A Step towards Achieving Sustainable Otologic Surgery in Low-Resource Settings: A Cost Comparison between Shipping an Otologic versus Microscopic Surgical Setup.

Background: The advancement of otologic surgery in low-resource settings has been limited by the cost and transport of surgical equipment. This study compared the transportation costs of an otologic microscopic surgical setup (MSS) versus an endoscopic surgical setup (ESS) in low- and low to middle-income countries (LMICs) for surgical teaching. Methods: Dimensions of microscopes, endoscopes and associated surgical instruments were used to calculate shipping costs from Minneapolis, MN, USA to Kenya, Haiti and Sri Lanka. Results: The average cost of internationally shipping the ESS is less than the MSS in Kenya (ESS: USD 1344.03; MSS: USD 20,947.00; p = 0.370), Haiti (ESS: USD 549.11; MSS: USD 1679.00; p < 0.05) and Sri Lanka (ESS: USD 945.38; MSS: USD 8490.57; p = 0.377). Freight shipping was required for the MSS while the ESS can be packed into an international checked bag for USD 35.00 USD. Discussion: The ESS has fewer logistical barriers than the MSS, making the endoscope a feasible option for surgical teaching in LMICs.

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group.

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Cost Analysis of an Annual School-Based Pediatric Hearing Screening Program in Semi-Rural Kenya.

INTRODUCTION: Approximately 8.9 million children in Sub-Saharan Africa have disabling hearing loss, accounting for 11% of the global child healthcare hearing costs. For children living in Low- and Middle-Income Countries (LMICs), 75% of hearing loss is preventable. METHODS: We evaluate the overall intervention and expansion costs of a humanitarian, pediatric hearing health and screening program in Malindi, Kilifi County, Kenya. A cost analysis is conducted from the provider perspective, identifying the mean cost incurred for each case of newly identified hearing loss. Estimates were made for 3 different cost scenarios. A one-way sensitivity analysis and probabilistic sensitivity analysis using Monte Carlo simulation determined the impact of variations in individual cost parameters. These results were used to project scale-up costs to achieve sub-county expansion of the program. RESULTS: 155 children ages 5 to 16 years old were screened, of which 5.8% were diagnosed with hearing impairment. The total cost for implementation in four schools was $6,783 USD, thus a mean cost of $212 per diagnosis of hearing loss. The highest proportion of costs were recurrent costs of resident travel (27.9%), capital costs for providing audiometric testing (25.3%), and equipment maintenance (18.7%). Expansion of an exclusively CHW-run program across all 77 primary public schools in Malindi is projected to be $130,573 (range $119,352 to $142,240). CONCLUSION: We provide relevant cost-estimation for an expansion of an intervention which identified higher than average rates of hearing loss. Humanitarian aid plays a key role in the sustainability and feasibility of expanding this program.

Universal newborn hearing screening in South Africa: a single-centre study.

Hearing screening for newborn babies is an established protocol in many high-income countries. Implementing such screening has yielded significant socioeconomic advantages at both an individual and societal level. This has yet to permeate low/middle-income countries (LMIC). Here, we illustrate how newborn hearing screening needs to be contextually adapted for effective utilisation and implementation in an LMIC. Specifically, this advocates the use of auditory brainstem testing as the first-line approach. We propose that such adaptation serves to maximise clinical efficacy and community participation at a reduced cost.

Eosinophilic Granulomatosis With Polyangiitis: An Unusual Case of Pediatric Subglottic Stenosis.

Systemic disease is an uncommon cause of subglottic stenosis (SGS). We report a case of severe SGS due to underlying eosinophilic granulomatosis with polyangiitis (EGPA) in a child presenting with isolated stridor. EGPA is a rare systemic vasculitis with very limited cases reported in the pediatric population. While surgical intervention was required given the degree of stenosis in this case, medical management of the underlying systemic disease process is critical when there is clinical suspicion of SGS in the context of systemic vasculitis. Laryngoscope, 131:656-659, 2021.

Teacher Prescreening for Hearing Loss in the Developing World.

