Survey of Pediatric Otolaryngology Frenotomy Practice Patterns.

OBJECTIVES: Assess current frenotomy practice patterns of pediatric otolaryngologists via a cross-sectional survey. STUDY DESIGN: Survey study. METHODS: A 31-question electronic survey assessing frenotomy practice patterns was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were used to summarize responses and demographics of respondents. RESULTS: Of all ASPO members, 41% (240/588) completed the survey. Most respondents, 185 (77%), reported increased frenotomy referrals over the last 5 years and 144 (60%) described the current number of referrals as "too many." The two primary lingual frenotomy indications identified in infants were: breastfeeding/nipple pain (92%) and inability to latch (83%). For older children, speech difficulty (87%) was the primary indication. Maxillary frenotomy indications in infants varied amongst respondents. For analgesia during in-office frenotomy procedures, respondents used glucose/sucrose drops (48%), topical lidocaine (29%), or no pain control measure (27%). For post-procedure care, respondents recommended continuing lactation support (45%), massaging/stretching the wound (38%), or none (40%). Most respondents, 143 (60%), reported having seen a complication from frenotomy, and the most reported frenotomy complications were frenulum re-attachment and excessive bleeding. CONCLUSIONS: In the last 5 years, otolaryngologists have seen an increase in referrals for frenotomy. Pediatric otolaryngologists have varying practice patterns with regards to ankyloglossia diagnosis and treatment. The reported indications for frenotomy varied amongst pediatric otolaryngologists especially with respect to maxillary frenotomy. Practice patterns also varied with respect to procedural pain control and frenotomy aftercare recommendations. More frenotomy research is needed to establish a standard of care for patients with ankyloglossia. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:2505-2512, 2022.

Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy of upper airway surgery for children with persistent obstructive sleep apnea after adenotonsillectomy and to assess sleep study outcomes when Drug Induced Sleep Endoscopy, Cine MRI, or other imaging procedure is performed to assist in identifying the location of obstruction and planning surgery. METHODS: Systematic review and meta-analysis was performed. Inclusion criteria was English-language studies with original data including pediatric patients with persistent OSA after T&A. Exclusion criteria included case reports and lack of pre and post-operative sleep study data. Data Sources were PubMed, Cochrane Central, and Embase from 2000 to 2018. PRISMA standards were followed for the selection and review of articles. The Newcastle-Ottawa Quality Assessment scale was used to score the quality of evidence of the studies. All manuscripts were reviewed independently by two investigators. Primary outcome measures were apnea-hypopnea index and minimum oxygen saturation. Data was pooled using a random-effects model. RESULTS: Of the 1902 abstracts identified, 11 studies (214 patients) met inclusion criteria for systematic review, 5 with Drug Induced Sleep Endoscopy as the diagnostic technique, 4 with Cine MRI, and 2 with MRI/CT. All studies were case series. Most subjects had syndromic comorbidities and/or obesity. Ten studies (198 patients) were included in the meta-analysis. Overall, there was a change in apnea hypopnea index of -6.51 (95% CI, -8.17 to - 4.85; p < 0.001) and an increase in minimum oxygen saturation by 3.24% (95% CI, 1.49%-4.98%; p < 0.001) following surgical intervention. Both Drug Induced Sleep Endoscopy and Cine MRI directed surgeries resulted in significant improvement in sleep study parameters. The two techniques could not be directly compared due to significant differences in co-morbidity rates between patients. CONCLUSIONS: Surgery for pediatric persistent obstructive sleep apnea improves apnea hypopnea index and minimum oxygen saturation but does not resolve the disease. This is true when both Drug Induced Sleep Endoscopy and Cine MRI findings were used to direct surgery.

Diagnostic Criteria for Detection of Vestibular Schwannomas in the VA Population.

OBJECTIVE: To investigate the prevalence of vestibular schwannoma (VS) and asymmetric sensorineural hearing loss in the Veterans Administration hospital population and analyze a more efficient method of diagnosing VS in a population with significant noise exposure. STUDY DESIGN: Retrospective review of South Central (VISN 16) Veterans Administration hospitals. METHODS: Record query for ICD-9 codes for asymmetric sensorineural hearing loss or VS between 1999 and 2012. Patient demographics, signs and symptoms at presentation, audiogram and imaging data, and management data were collected and analyzed. Audiograms from tumor patients were compared with controls matched for age, sex, combat experience, and medical comorbidity (2:1 control to case ratio). RESULTS: The prevalence of VS was 1 per 1,145 patients in this population, with average age at diagnosis of 62. Patients with VS presented more commonly with unilateral tinnitus, rollover, and absent acoustic reflexes when compared with matched controls, but positive predictive value was low. Published criteria for defining hearing asymmetry showed variable sensitivity (51-89%) and low specificity (0-42%) for the detection of VS in this population. Criteria meeting the definitions of significant asymmetry with specificity for VS of 80% or greater were as follows: >15 dB threshold difference at 3 kHz and unilateral tinnitus, ≥45 dB threshold difference at 3 kHz regardless of tinnitus, or when the word recognition score difference was ≥80%. With serial audiograms 2.5 years apart or greater, a ≥10 dB threshold increase at any frequency between 0.5 and 4 kHz had a 100% sensitivity for tumor and a ≥10 dB increase at 3 kHz had a specificity of 84%. The majority of patients were observed, whereas only 30% had surgery. Patients who were observed were older than those treated with surgery or radiation (p <0.001). CONCLUSION: Typical audiometric screening criteria should be modified in the veteran population to improve cost efficiency of diagnosis. Observation is the primary management strategy in the veteran population because of age.