Assessing the Relationship Between Infection Frequency and Risk of Post-Tonsillectomy Hemorrhage.

OBJECTIVE: To determine the relationship between frequency of tonsillitis and the risk of post-tonsillectomy hemorrhage (PTH) in pediatric patients undergoing tonsillectomy for recurrent tonsillitis. METHODS: After obtaining IRB approval from Nationwide Children's Hospital, charts for all patients who underwent a total tonsillectomy in 2017 for recurrent or chronic tonsillitis were retrospectively reviewed (n = 424). Patients were divided into 2 cohorts based on the frequency of tonsillitis prior to surgery: those meeting the 1-year criteria with 7 or more infections in the past year (n = 100), and those who did not meet criteria defined as those with fewer than 7 infections in the past year (n = 324). The primary outcome of interest was PTH. Comparison of cohorts and frequency of PTH were assessed using bivariate analyses. Kaplan-Meier curves were used to compare time to onset of hemorrhage between primary vs. secondary PTH. Generalized mixed and logistic regression models were used to evaluate risk of hemorrhage following tonsillectomy. RESULTS: Among a total cohort of 424 patients undergoing tonsillectomy, 23.58% (n = 100) met criteria while 76.42% (n = 324) did not. A total of 8.73% (n = 37) patients experienced PTH. Compared to those who did not meet criteria, those who met criteria had a higher odds of developing PTH; however, this was not significant (OR: 1.42 [95% CI: 0.67, 2.98], P = .3582). Estimated probability of developing PTH for those who met criteria was 11% [95% CI: 6.19, 18.81] compared to 8.03% [95% CI: 5.52, 11.54] for those who did not meet criteria. Among all PTH cases, 5.41% (n = 2) were primary hemorrhage while 94.59% (n = 35) were secondary hemorrhage with 50% of those with secondary PTH having experienced hemorrhage within 6 days [95% CI: 5, 7] of tonsillectomy. Patients with neuromuscular conditions had significantly higher odds of PTH (OR: 4.75 [95% CI: 1.19, 18.97], P = .0276). CONCLUSION: Patients who met the 1-year criteria for tonsillectomy did not have a significantly higher odds of PTH. Further research is needed to better evaluate the relationship between infection frequency and risk of PTH.

Tolerance of one-way in-line speaking valve trials in ventilator dependent children.

BACKGROUND: Despite the advantages of tracheostomy placement in children requiring prolonged mechanical ventilation, vocalization and verbal communication remains limited in this population of children. The lack of these essential elements during a critical period of development can have a negative impact on overall development. In ventilator dependent children, in-line speaking valves (ISV) provide an opportunity for initiating speech and communication. The objective of this study is to examine patient characteristics and risk factors associated with tolerance and success of ISV trials performed with mechanically ventilated children. METHODS: A retrospective cohort study was conducted at a large, tertiary care children's hospital to evaluate the outcomes of ISV trials in ventilator-dependent children with tracheostomies, from 2009 to 2019. The primary endpoints were tolerance of the initial ISV assessment, and successful completion of a trial. We compared demographic and clinical characteristics among children that had a successful ISV trial to those that did not. RESULTS: Eighty-nine patients were included, 56 (62%) were male and 33 (38%) were female. Overall, 76 (85%) patients completed an ISV assessment and trial successfully during their hospitalization. The number of attempts before completing a successful trial varied with 41 (46%) patients succeeding on the first attempt. Children that underwent a tracheostomy for airway obstruction were more likely to fail. CONCLUSIONS: Ventilator-dependent children with complex comorbidities demonstrate excellent tolerance of in-line speaking valves. Patients should be selected for ISV trials in a multidisciplinary setting. Airway obstruction as an indication for tracheostomy placement is a significant predictor of failure for ISV trials.

Outcomes intensive care unit placement following pediatric adenotonsillectomy.

INTRODUCTION: Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care. METHODS: This is a retrospective chart review from the years of 2009-2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU. RESULTS: There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement. CONCLUSIONS: This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.

Investigation of Novel Grafts in Use for Pediatric Tympanoplasty.

OBJECTIVES: To evaluate the impact of allograft and xenograft in pediatric tympanoplasty on patient outcomes. METHODS: A retrospective cohort study of 50 pediatric patients undergoing tympanoplasty at a single tertiary pediatric hospital system that received either autograft, allograft, or xenograft. Patients were evaluated for persistent perforation, recurrent perforation, revision surgery, and postoperative infection. Hearing outcomes, operative charges, and operative time were also evaluated. Statistical analyses included chi-square and Fisher exact tests for categorical data and Wilcoxon-Mann-Whitney tests for continuous data. RESULTS: Half of the cohort received autografts, whereas 38% received xenografts and 14% received allografts. Although there was not a significant difference in charges associated with these procedures, xenografts had the shortest mean operative time (mean: 39 vs 68 minutes in autografts, p = .05). Overall, the rate of persistent perforation was 10%, recurrent perforation was 20%, revision surgery was 16%, and postoperative infection was 18%. There were no differences in the rates of these outcomes by graft type. Furthermore, there was no observed difference in hearing outcomes among autograft and xenograft recipients, but allograft recipients had significantly improved hearing postoperatively. CONCLUSIONS: Similar rates of complications were observed among autografts, xenografts, and allografts, providing preliminary evidence that they are safe to use in pediatric tympanoplasty.