Proposed Quality Indicators for Aspects of Pediatric Acute Otitis Media Management.

BACKGROUND: The high incidence of pediatric acute otitis media (AOM) makes the implications of overdiagnosis and overtreatment far-reaching. Quality indicators (QIs) for AOM are limited, drawing from generalized upper respiratory infection QIs, or locally developed benchmarks. Recognizing this, we sought to develop pediatric AOM QIs to build a foundation for future quality improvement efforts. METHODS: Candidate indicators (CIs) were extracted from existing guidelines and position statements. The modified RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness methodology was used to select the final QIs by an 11-member expert panel consisting of otolaryngology-head and neck surgeons, a pediatrician and family physician. RESULTS: Twenty-seven CIs were identified after literature review, with an additional CI developed by the expert panel. After the first round of evaluations, the panel agreed on 4 CIs as appropriate QIs. After an expert panel meeting and subsequent second round of evaluations, the panel agreed on 8 final QIs as appropriate measures of high-quality care. The 8 final QIs focus on topics of antimicrobial management, specialty referral, and tympanostomy tube counseling. CONCLUSIONS: Evidence of variable and substandard care persists in the diagnosis and management of pediatric AOM despite the existence of high-quality guidelines. This study proposes 8 QIs which compliment guideline recommendations and are meant to facilitate future quality improvement initiatives that can improve patient outcomes.

Predictors of Surgical Site Infection in Pediatric Cochlear Implantation.

OBJECTIVE: To determine risk factors for surgical site infection (SSI) after cochlear implantation (CI) in pediatric patients. STUDY DESIGN: Case-control study. SETTING: A total of 150 hospitals contributing data to the ACS-NSQIP Pediatric database (American College of Surgeons National Surgical Quality Improvement Program) in North America and worldwide. METHODS: Pediatric patients (aged <18 years) undergoing CI during the years 2012 to 2017 were identified in the ACS-NSQIP Pediatric database. Uni- and multivariable logistic regression analyses were used to determine the odds ratios (ORs) of SSI (including superficial incisional, deep incisional, organ/space) occurring up to 30 days postoperatively. RESULTS: A total of 79 SSIs occurred over a 5-year period (n = 5146). Longer operative time significantly increased the odds of SSI (OR, 1.965; 95% CI, 1.205-3.289). Younger age was also found to raise the odds of SSI, with decreased odds associated with each 6-month increase in age (OR, 0.887; 95% CI, 0.814-0.958). CONCLUSION: Longer operative time and younger age appear to significantly increase the odds of SSI in pediatric CI. Body mass index, recent steroid use, American Society of Anesthesiologists class, bilateral vs unilateral implantation, and hospital length of stay do not appear to significantly influence SSI risk. These findings must be interpreted in the context of the limitations inherent to adverse events reporting, which are mitigated by the stringent manner of data collection by the ACS-NSQIP, and those inherent to the definition of SSI. Future prospective studies should investigate the impact of reducing operative time on the risk of SSI and other complications in pediatric CI.

The Feasibility of Magnetic Resonance Imaging Without General Anesthesia Using the "Bundle and Scan" Technique for Infants With Sensorineural Hearing Loss.

OBJECTIVE: The purpose of this study is to determine the feasibility of magnetic resonance imaging (MRI) without general anesthesia (GA) for infants being evaluated for sensorineural hearing loss (SNHL) using the bundle and scan technique. STUDY DESIGN: Retrospective study. SETTING: Pediatric tertiary care hospital. PATIENTS: All infants who underwent MRI using the bundle and scan technique as part of the diagnostic workup for unilateral or bilateral SNHL between June 2016 to April 2019 were included. MAIN OUTCOME MEASURE: The primary outcome was the proportion of clinically useful images produced. RESULTS: We reviewed 21 bundle and scan MRI examinations in infants being evaluated for SNHL. Patients had a median age of 10 (range: 6-25) weeks at the time of MRI. Motion artifact was noted in 38% (8/21) of cases. Eighty-six percent (18/21) of the magnetic resonance images produced using the bundle and scan technique were of diagnostic quality and/or sufficient for surgical planning for cochlear implantation. Repeat imaging with GA was required for three cases (14%) as the initial images were not clinically useful. All patients requiring GA had unilateral SNHL. All patients with bilateral SNHL successfully underwent MRI without GA using the bundle and scan technique. CONCLUSION: The results of our study demonstrate that it is feasible to perform MRI using the bundle and scan technique in the majority of young infants being evaluated for SNHL. This has the potential to help determine cochlear implant candidacy earlier, reduce exposure to GA, and reduce healthcare costs.

