Algorithm for Airway Management in Patients With Pierre Robin Sequence.

PURPOSE: Airway management in neonates with Pierre Robin sequence (PRS) can be challenging. The goal was to describe the algorithm developed by the authors over the past 8 years. METHODS: A retrospective case series analyzing airway management in neonates with PRS admitted to the neonatal intensive care unit at a tertiary care pediatric hospital was performed. The utility of the proposed algorithm for airway management incorporating more consistent use of polysomnography (PSG), and airway assessment was assessed. RESULTS: A total of 31 neonates with PRS (12 men, 19 women) with a mean gestational age of 38.2 weeks were analyzed. Thirteen (41.9%) patients had a named syndrome, chromosomal abnormality, or global delay. Twenty (64.5%) patients had pre-intervention PSG, and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) ≥ 10 events/hour was identified in 19 (95.0%). Mandibular distraction osteogenesis was performed in 18 (58.1%) patients, and improved the AHI on post-operative PSGs. Direct assessment of the upper and lower airways was performed in 19 patients, and 13 (68.4%) were found to have secondary airway pathology. Presence of a concomitant syndrome was significantly associated with need for tracheostomy. CONCLUSION: The algorithm differs from previous ones in that it relies on rigorous pre- and post-intervention PSG (including with a nasopharyngeal airway), as well as that it allows flexibility between treatment options given the whole-patient clinical scenario and endoscopic findings. Results from these studies may be integrated to stratify patients into those who are most likely to benefit from conservative interventions or surgical procedures.

Graft Transit Time Has No Effect on Outcome of Unrelated Donor Hematopoietic Cell Transplants Performed in Australia and New Zealand: A Study from the Australasian Bone Marrow Transplant Recipient Registry.

A previous study found that platelet recovery and mortality were worse in recipients of myeloablative bone marrow transplants where graft transit times were longer than 20 hours. This retrospective study of unrelated myeloablative allogeneic transplantation performed within Australia and New Zealand analyzed transplant outcomes according to graft transit times. Of 233 assessable cases, 76 grafts (33%) were sourced from bone marrow (BM) and 157 (67%) from peripheral blood. Grafts sourced from Australia and New Zealand (47% of total) were associated with a median transit time of 6 hours versus 32 hours for overseas sourced grafts (53% of total). Graft transit temperature was refrigerated in 85%, ambient in 6%, and unknown in 9% of cases, respectively. Graft transit times had no significant effect on neutrophil or platelet engraftment, treatment-related mortality, overall survival, and incidence of acute or chronic graft-versus-host disease. Separate analysis of BM grafts, although of reduced power, also showed no significant difference in either neutrophil or platelet engraftment or survival between short and longer transport times. This study gives reassurance that both peripheral blood stem cell and especially BM grafts subjected to long transit times and transported at refrigerated temperatures may not be associated with adverse recipient outcomes.

Functional invariant natural killer T-cell and CD1d axis in chronic lymphocytic leukemia: implications for immunotherapy.

Invariant natural killer T cells recognize glycolipid antigens such as α-galactosylceramide presented by CD1d. In preclinical models of B-cell malignancies, α-galactosylceramide is an adjuvant to tumor vaccination, enhancing tumor-specific T-cell responses and prolonging survival. However, numerical and functional invariant natural killer T-cell defects exist in patients with some cancers. Our aim was to assess this axis in patients with chronic lymphocytic leukemia. The numbers of circulating invariant natural killer T cells and the expression of CD1d on antigen-presenting cells were evaluated in patients with chronic lymphocytic leukemia and age-matched controls. Cytokine profile and in vitro proliferative capacity were determined. Patient- and control-derived invariant natural killer T-cell lines were generated and characterized, and allogeneic and autologous responses to α-galactosylce-ramide-treated leukemia cells were assessed. Absolute numbers and phenotype of invariant natural killer T cells were normal in patients with untreated chronic lymphocytic leukemia, and cytokine profile and proliferative capacity were intact. Chemotherapy-treated patients had reduced numbers of invariant natural killer T cells and myeloid dendritic cells, but α-galactosylceramide-induced proliferation was preserved. Invariant natural killer T-cell lines from patients lysed CD1d-expressing targets. Irradiated α-galactosylceramide-treated leukemic cells elicited allogeneic and autologous invariant natural killer T-cell proliferation, and α-galactosylceramide treatment led to increased proliferation of conventional T cells in response to tumor. In conclusion, the invariant natural killer T-cell and CD1d axis is fundamentally intact in patients with early-stage chronic lymphocytic leukemia and, despite reduced circulating numbers, function is retained in fludarabine-treated patients. Immunotherapies exploiting the adjuvant effect of α-galactosylceramide may be feasible.