The goal of this prospective cohort study was to characterize the ability of teachers to identify schoolchildren at risk of hearing loss in order to maximize hearing screening efficiency in low-resource settings. At 4 semirural schools in Malindi, Kenya, preselected schoolchildren perceived as hearing impaired were compared to children thought to have normal hearing using portable audiometry. Eight of 127 children (54% male) failed hearing screening, all of who were identified by schoolteachers as having a high risk of hearing loss. Thus, for every 5 children prescreened by schoolteachers, an average of 1 child would be identified as having hearing loss. Overall, teacher prescreening had a 100% hearing loss identification rate and a 20% referral rate. In conclusion, in resource-limited settings, where universal hearing screening is challenging, teachers can effectively identify children with hearing loss for early intervention.

A Sustainable and Scalable Multidisciplinary Airway Teaching Mission: The Operation Airway 10-Year Experience.

OBJECTIVE: To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy. STUDY DESIGN: Consecutive case series with chart review. SETTING: This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic. METHODS: Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes. RESULTS: A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded. CONCLUSION: This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.

Pediatric, Family-Centered, "At-Home" Otologic Physical Examination in the COVID-19 Era.

SARS-CoV-2, the novel coronavirus resulting in the present COVID-19 pandemic, has increased the otolaryngologist's reliance on telemedicine to manage outpatient pathology. The nature of telemedicine, however, limits a provider's ability to obtain a comprehensive physical examination, specifically of the tympanic membrane. Various smartphone-based otoscopic attachments are now available that facilitate patient-obtained otoscopic image capture of the tympanic membrane. Here, we present 3 cases in which a patient-purchased, over-the-counter otoscope was utilized to alter otologic management during the time of social distancing. Further research is necessary to improve our understanding the safety and efficacy of patient-based "at-home" otoscopic examination and to optimize the use of these devices.

Family-Centered Information Dissemination: A Multidisciplinary Virtual COVID-19 "Town Hall".

Significant misinformation about COVID-19 has been spread on the internet. Parents of children with complex aerodigestive problems have a hard time understanding the information they encounter on the internet and the news media and interpreting how it relates to their child's complex needs. Our multidisciplinary team, at the suggestion of a parent, hosted 3 virtual "town halls" in which families could ask questions directly of pediatric otolaryngology, pediatric pulmonology and case management in order to efficiently obtain factual evidence-based up-to-date advice. The information discussed at the town halls was then annotated and disseminated via active, parent-run aerodigestive social media forums. The information disseminated via the town halls reached 4787 Facebook participants.

Working towards consensus in the management of pediatric chronic rhinosinusitis in cystic fibrosis.

OBJECTIVE: The prevalence of chronic rhinosinusitis (CRS), defined by mucosal thickening on imaging, approaches 100% in the cystic fibrosis (CF) population. CRS is associated with significant morbidity in CF, including its ability to trigger pulmonary exacerbations. CRS in CF is typically managed by pediatricians, otolaryngologists and pulmonologists. This survey evaluates the variance in practice patterns of CRS in CF amongst specialists. METHODS: This is a cross-sectional, electronic survey in which maximum variation purposive sampling was used by a multi-disciplinary group of pediatric, otolaryngology and pulmonology providers in order to select a survey population with expertise in CRS in CF patients. The survey was distributed to 381 practitioners from September to October 2019. RESULTS: 175 participants responded (45% response rate). Ten (of 54) statements achieved 75% consensus agreement. Consensus statements included: The decision to pursue surgical intervention for CRS in CF is a multi-disciplinary approach (94%; n = 146); maximal medical management should include nasal saline irrigation (93%; n = 142), topical steroids (75%; n = 117), maximal medical management should not include intravenous steroids (79%; n = 122); image guidance in surgery is necessary for all surgery involving the frontal sinuses (77%; n = 43), and all revision surgery(80%, n = 45); the appropriate setting for sinus surgery in a CF patient varies depending on patient presentation (89%; n = 133); post-operative regimen should include nasal saline (93%; n = 137); but does depend on the severity of disease discovered intra-operatively (84%; n = 124); post-operative antibiotics should be guided by intra-operative culture data (82%; n = 121). CONCLUSIONS: There is a great deal of variation amongst specialists in the treatment of CRS in CF, however 10 statements met consensus criteria and should be considered when forming clinical care guidelines in this population.

Laryngotracheal Reconstruction in the Pediatric Burn Patient: Surgical Techniques and Decision Making.