Quality indicators for the diagnosis and management of pediatric tonsillitis.

INTRODUCTION: Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options. METHODS: A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology - head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology. RESULTS: Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care. CONCLUSIONS: This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

Development and validation of an algorithm of diagnostic and procedural codes for the identification of children hospitalized with a tracheostomy in Ontario, Canada.

BACKGROUND: The requirement for a tracheostomy in children is associated with significant morbidity, mortality, and healthcare utilization. Easy identification of children with tracheostomies would facilitate important research on this population and provide quality improvement initiatives. AIM: The purpose of this study is to determine whether an algorithm of diagnostic and procedural codes can accurately identify children hospitalized with a tracheostomy using routinely collected health data. METHODS: Chart reviews were performed at the Children's Hospital of Eastern Ontario (CHEO) and the London Health Sciences Center (LHSC) to establish a true positive cohort of pediatric patients with tracheostomies admitted between 2008 and 2016. A multidisciplinary team developed algorithms of diagnostic and procedural codes contained within the Canadian Institute for Health Information Discharge Abstract Database. Algorithms were tested and refined against the true-positive and true-negative cohort. The accuracy of the diagnostic codes related to tracheostomy complications was also evaluated. RESULTS: A chart review identified 158 unique children with tracheostomies (77 at CHEO, 81 at LHSC) with 901 individual admissions (401 at CHEO, 507 at LHSC). The best algorithms for identifying children with a tracheostomy had a sensitivity and specificity of more than 99%, a positive predictive value (PPV) of 94.0% and negative predictive value (NPV) of 100%. The algorithm for the identification of tracheostomy-related complications had a sensitivity of 76.7%, a specificity of 65%, PPV of 52.3%, and an NPV of 84.7%. CONCLUSIONS: This study provides an algorithm for the accurate identification of children hospitalized in Canada with a tracheostomy, facilitating population-level epidemiological research and quality improvement initiatives.

Factors Impacting Physician Recommendation for Tracheostomy Placement in Pediatric Prolonged Mechanical Ventilation: A Cross-Sectional Survey on Stated Practice.

OBJECTIVES: To characterize the stated practices of qualified Canadian physicians toward tracheostomy for pediatric prolonged mechanical ventilation and whether subspecialty and comorbid conditions impact attitudes toward tracheostomy. DESIGN: Cross sectional web-based survey. SUBJECTS: Pediatric intensivists, neonatologists, respirologists, and otolaryngology-head and neck surgeons practicing at 16 tertiary academic Canadian pediatric hospitals. INTERVENTIONS: Respondents answered a survey based on three cases (Case 1: neonate with bronchopulmonary dysplasia; Cases 2 and 3: children 1 and 10 years old with pediatric acute respiratory distress syndrome, respectively) including a series of alterations in relevant clinical variables. MEASUREMENTS AND MAIN RESULTS: We compared respondents' likelihood of recommending tracheostomy at 3 weeks of mechanical ventilation and evaluated the effects of various clinical changes on physician willingness to recommend tracheostomy and their impact on preferred timing (≤ 3 wk or > 3 wk of mechanical ventilation). Response rate was 165 of 396 (42%). Of those respondents who indicated they had the expertise, 47 of 121 (38.8%), 23 of 93 (24.7%), and 40 of 87 (46.0%) would recommend tracheostomy at less than or equal to 3 weeks of mechanical ventilation for cases 1, 2, and 3, respectively (p < 0.05 Case 2 vs 3). Upper airway obstruction was associated with increased willingness to recommend earlier tracheostomy. Life-limiting condition, severe neurologic injury, unrepaired congenital heart disease, multiple organ system failure, and noninvasive ventilation were associated with a decreased willingness to recommend tracheostomy. CONCLUSION: This survey provides insight in to the stated practice patterns of Canadian physicians who care for children requiring prolonged mechanical ventilation. Physicians remain reluctant to recommend tracheostomy for children requiring prolonged mechanical ventilation due to lung disease alone at 3 weeks of mechanical ventilation. Prospective studies characterizing actual physician practice toward tracheostomy for pediatric prolonged mechanical ventilation and evaluating the impact of tracheostomy timing on clinically important outcomes are needed as the next step toward harmonizing care delivery for such patients.

