Epidemiology of Surgical Procedures, Anesthesia, and Imaging Studies by Gestational Age during the First Year of Life in Medicaid-Insured Infants.

OBJECTIVES: To evaluate the rate of surgical procedures, anesthetic use, and imaging studies by prematurity status for the first year of life we analyzed data for Texas Medicaid-insured newborns. STUDY DESIGN: We developed a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 4 subcohorts: extremely premature, very premature, moderate/late premature, and term. RESULTS: In 1 102 958 infants, surgical procedures per 100 infants were 135.9 for extremely premature, 35.4 for very premature, 15.5 for moderate/late premature, and 6.5 for term. Anesthetic use was 62.0 for extremely premature, 20.8 for very premature, 11.1 for moderate/late premature, and 5.6 for the term subcohort. The most common procedures in the extremely premature were neurosurgery, intubations, and procedures that facilitated caloric intake (gastrostomy tubes and fundoplications). The annual rates for the first year of life for chest radiograph ranged from 15.0 per year for the extremely premature cohort to 0.6 for term infants and for magnetic resonance imaging (MRI) from 0.3 to 0.01. MRI was the most common imaging study with anesthesia support in all maturity levels. MRIs were done in extremely premature without anesthesia in over 90% and in term infants in 57.2%. CONCLUSIONS: Surgical procedures, anesthetic use, and imaging studies in infants are common and more frequent with higher a degree of prematurity while the use of anesthesia is lower in more premature newborns. These findings can provide direction for outcome studies of surgery and anesthesia exposure.

Variation in Utilization and Need for Tympanostomy Tubes across England and New England.

OBJECTIVES: To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries. STUDY DESIGN: This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion. RESULTS: Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was -3.41 per 1000 child-years in England and -0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates. CONCLUSIONS: Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.

Evidence-based medicine in otolaryngology, part 2: the current state of affairs.

What is the current state of evidence-based medicine in otolaryngology? This question inquires about the state of our literature, our attitudes and capabilities, and our patients' desires. Thus, this installment of "Evidence-Based Medicine in Otolaryngology" focuses on these 3 topics. First, the authors consider the literature relative to benchmarks for study design. Second, the data regarding otolaryngologists' and other surgical specialists' attitudes and understanding of clinical data are discussed. Third, patient-based efforts to promote and participate in evidence-based practice are explored. In addition, a discussion of the relevant supportive efforts made by our professional organizations is included.

Determination of the function of the internal branch of the superior laryngeal nerve after thyroidectomy.

BACKGROUND: Several unique complications of thyroidectomy exist because of its regional anatomy; they are well studied and reported. A majority of thyroidectomy patients report vague upper aerodigestive tract complaints. Despite this, no formal assessment of the integrity of the internal branch of the superior laryngeal nerve after thyroidectomy exists in the literature. METHODS: Thirty three patients undergoing thyroidectomy were prospectively evaluated with preoperative and postoperative laryngopharyngeal sensory testing. RESULTS: Preoperatively, 16 patients (49%) reported dysphagia, and 19 (58%) complained of globus sensation. Postoperatively, 24 (73%) patients complained of dysphagia, and 25 (76%) reported globus sensation. Preoperative sensory testing showed a mean sensory threshold of 2.79 +/- 0.51 mm Hg. The mean change in thresholds postoperatively was trivial (0.07 +/- 0.29 mm Hg), and did not differ significantly from zero (p = .19). CONCLUSIONS: Although most patients report significant difficulty swallowing after thyroidectomy, the sensory nerve to the laryngopharynx remains intact and is not at risk during thyroid surgery.

Factors influencing publication of abstracts presented at the AAO-HNS Annual Meeting.

OBJECTIVE: To examine abstracts presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Annual Meeting and to identify factors associated with publication success. STUDY DESIGN AND SETTING: All abstracts published in the August 1999 official program issue of the AAO-HNS Journal were examined. MEDLINE searches were performed to assess publication success. Multivariate analysis was performed to identify factors related to successful publication. RESULTS: We identified 473 abstracts, of which 260 (55%) were poster presentations. Median publication time was 16 months, with a publication rate of 50%. Multivariate analysis revealed oral presentation, statistical analysis, and number of authors to be the most significant predictive factors of publication success (odds ratios of 2.2, 1.9, and 1.2 respectively). Level of evidence did not correlate with publication success, even when case reports (n = 70) were excluded from the analysis. Publication rates in other disciplines ranged from 25% to 68%, with a mean of 47%. CONCLUSIONS: The rate of publication from the AAO-HNS Annual Meeting is similar to other disciplines. Oral presentations with inferential statistics in the abstract were most likely to be published. Conversely, level of evidence and direction of study inquiry were not significant predictors, suggesting that research design is a less important determinant of publication success. SIGNIFICANCE: Our investigation is one of the first to critically analyze the factors in presentations at annual meetings that predict successful publication.

