maternity leave policies and breastfeeding and childcare facilities are variable and often inadequate. Many female surgeons would agree that greater institutional support would help support women in both their roles as mothers and as surgeons. CONCLUSIONS: Both female residents and staff surgeons experience significant and unique barriers before, during, and after motherhood that impact their personal and professional lives. Understanding the unique challenges that mothers face when pursuing surgical specialties is critical to achieving gender equity.

Improving Timeliness in Surgical Discharge Summary Distribution: A Quality Improvement Initiative.

Objective: To implement a quality improvement initiative to achieve an institutional targeted discharge summary distribution metric of 50% within 48 hours of patient discharge from hospital within an academic tertiary care otolaryngology-head and neck surgery department. Methods: A pre- and postintervention study was conducted. Process mapping was performed. Interventions included education and engagement, implementation of auto-authentication (distribution immediately following transcription without review by the most responsible physician), and audit and feedback. The percentage of discharge summaries dictated with the auto-authentication code was evaluated. Process measures were collected for 12 months pre- and postimplementation. Balancing measures included workload and revisions to auto-authenticated notes. Analysis included summary statistics, statistical process control charting, and unpaired t tests. Results: The mean ± SD percentage of discharge summaries distributed within 48 hours increased from 19% ± 6.4% preintervention to 54% ± 20% postintervention (P < .0001). Seventy-four percent of discharge summaries were dictated via the auto-authentication code. The target metric was met in 71% of discharges with the auto-authentication codes as compared with 26% with non-auto-authentication. The interventions did not result in any change to perceived workload, and the incidence of auto-authentication revisions was <1%. The results were sustained with an increase of 72% the following quarter. For fiscal year 2021-2022, performance remained sustained with an 85% completion rate. Discussion: Our surgical department exceeded and sustained the targeted metric for timely discharge summary distribution using a quality improvement approach. Implications for Practice: Timely distribution of discharge summaries optimizes patients' transitions of care and can be achieved through stakeholder education and engagement, auto-authentication, and audit with feedback.

Experience of Pediatricians and Pediatric Surgeons With Virtual Care During the COVID-19 Pandemic: Descriptive Study.

BACKGROUND: Prior to the COVID-19 pandemic, in-clinic visits were the standard of care for pediatric physicians and surgeons at our center. At the pandemic onset, web-based care was adopted at an unprecedented scale and pace. OBJECTIVE: This descriptive study explores the web-based care experience of pediatric physicians and surgeons during the pandemic by determining factors that supported and challenged web-based care adoption. METHODS: This study took place at the Children's Hospital at London Health Sciences Centre, a children's hospital in London, Ontario, Canada, which provides pediatric care for patients from the London metropolitan area and the rest of Southwestern Ontario. The Donabedian model was used to structure a web-based survey evaluating web-based care experience, which was distributed to 121 department-affiliated pediatric physicians (including generalists and subspecialists in surgery and medicine). Recruitment occurred via department listserv email. Qualitative data were collected through discrete and free-text survey responses. RESULTS: Survey response rate was 52.1% (63/121). Before the pandemic, few physicians within the Department of Paediatrics used web-based care, and physicians saw <10% of patients digitally. During March-May 2020, the majority transitioned to web-based care, seeing >50% of patients digitally. Web-based care use in our sample fell from June to September 2020, with the majority seeing <50% of patients digitally. Telephone and Ontario Telemedicine Network were the platforms most used from March to September 2020. Web-based care was rated to be convenient for most providers and their patients, despite the presence of technical difficulties. Challenges included lack of physical exam, lower patient volumes, and poor patient digital care etiquette. Regardless of demographics, 96.4% (116/121) would continue web-based care, ideally for patients who live far away and for follow-ups or established diagnoses. CONCLUSIONS: Transition to web-based care during COVID-19 was associated with challenges but also positive experiences. Willingness among pediatricians and pediatric surgeons to continue web-based care was high. Web-based care experiences at our center could be improved with patient education and targeting select populations. Future research is needed to improve practice efficiency and to inform regulatory guidelines for web-based care.

Cervicofacial Actinomycosis in the Pediatric Population: Presentation and Management.

BACKGROUND: Infection caused by Actinomyces species is a rare cause of head and neck infection in children. This chronic cervicofacial infection can present with localized swelling, abscess formation, sinus drainage and can be complicated by osteomyelitis. METHODS: Presented are 2 pediatric cases of secondary actinomycosis in the context of congenital lesions: 1 patient with a previously excised preauricular sinus and another with a persistent sublingual mass. A comprehensive literature search was conducted for reported cases of pediatric actinomycosis in the cervicofacial region. RESULTS: Both cases presented were successfully treated with a combination of complete surgical excision of the lesions and prolonged antibiotic therapy. Thirty-four pediatric cases of cervicofacial actinomycosis are reviewed, 2 presented herein, and 32 from the published literature. There was equal gender distribution and the median age was 7.5 years. The most common site for infection was the submandibular area. Four (12%) of cases arose in pre-existing congenital lesions. Most patients were treated with penicillin-based antibiotics for a median duration of 6 months following surgical excision or debridement. CONCLUSIONS: Actinomycosis is a rare infection of the cervicofacial region; secondary infections arising from congenital lesions of the head and neck are even more rare. A previously excised pre-auricular sinus and a sublingual dermoid cyst are not previously reported sites of infection. Actinomycosis should be suspected in chronically draining sinuses of the head and neck region and confirmed through anaerobic culture. Osteomyelitis is a potential complication and magnetic resonance (MR) imaging is warranted. Long-term antibiotic therapy with a penicillin-based antibiotic and surgical excision should be considered.

Double Fogarty balloon catheter technique for difficult to retrieve esophageal foreign bodies.

BACKGROUND: Foreign body ingestion is common, especially in the pediatric population. Plans for retrieval should be tailored to the specific esophageal foreign bodies. CASE PRESENTATION: We present a difficult to retrieve esophageal foreign body in a 3-year-old girl who ingested a 2 cm glass pebble. Intraoperatively, attempts using conventional optical forceps and retrieval baskets were unsuccessful due to the size and smooth texture of the object. A novel strategy using double Fogarty embolectomy balloon catheters for retrieval of blunt esophageal foreign bodies was devised and described. CONCLUSION: The double fogarty retrieval technique described appeared to be safe and efficacious, allowing for extraction of large esophageal foreign bodies under direct visualization.