Crowdsourcing the Citation Screening Process for Systematic Reviews: Validation Study.

BACKGROUND: Systematic reviews (SRs) are often cited as the highest level of evidence available as they involve the identification and synthesis of published studies on a topic. Unfortunately, it is increasingly challenging for small teams to complete SR procedures in a reasonable time period, given the exponential rise in the volume of primary literature. Crowdsourcing has been postulated as a potential solution. OBJECTIVE: The feasibility objective of this study was to determine whether a crowd would be willing to perform and complete abstract and full text screening. The validation objective was to assess the quality of the crowd's work, including retention of eligible citations (sensitivity) and work performed for the investigative team, defined as the percentage of citations excluded by the crowd. METHODS: We performed a prospective study evaluating crowdsourcing essential components of an SR, including abstract screening, document retrieval, and full text assessment. Using CrowdScreenSR citation screening software, 2323 articles from 6 SRs were available to an online crowd. Citations excluded by less than or equal to 75% of the crowd were moved forward for full text assessment. For the validation component, performance of the crowd was compared with citation review through the accepted, gold standard, trained expert approach. RESULTS: Of 312 potential crowd members, 117 (37.5%) commenced abstract screening and 71 (22.8%) completed the minimum requirement of 50 citation assessments. The majority of participants were undergraduate or medical students (192/312, 61.5%). The crowd screened 16,988 abstracts (median: 8 per citation; interquartile range [IQR] 7-8), and all citations achieved the minimum of 4 assessments after a median of 42 days (IQR 26-67). Crowd members retrieved 83.5% (774/927) of the articles that progressed to the full text phase. A total of 7604 full text assessments were completed (median: 7 per citation; IQR 3-11). Citations from all but 1 review achieved the minimum of 4 assessments after a median of 36 days (IQR 24-70), with 1 review remaining incomplete after 3 months. When complete crowd member agreement at both levels was required for exclusion, sensitivity was 100% (95% CI 97.9-100) and work performed was calculated at 68.3% (95% CI 66.4-70.1). Using the predefined alternative 75% exclusion threshold, sensitivity remained 100% and work performed increased to 72.9% (95% CI 71.0-74.6; P<.001). Finally, when a simple majority threshold was considered, sensitivity decreased marginally to 98.9% (95% CI 96.0-99.7; P=.25) and work performed increased substantially to 80.4% (95% CI 78.7-82.0; P<.001). CONCLUSIONS: Crowdsourcing of citation screening for SRs is feasible and has reasonable sensitivity and specificity. By expediting the screening process, crowdsourcing could permit the investigative team to focus on more complex SR tasks. Future directions should focus on developing a user-friendly online platform that allows research teams to crowdsource their reviews.

Immediate versus delayed surgery in congenital choanal atresia: A systematic review.

OBJECTIVES: To evaluate immediate versus delayed surgical intervention on treatment outcomes in the management of congenital choanal atresia. METHODS: This study adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines in reporting a systematic review of the literature. OVID Medline, EMBASE and Pubmed databases were searched using relevant key terms. Inclusion and exclusion criteria were designed to capture studies examining immediate versus delayed primary surgery for congenital choanal atresia. Timing of surgery was classified as immediate or delayed based on median age of intervention stratified by type of obstruction. Primary outcomes were primary treatment failure, respiratory function and mortality rates. RESULTS: A total of 2765 abstracts were identified and screened by 2 independent reviewers. Of the 688 articles reviewed in full text, 23 articles met the study criteria and were subjected to quality assessment. The full study assessment and quality control measures yielded 23 studies (representing 362 patients) for pooled patient-level analysis in the systematic review. Primary treatment failures occurred in 24.8% of patients that underwent immediate surgery and 42.6% of patients that underwent delayed surgery for bilateral choanal atresia (p = 0.01). There were no differences in mortality rates (5.6% vs 4.2%; p = 1.00) or qualitative measures of respiratory function. There were no difference in treatment outcomes for patients with unilateral choanal atresia (p > 0.05). CONCLUSIONS: Through an analysis of pooled individual patient data, this systematic review of the literature demonstrated that there was significantly higher rates of treatment failure in patients that underwent delayed surgery for bilateral choanal atresia. Clinical trials and large prospective cohort studies investigating outcomes following immediate and delayed surgical intervention will provide further insight into treatment strategies.