The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multidisciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific LTR techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus, and neck contractures-the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision making regarding pursuing single-stage LTR, double-stage LTR, and 1.5-stage LTR can be challenging-the authors recommend 1.5-stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include obtaining intravenous access, securing the airway, and intravenous induction-the authors recommend peripherally inserted central catheter when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the TBSA covered by the burn injury-the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric LTR in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision making.

Modified external approach to the pediatric cricopharyngeal myotomy: A case series.

OBJECTIVE: To assess the success of a modified approach to external pediatric cricopharyngeal myotomy in children with inappropriate upper esophageal sphincter relaxation as determined by video fluoroscopic swallow study (VFSS) and pediatric manometry findings. METHODS: This is a case series in which hospital records of all patients who underwent a modified external approach to pediatric cricopharyngeal myotomy 2017 to 2019 were reviewed at a single institution. The primary outcome measure was post-operative diet and presence of aspiration/penetration on post-operative VFSS. RESULTS: A total of 7 patients underwent modified external approach to pediatric cricopharyngeal myotomy. The average age of the child at the time of surgery was 5.6 (±3.7) years. The average duration (SD) of surgery was 90 (±30) minutes and no complications were observed. 6 of 7 patients (86%) demonstrated an improvement in swallow function after the procedure. The single child who did not was suffering from a posterior fossa tumor which was resected and radiated, which likely made their dysphagia multi-factorial. Although no pediatric normative data exists for upper esophageal sphincter pressure, we observed an average decrease in UES residual pressure of 8.5 (±15.1) mmHg and an average decrease in mean UES pressure of 21.2 (±35.1) mmHg. CONCLUSIONS: The modified external approach to the pediatric cricopharyngeal myotomy appears to be a safe and efficient procedure with no apparent complications to date. However, further longitudinal data is needed to formally evaluate the efficacy of this procedure when treating pediatric cricopharyngeal achalasia.

Community health workers obtain similar results using cell-phone based hearing screening tools compared to otolaryngologists in low resourced settings.

OBJECTIVE: To establish community health workers as reliable hearing screening operators in a technology-based pre-surgical hearing screening program in a low and middle-income country (LMIC). METHODS: This is a cross sectional study that evaluated community health worker driven hearing screening that took place in semi-rural Malindi, Kenya during an annual two-week otolaryngology surgical training mission in October 2017. At five separate locations (four schools) near Malindi, Kenya, children between the ages of 2-16 underwent hearing screening using screening audiometry (Android-based HearX Group). Children were screened by a community health worker who underwent a short training course, a senior otolaryngology resident, or both. Hearing screening results were compared to determine the reliability and concordance between independent, blinded community health worker and otolaryngology resident testing. RESULTS: One hundred and four participants (53% males) underwent hearing screening. Hearing screening pass rate was 93%. Community health workers obtained a similar result to otolaryngology residents 96% of the time (McNemar test: p = 0.16, OR 0.96, 95% CI 0.9-1.0). CONCLUSION: Community health workers can obtain reliable results using a technology-based, pre-surgical hearing screening platform when compared to otolaryngology residents. This finding has profound implications in low-resourced settings where hearing healthcare specialists (audiologists and otolaryngologists) are limited and can ultimately improve the surgical yield of patients presenting to local otolaryngologists in these settings.

Early Surgical Management of Thermal Airway Injury: A Case Series.

Inhalation injury is an independent risk factor in burn mortality, imparting a 20% increased risk of death. Yet there is little information on the natural history, functional outcome, or pathophysiology of thermal injury to the laryngotracheal complex, limiting treatment progress. This paper demonstrates a case series (n = 3) of significant thermal airway injuries. In all cases, the initial injury was far exceeded by the subsequent immune response and aggressive fibroinflammatory healing. Serial examination demonstrated progressive epithelial injury, mucosal inflammation, airway remodeling, and luminal compromise. Histologic findings in the first case demonstrate an early IL-17A response in the human airway following thermal injury. This is the first report implicating IL-17A in the airway mucosal immune response to thermal injury. Their second and third patients received Azithromycin targeting IL-17A and showed clinical responses. The third patient also presented with exposed tracheal cartilage and underwent mucosal reconstitution via split-thickness skin graft over an endoluminal stent in conjunction with tracheostomy. This was associated with rapid abatement of mucosal inflammation, resolution of granulation tissue, and return of laryngeal function. Patients who present with thermal inhalation injury should receive a thorough multidisciplinary airway evaluation, including early otolaryngologic evaluation. New early endoscopic approaches (scar lysis and mucosal reconstitution with autologous grafting over an endoluminal stent), when combined with targeted medical therapy aimed at components of mucosal airway inflammation (local corticosteroids and systemic Azithromycin targeting IL-17A), may have potential to limit chronic cicatricial complications.