Levels of evidence in otolaryngology journals.

OBJECTIVE: To identify trends in clinical research and levels of evidence in otolaryngology journals. STUDY DESIGN AND SETTING: We reviewed all original research articles from 1993, 1998, and 2003, in 4 major otolaryngology journals. Levels of evidence were graded 1 (strongest) through 5 (weakest). RESULTS: Of 2584 total articles, 1924 (75%) were clinical research. During the study period, there was increased median sample size (from 22 to 30, P=0.06), more planned research (from 30% to 37%, P=0.023), more internal control groups (from 36% to 43%, P=0.011), and more articles with P values (from 26% to 45%, P<0.001) or confidence intervals (from 1.2% to 7.6%, P<0.001). Most evidence was level 4 (57%), but median levels increased slightly over time (P=0.027). Therapy articles had the weakest evidence (80% levels 3 to 5) and diagnostic test assessments had the strongest (75% levels 1 and 2). CONCLUSION: Although clinical research increased in quantity and quality, sample sizes were modest, most articles lacked controls, and confidence intervals were rare. Therapy articles would benefit from higher evidence levels. SIGNIFICANCE: By defining the current levels of evidence in otolaryngology journals, this overview should help guide future efforts.

Systematic review of topical antimicrobial therapy for acute otitis externa.

OBJECTIVE: To determine the efficacy of topical antimicrobials for acute otitis externa. STUDY DESIGN: Systematic review and random effects meta-analysis of randomized, controlled trials with parallel groups permitting one or more of the following comparisons: antimicrobial vs placebo, antiseptic vs antimicrobial, quinolone antibiotic vs nonquinolone antibiotic, steroid-antimicrobial vs antimicrobial, or antimicrobial-steroid vs steroid. RESULTS: Twenty trials met inclusion criteria and 18 had data suitable for pooling. Topical antimicrobials increased absolute clinical cure rates over placebo by 46% (95% confidence interval [CI], 29% to 63%) and bacteriologic cure rates by 61% (95% CI, 46% to 76%). No significant differences were noted in clinical cure rates for other comparisons, except that steroid alone increased cure rates by 20% compared with steroid plus antibiotic (95% CI, 3% to 38%). Quinolone drops increased bacteriologic cure rates by 8% compared with nonquinolone antibiotics (95% CI, 1% to 16%), but had statistically equivalent rates of clinical cure and adverse events. CONCLUSION: Topical antimicrobial is highly effective for acute otitis externa with clinical cure rates of 65% to 80% within 10 days of therapy. Minor differences were noted in comparative efficacy, but broad confidence limits containing small effect sizes make these of questionable clinical significance. SIGNIFICANCE: Summary estimates from the 13 meta-analyses can be used to facilitate evidence-based management recommendations and clinical practice guideline development.

Intraoperative evaluation of a pulsatile oropharyngeal mass during adenotonsillectomy.

Iatrogenic injury to the internal carotid artery (ICA) is a rare complication of pharyngeal surgery that most commonly occurs in children with an anomalous course to the internal carotid artery. Most aberrant arteries are asymptomatic. They can remain undiscovered preoperatively or be found incidentally on radiographic studies completed for an unrelated reason. Evaluation of definitive internal carotid artery injuries is well documented in the trauma literature. We present a case of a suspected intraoperative injury to the internal carotid artery during routine pharyngeal surgery. Ultimately no injury was found, however, aberrant internal carotid arteries were coincidentally discovered.

Parathyroid adenoma autoinfarction: a report of a case.

BACKGROUND: Parathyroid adenoma autoinfarction, although uncommon, is an entity that has been previously reported in the literature; however, the influence of intraoperative parathyroid hormone (PTH) monitoring on therapeutic management has not been reported. METHODS: We present a case of parathyroid autoinfarction that is unique in that it applies a new technology to parathyroid surgery: intraoperative PTH monitoring. RESULTS: Intraoperative PTH monitoring aided in the successful surgical management of this patient. CONCLUSIONS: Intraoperative PTH monitoring can serve as a therapeutic adjunct in the surgical management of parathyroid adenoma autoinfarction.