Effect of Home-Call on Otolaryngology Resident Education: A Pilot Study.

OBJECTIVE: To inform institutional policies regarding call encounters through an evaluation of the effect of home-call on academic experience and fatigue among surgical residents. This study conducted an assessment of the nature of resident call encounters premidnight and postmidnight and a comparative analysis of sleep deprivation and efficiency in residents during home-call and off call. DESIGN, SETTING, AND PARTICIPANTS: All Otolaryngology-Head and Neck Surgery residents (n = 9) at single Canadian institution were asked to establish the time and nature of call encounters during home-call. Residents completed the Stanford Sleepiness Scale precall and postcall to measure sleepiness and wore an Actigraph device to measure sleep efficiency to establish fatigue in the setting of home-call as compared with residents off call. Home-call and off call patterns were studied using a random computer-generated selection of days for participants in both study groups. Analysis was conducted from December 1, 2013 to December 30, 2014. RESULTS: Residents received on average 7 pages per night, of which 78.5% of pages were for nonurgent issues. On an average, change in sleep deprivation scores postcall was 3.0 points higher (95% CI: 2.48-3.57, p < 0.0001) in residents who were qualified for a postcall day compared with residents who did not qualify for a postcall day and residents off call according to the Stanford Sleepiness Scale. Postcall sleep deprivation was significantly associated with number of encounters managed after midnight, regardless of management through telephone or in-hospital (p = 0.01). The Actigraph device identified a significant decrease in sleep efficiency in residents who were qualified for a postcall day compared with residents off call (mean = -31.1; 95% CI: -38.9, -23.4; p < 0.001). CONCLUSIONS: This is the first study to evaluate surgical residents' home-call experience. We identified a high proportion of nonurgent encounters that residents managed on call and increased postcall fatigue associated with postmidnight telephone encounters. This study highlights the detrimental effects of frequent sleep interruptions because of encounters on call and suggests the need for institutional guidelines to help minimize these interruptions.

Congenital Trismus From Brainstem Dysgenesis: Case Report and Review of Literature.

Trismus refers to any condition inducing limited mouth opening and may present as a result of acquired or congenital pathology. We present the case of a newborn who presented with severe, congenital trismus due to brainstem dysgenesis. We describe the course of his investigations, and a multidisciplinary approach to the management of his care and follow-up. To our knowledge, this is one of the earliest reported cases of congenital trismus attributable to brainstem dysgenesis. A literature review was conducted to provide an overview of the differential pathogenesis as it presents in congenital cases and discuss the complexity of managing congenital trismus due to brainstem dysgenesis in a neonate and infant.

Direct molecular detection of a broad range of bacterial and viral organisms and Streptococcus pneumoniae vaccine serotypes in children with otitis media with effusion.

BACKGROUND: Otitis media with effusion (OME) causes significant morbidity in children, but the causes of OME and methods for prevention are unclear. To look for potential infectious etiologies, we performed a pilot study using multiple-target real-time polymerase chain reaction (qPCR) for 27 infectious agents, including nine bacterial organisms and 18 respiratory viruses in middle ear fluids (MEFs) from children with OME. QPCR was also performed for the 13 Streptococcus pneumoniae serotypes contained in the current vaccine. RESULTS: Forty-eight MEF samples were obtained and qPCR detected bacterial nucleic acid (NA) in 39/48 (81%) and viral NA in 7/48 (15%). Alloiococcus otitidis and S. pneumoniae were both detected in 15/48 (31%) MEFs, followed by M. catarrhalis in 14/48 (29%), H. influenzae in 5/48 (10%) and M. pneumoniae in 4/48 (8%). Rhinoviruses were most common virus type detected, found in 4/48 (8%) MEFs. Serotypes included in the current 13-serotype vaccine were detected in only 3/15 (20%) S. pneumoniae qPCR-positive MEFs. CONCLUSIONS: Bacteria may play an important role in OME, since over 80% of MEFs contained bacterial NA. Further research into the role of A. otitidis in OME will be helpful. Serotypes of S. pneumoniae not included in the current 13-serotype vaccine may be involved in OME. Larger studies of OME S. pneumoniae serotypes are needed to help determine which additional serotypes should be included in future vaccine formulations in order to try to prevent OME.