Revision surgery following minimally invasive image-guided cochlear implantation.

Minimally invasive image-guided cochlear implantation (CI) research continues to progress. We previously performed the procedure in nine patients. Herein, we describe the first revision operation for device failure following minimally invasive image-guided CI. It was possible to reuse the original drill channel, obviating the need to convert to a wide-field mastoidectomy. Revision surgery, if required, can therefore be performed safely after minimally invasive image-guided CI. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1458-1461, 2019.

Expanding the Capacity of Otolaryngologists in Kenya through Mobile Technology.

OBJECTIVE: To determine if reliable, objective audiologic data can be obtained by nonotolaryngology and nonaudiology practitioners using novel mobile technology in an effort to expand the capacity for early identification and treatment of disabling hearing loss in the developing world. STUDY DESIGN: Cross-sectional, proof-of-concept pilot study. SETTING: Screenings took place during an annual 2-week otolaryngology surgical mission in October 2016 in semirural Malindi, Kenya. SUBJECT AND METHODS: Eighty-seven patients (174 total ears) were included from 2 deaf schools (n = 12 and 9), a nondeaf school (n = 9), a tuberculosis ward (n = 8), and a walk-in otology clinic at a local hospital (n = 49). An automated, tablet-based, language-independent, clinically validated, play audiometry system and wireless otoscopic endoscopy via an iPhone or laptop platform was administered by Kenyan community health workers (CHWs) and nursing staff. RESULTS: Various degrees of hearing loss and otologic pathology were identified, including 1 child presumed to be deaf who was found to have unilaterally normal hearing. Other pathology included 2 active perforations, 2 healed perforations, 2 middle ear effusions, and 1 cholesteatoma. CHWs and nursing staff demonstrated proficiency performing audiograms and endoscopy. Patients screened in a deaf school were more likely to complete an unreliable audiogram than patients screened in other settings (P < .01). CONCLUSION: This study demonstrates the feasibility of a non-otolaryngology-based hearing screening program. This may become an important tool in reducing the impact of hearing loss and otologic pathology in areas bereft of otolaryngologists and audiologists by allowing CHWs to gather important patient data prior to otolaryngologic evaluation.

Evidence-Based Use of Perioperative Antibiotics in Otolaryngology.

Objective To identify and clarify current evidence supporting and disputing the effectiveness of perioperative antibiotic use for common otolaryngology procedures. Data Sources PubMed, Embase (OVID), and CINAHL (EBSCO). Review Methods English-language, original research (systematic reviews/meta-analyses, randomized control trials, prospective or retrospective cohort studies, case-control studies, or case series) studies that evaluated the role of perioperative antibiotic use in common otolaryngology surgeries were systematically extracted using standardized search criteria by 2 investigators independently. Conclusions Current evidence does not support routine antibiotic prophylaxis for tonsillectomy, simple septorhinoplasty, endoscopic sinus surgery, clean otologic surgery (tympanostomy with tube placement, tympanoplasty, stapedectomy, and mastoidectomy), and clean head and neck surgeries (eg, thyroidectomy, parathyroidectomy, salivary gland excisions). Antibiotic prophylaxis is recommended for complex septorhinoplasty, skull base surgery (anterior and lateral), clean-contaminated otologic surgery (cholesteatoma, purulent otorrhea), and clean-contaminated head and neck surgery (violation of aerodigestive tract, free flaps). In these cases, antibiotic use for 24 to 48 hours postoperatively has shown equal benefit to longer duration of prophylaxis. Despite lack of high-quality evidence, the US Food and Drug Administration suggests antibiotic prophylaxis for cochlear implantation due to the devastating consequence of infection. Data are inconclusive regarding postoperative prophylaxis for nasal packing/splints after sinonasal surgery. Implications for Practice Evidence does not support the use of perioperative antibiotics for most otolaryngologic procedures. Antibiotic overuse and variability among providers may be due to lack of formal practice guidelines. This review can help otolaryngologists understand current evidence so they can make informed decisions about perioperative antibiotic usage.