Pre-operative ultrasound guided wire localization for recurrent or persistent thyroid disease: A series of four cases.

INTRODUCTION: Successful pediatric revision thyroid surgery depends primarily on effective localization of recurrent or persistent lesions. Secondary to fibrosis and scarring, blind regional dissection can fail to retrieve the tissues of concern. Conventionally, high resolution CT or ultrasound of the neck has been used to map lesions within the thyroid bed. The success rate of excising recurrent lesions using these mapping techniques is at best 80%. We present a small series of patients in which hook wire localization was used to help localize and excise recurrent and/or persistent neck disease during secondary operations. METHODS: The wire-localization technique was utilized for a prospective case series of four pediatric patients with history of previous thyroidectomy and recurrent or persistent malignant thyroid disease. RESULTS: All four patients had recurrence or persistence of their disease process in the central or lateral neck. Patients successfully underwent preoperative hook wire localization of their persistent or recurrent neck lesions with successful subsequent neck dissection. Each case involved a single wire localization for a unique mass, equally a total of 4 lesions accessed by the technique over the four cases. The ultrasound-guided wire-localization technique assisted in the localization and excision of non-palpable lesions. No complications were seen in our small series as a result of this technique. CONCLUSION: Hook wire localization may be a useful tool to help the surgeon more efficiently localize and excise recurrent or persistent disease in a scarred/previously operated field.

Association Between Age and Weight as Risk Factors for Complication After Tonsillectomy in Healthy Children.

Importance: The 1996 Tonsillectomy and Adenoidectomy Inpatient Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Pediatric Otolaryngology Committee recommended that children younger than 3 years be admitted following tonsillectomy. Recommendations for hospital observation were not included as a key action statement in the 2011 AAO-HNS Clinical Practice Guidelines for Tonsillectomy in Children. Objective: To examine the association between posttonsillectomy complication rate and the age and weight of the child at the time of surgery. Design, Setting, and Participants: This was a multicenter case series study with medical record review of 2139 consecutive children ages 3 to 6 years who underwent tonsillectomy at 1 tertiary care academic center and 5 acute care centers in New Orleans, Louisiana, between 2005 and 2015. Children with moderate to severe developmental delay, bleeding disorders, and other major medical comorbidities were excluded. Main Outcomes and Measures: Complications examined included respiratory distress, dehydration requiring intravenous fluids, and bleeding. Results: Of the 2139 patients, 1817 met inclusion criteria. A total of 1011 (55.6%) were male. The mean (SD) age at the time of the procedure was 46 (14) months (range, 12-72 months). The mean weight at the time of the procedure was 17 (5) kg (range, 9-43 kg). A total of 95 patients (5.2%) had a postoperative complication. Of the 455 children younger than 3 years in the study, 32 (7.0%) had complications compared with 63 (4.6%) of the 1362 patients 3 years or older. The odds of having a complication in children younger than 3 years was 1.5 times greater than it was in children 3 years or older (odds ratio [OR], 1.56; 95% CI, 1.00-2.42). When examining total complications, children younger than 3 years were more likely to experience a complication within the first 24 hours after surgery than children 3 years or older (25% vs 9.5%; OR, 3.17; 95% CI, 1.00-10.11). The children admitted to the hospital had a greater risk of complication than those treated as an outpatient, independent of age (6.9% vs 93.0%; OR, 3.49; 95% CI, 2.0.18-6.05). No association between weight and complications was found on logistic regression (area under the curve = 0.5268; P = .66). Conclusions and Relevance: Healthy children younger than 3 years may be at an increased risk for complication following tonsillectomy. Those children may also be at increased risk for complications within the first 24 hours after surgery compared with children 3 years or older. Our data suggest that complications are independent of weight in these patients. In our cohort, those patients selected for overnight observation were associated with an increased number of adverse events following tonsillectomy, suggesting that clinician judgment is crucial in determining which patients are safe for outpatient tonsillectomy.