The effectiveness of webcast compared to live lectures as a teaching tool in medical school.

OBJECTIVE: The purpose of this study is to investigate whether webcast lectures are comparable to live lectures as a teaching tool in medical school. METHODS: Three Otolaryngology-Head&Neck Surgery (OTO-HNS) lectures were given to third year medical students through their regular academic curriculum with one group receiving lectures in a live lecture format and the other group in a webcast format. All lectures (live or webcast) were given by the same lecturer and contained identical material. Three outcome measures were used: a student satisfaction survey, performance on the OTO-HNS component of their written examination, and performance on an OTO-HNS OSCE station in the general end of year OSCE examination session. RESULTS: Students performance on the written examination was equal between the two groups. The webcast group outperformed the live lecture group in the OSCE station. The majority of students in the webcast group felt it was an effective learning tool for them. Most viewed the lectures more than once, and felt that this was beneficial to their learning. CONCLUSION: Webcasts appear equally effective to live lectures as a teaching tool.

Neck circumference percentile: A screening tool for pediatric obstructive sleep apnea.

RATIONALE: Large neck circumference (NC) is associated with obstructive sleep apnea (OSA) in adults, especially males. Since NC changes with age and sex, a lack of reference ranges makes neck size difficult to assess as a screening tool in children. METHODS: Using a population-based dataset of 1,913 children, we developed reference ranges for NC by age and sex for children aged 6-17 years. In this study, we collected NC data on 245 children aged 6-17 years presenting to the Children's Hospital of Eastern Ontario for polysomnography. The association between NC>the 95th percentile and OSA (total apnea-hypopnea-index>5 events/hr and/or obstructive-apnea-index ≥ 1 event/hr) was explored. Thresholds of BMI percentile and waist circumference were also examined. RESULTS: Individuals with NC>95th percentile for age and sex had increased risk of OSA (relative risk 1.7 [95% CI 1.0-3.0], P=0.04), compared to those with NC ≤ 95th percentile. BMI ≥ 95th percentile gave similar results (relative risk 1.8 [95% CI 1.1-2.9], P=0.02). When examined by sex, the association was significant in males ≥ 12 years (relative risk 3.3 [95% CI 1.0-10.4], P=0.04), but not females (P=0.63). Neither BMI ≥ 95th percentile nor waist circumference>95th percentile was significant. CONCLUSIONS: Children and youth with NC>95th percentile for age and sex have significantly increased risk of OSA. This effect is significant in males ≥ 12 years, whereas BMI is not. NC percentile may be an additional screening tool for OSA in children and youth.

Does neck-to-waist ratio predict obstructive sleep apnea in children?

OBJECTIVES: Central adiposity and large neck circumference are associated with obstructive sleep apnea (OSA) in adults but have not been evaluated in children as predictors of OSA. Study objectives were to determine whether (1) anthropometric measures including neck-to-waist ratio are associated with OSA in older children; (2) body fat distribution, measured by neck-to-waist ratio, is predictive of OSA in overweight/obese children. METHODS: Cross-sectional study involving children 7-18 years scheduled to undergo polysomnography at a tertiary care children's hospital. OSA was defined as total apnea-hypopnea index > 5 events/h and/or obstructive apnea index > 1 event/h. Recursive partitioning was used to select candidate predictors of OSA from: age, sex, height and weight percentile, body mass index (BMI) z-score, neck-to-waist ratio, tonsil size, and Mallampati score. These were then evaluated using log binomial models and receiver operator characteristic analysis. RESULTS: Two hundred twenty-two participants were included; 133 (60%) were overweight/obese, 121 (55%) male,47 (21%) had OSA. Neck-to-waist ratio (relative risk [RR] 1.97 per 0.1 units, 95% CI 1.48 to 2.84) and BMI z-score (RR 1.63 per unit, 95% CI 1.30 to 2.05) were identified as independent predictors of OSA. Considering only overweight/obese children, neck-to-waist ratio (RR 2.16 per 0.1 units, 95% CI 1.79 to 2.59) and BMI z-score (RR 2.02 per unit, 95% CI 1.25 to 3.26) also independently predicted OSA. However, in children not overweight/obese, these variables were not predictive of OSA. CONCLUSIONS: Neck-to-waist ratio, an index of body fat distribution, predicts OSA in older children and youth, especially in those who were overweight/obese.

Creation of a reference dataset of neck sizes in children: standardizing a potential new tool for prediction of obesity-associated diseases?

BACKGROUND: Neck circumference (NC), is an emerging marker of obesity and associated disease risk, but is challenging to use as a screening tool in children, as age and sex standardized cutoffs have not been determined. A population-based sample of NC in Canadian children was collected, and age- and sex-specific reference curves for NC were developed. METHODS: NC, waist circumference (WC), weight and height were measured on participants aged 6-17 years in cycle 2 of the Canadian Health Measures Survey. Quantile regression of NC versus age in males and females was used to obtain NC percentiles. Linear regression was used to examine association between NC, body mass index (BMI) and WC. NC was compared in healthy weight (BMI < 85th percentile) and overweight/obese (BMI > 85th percentile) subjects. RESULTS: The sample included 936 females and 977 males. For all age and sex groups, NC was larger in overweight/obese children (p < 0.0001). For each additional unit of BMI, average NC in males was 0.49 cm higher and in females, 0.43 cm higher. For each additional cm of WC, average NC in males was 0.18 cm higher and in females, 0.17 cm higher. CONCLUSION: This study presents the first reference data on Canadian children's NC. The reference curves may have future clinical applicability in identifying children at risk of central obesity-associated conditions and thresholds associated with disease risk.

Connexin gene mutations among Ugandan patients with nonsyndromic sensorineural hearing loss.

OBJECTIVES/HYPOTHESIS: Congenital deafness occurs in approximately 1 in 1,000 live births, and 50% of these cases are hereditary. Connexin mutations have been identified as the most common cause of hereditary hearing loss in many populations. The prevalence of this mutation in African patients has not been adequately studied. The objective of this study was to determine the prevalence of connexin 26 and 30 mutations in a population of hearing-impaired patients from Uganda. STUDY DESIGN: This is an observational study. METHODS: Coding regions of both GJB2 and GJB6, noncoding exon 1 of GJB2, and 30 nucleotides of intronic sequence bordering the exons were analyzed in 126 subjects from Uganda with confirmed bilateral, severe-to-profound sensorineural hearing loss. All variants were analyzed for possible clinical significance using a combination of database searches and in silico tools. RESULTS: Complete sequence data were obtained on 115/126 individuals; 11 had only partial or no results. Only one reported pathogenic variant was found in GJB2 (c.208C>G; p.Pro70Ala) and none in GJB6. Three reported variants and two novel variants within intron 1 of GJB2 and two variants within exon 3 of GJB6 were also found. CONCLUSIONS: None of the most common types of deletions in the GJB2 gene (c.35delG, c.167delT or c.235delC) were found in this large cohort of deaf children from Uganda. This prompts a search for genetic causes of deafness among this and other previously studied African populations.

Increased frequency of visits improves the efficiency of surgical global health initiatives.