Endoscopic middle ear exploration in pediatric patients with conductive hearing loss.

OBJECTIVE: To describe our indications, findings, and outcomes for transcanal endoscopic middle ear exploration in pediatric patients with conductive hearing loss of unknown etiology, without effusions. METHODS: Prospective case series for all pediatric patients undergoing totally endoscopic transcanal middle ear exploration between April 2012 and October 2015 at a pediatric tertiary care referral hospital. Demographic data, operative findings, and hearing results were reviewed. RESULTS: 21 cases were performed in 20 ears (1 revision). Average age at surgery was 7.98 years and average follow up was 2.1 years. Middle ear pathology identified on CT imaging was confirmed in 55% of cases while identified in 45% of cases where pre-operative imaging was non-diagnostic. 6/20 patients (30%) had an ossicular deformity. 8/20(40%) had bony ossicular fixation. 5/20(25%) had ossicular discontinuity. 2/20(10%) had facial nerve dehiscence impinging on the stapes. 15% had adhesive myringosclerosis or severe granulation causing hearing loss. Prosthetic ossiculoplasty was done in 7/21 (33.3%) of the cases, with 1 TORP, 3 PORPs, and 3 IS joint replacements. Imaging was predictive of intra-operative findings in 13/20 cases (55%). Trainees assisted in 16/21(76%) of cases. The average improvement of PTA was 11.65 dB (range -10 to 36.25), and the average ABG improved 10.19 (range -11.25 to 28.75). There were no perioperative complications or adverse events. CONCLUSIONS: The endoscopic transcanal approach for middle ear exploration offers excellent visualization and is one of the best applications for the endoscopes in pediatric otology cases. This is particularly helpful for "unexplained" conductive hearing loss where ossicular deformity/fixation/discontinuity is suspected. The etiology of the conductive hearing loss was definitively found in 100% of cases, and can be repaired in the same sitting when applicable.

Endoscopic transcanal approach to the middle ear for management of pediatric cholesteatoma.

OBJECTIVES: To describe outcomes for endoscopic ear surgery (EES) for pediatric cholesteatoma at a tertiary pediatric hospital. METHODS: Retrospective case series of 65 pediatric cholesteatoma cases in 38 ears. Subgrouping based on cholesteatoma type and EES type. Surgical findings, outcomes, and demographic data were evaluated. RESULTS: Endoscopes were used in 65 pediatric cholesteatoma cases in 38 primary ears (34 patients), followed for an average of 2.6 years (9 months to 4.6 years). The endoscope was used as the primary visualization tool in 31 (81.6%) ears (EES 2 or 3), and as an adjunct to the microscope in seven ears (EES 1). Twenty-two (57.9%) ears and 35 (53.4%) cases were transcanal endoscopic ear surgery (EES 3 or TEES). Overall, there was recurrence in five (13.2%) ears and residual in four (10.5%) ears. Cholesteatoma was acquired in 27 ears, with average age 10.9 years; and congenital in 11 ears, with average age 3.8 years. Surgical time was longer for acquired cases (226 vs. 154 minutes). Hearing outcomes were comparable for both cholesteatoma types. Residual disease was seen in three (11.1%) acquired ears and one (9.1%) congenital ear. Overall, the lowest rates of recurrent and residual disease were seen in EES 3 cases, and relatively low rates in EES 2 and 3 ears, including four (12.9%) recurrences and two (6.5%) ears with residual disease. CONCLUSION: The endoscopes are a viable tool for resection of pediatric cholesteatoma and provide excellent visualization of the middle ear and associated recesses. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2653-2658, 2017.