BACKGROUND: The Uganda Hearing Project is a non-profit program assisting with teaching of ear surgery in Uganda. The project started with cadaveric temporal bone courses in 2003 and 2005, including donation of operating microscopes and ear instruments. In 2006, three surgical groups started regular surgical teaching visits. METHODS: A retrospective chart review of all cases of middle ear surgery performed in Uganda from 2003 to 2009. Surgeries by local surgeons without foreign presence were coded as 'local' and those performed with assistance of visiting surgeons were coded as 'visitors'. RESULTS: In 2005, two middle ear surgeries using the operating microscope were done in the Ugandan teaching hospitals by Ugandan Otolaryngologists alone. From the onset of surgical visits in 2006, a total of 193 middle ear surgeries were performed--115 tympanomastoidectomies, 77 tympanoplasties, and 1 cochlear implant. In 2006 (one surgical teaching visit), 6 middle ear surgeries were performed with visiting surgeon presence and 2 surgeries were performed by the local team alone. This increased in 2007 (2 visits) and again in 2008 (3 visits) to 34 cases with visiting surgeon presence and 48 local cases. CONCLUSIONS: The temporal bone courses and donation of operating microscopes to Ugandan hospitals have revolutionized middle ear surgery in Uganda. The surgical visits by the Uganda Hearing Project have led to a 24-fold increase in annual middle ear surgeries performed with the operating microscope by Ugandan Otolaryngologists. Increased frequency of surgical visits was correlated with an increase in local surgical output, hopefully resulting in improved care for Ugandans with ear disorders.

Success of supraglottoplasty for severe laryngomalacia: the experience from Northeastern Ontario, Canada.

OBJECTIVES: To review the outcomes of supraglottoplasty performed in children with severe laryngomalacia at a pediatric university teaching hospital and to determine if these outcomes are influenced by gender, age at time of supraglottoplasty, or medical comorbidities. METHODS: Retrospective chart review of children who underwent supraglottoplasty for severe laryngomalacia between 2001 and 2010 at the Children's Hospital of Eastern Ontario in Ottawa, Canada. Statistical significance was obtained using 2-tailed Fisher's exact test. The outcome measures were resolution of laryngomalacia symptoms or persistence of laryngomalacia symptoms with or without additional surgery. RESULTS: Among 26 post-primary supraglottoplasty patients, 46.2% had resolution and 53.8% had persistence, including 19.2% with partial improvement and 34.6% requiring revision supraglottoplasty and/or tracheostomy. Resolution was present in 35.7% of males and 58.3% of females (p = 0.43); in 33.3% of all patients ≤2 months old and 52.9% of all patients >2 months old (p = 0.43); and in 50.0% of non-comorbid patients ≤2 months old and 80.0% of non-comorbid patients >2 months old (p = 0.52). 71.4% of persistence cases were found in comorbid patients. 83.3% of comorbid patients had persistence, compared to 28.6% of non-comorbid patients (p=0.008). Of the 3 patients with overlapping comorbid categories, 2 required at least 2 revision supraglottoplasties and ultimately required a tracheostomy. CONCLUSIONS: Persistence of laryngomalacia symptoms post-primary supraglottoplasty was not associated with gender or age at time of surgery, and was more commonly found in children with comorbidities. Patients with coexisting medical conditions appear to require more aggressive surgical management, beyond one revision supraglottoplasty.

A case-control study of repeated adenoidectomy in children.

OBJECTIVES: To determine the rate of repeated adenoidectomy in children and examine the risk factors associated with this condition. DESIGN A retrospective nested case-control study was performed. All cases of adenoidectomy performed at a single pediatric institution between 1990 and 2010 were examined. A total of 168 children who had undergone a repeated adenoidectomy were identified. A 1:1 matched case-control study was performed. The data were analyzed using a conditional logistic analysis. SETTING: Single tertiary pediatric institution. PATIENTS: Children aged 0 to 18 years having undergone at least 1 adenoidectomy. MAIN OUTCOME MEASURES: Risk factors associated with repeated adenoidectomy. RESULTS: A total of 10 948 adenoidectomies were performed in the study period. The rate of repeated adenoidectomy was 1.5% (168 cases). The mean age at first adenoidectomy was significantly lower in the repeated adenoidectomy group (P < .001), and children younger than 5 years at the time of adenoidectomy were 2.5 times more likely to require a repeated procedure. The case-control study identified a strong association between adenoidectomy without tonsillectomy and repeated adenoidectomy, with children who had undergone a repeated adenoidectomy having a 3.68-times higher odds (95% CI, 2.10-6.45) of having an adenoidectomy alone. CONCLUSIONS: Age younger than 5 years and adenoidectomy without tonsillectomy were identified as important risk factors for repeated adenoidectomy in children. Parents should be made aware of the increased risk of adenoid regrowth if surgery is performed at a young age. Children undergoing adenoidectomy alone should be followed up carefully to monitor for symptom recurrence.