Rapid, Multiplexed Characterization of Shiga Toxin-Producing Escherichia coli (STEC) Isolates Using Suspension Array Technology.

Molecular methods have emerged as the most reliable techniques to detect and characterize pathogenic Escherichia coli. These molecular techniques include conventional single analyte and multiplex PCR, PCR followed by microarray detection, pulsed-field gel electrophoresis (PFGE), and whole genome sequencing. The choice of methods used depends upon the specific needs of the particular study. One versatile method involves detecting serogroup-specific markers by hybridization or binding to encoded microbeads in a suspension array. This molecular serotyping method has been developed and adopted for investigating E. coli outbreaks. The major advantages of this technique are the ability to simultaneously serotype E. coli and detect the presence of virulence and pathogenicity markers. Here, we describe the development of a family of multiplex molecular serotyping methods for Shiga toxin-producing E. coli, compare their performance to traditional serotyping methods, and discuss the cost-benefit balance of these methods in the context of various food safety objectives.

Thirty-Day Perioperative Outcomes in Pediatric Parotidectomy.

IMPORTANCE: Limited information exists about the short-term morbidity of parotidectomy in children. This information is important when counseling parents and planning treatment for children with parotid masses. OBJECTIVE: To examine 30-day perioperative outcomes after parotidectomy in the pediatric population. DESIGN, SETTING, AND PARTICIPANTS: A prospective case series of 87 pediatric patients who underwent parotidectomy from January 1, 2008, to June 30, 2015, performed by 2 pediatric head and neck specialists in a tertiary care pediatric hospital. MAIN OUTCOMES AND MEASURES: Thirty-day perioperative complications, postoperative facial nerve function, reoperation rates, and readmission rates were the main outcome measures. Secondary outcome measures were operative time and length of stay. RESULTS: Ninety parotidectomies (71 superficial and 19 total) were performed in 87 patients (48 male and 39 female). Mean age at operation was 8.3 years. Eighty-five of the cases (94%) were performed for benign disease. Mean operative time was 4.09 hours (range, 1.58-10.43 hours) and mean length of stay was 2.24 days (range, 0.97-4.33 days). Immediate postoperative facial weakness was observed in 32 cases (36%); 10 of these cases (31%) involved the upper branch and 29 (90%) involved the lower branch. Immediate postoperative paresis occurred more often after total parotidectomy vs superficial parotidectomy (11 of 19 [58%] vs 21 of 71 [30%]; P = .03) but was unrelated to the etiologic cause of the patients' parotid disease. Thirty of 32 cases (94%) of facial nerve weakness were transient, and the mean time to resolution was 61 days. Eleven complications (12%) other than facial nerve weakness occurred during the 30-day postoperative period. Three patients (3%) required a return to the operating room for hematoma or wound dehiscence. One patient (1%) required readmission in the 30-day postoperative period for contralateral parotitis. CONCLUSIONS AND RELEVANCE: We observed a low rate of 30-day perioperative complications as a result of superficial or total parotidectomy for pediatric parotid disease. Major adverse events included return to the operating room and 1 wound infection. Only 1 patient required readmission. Transient weakness of the facial nerve is relatively common, observed more often in the lower division, and can be expected to resolve in most patients by an average of 2 months.

The Pursuit of Otolaryngology Subspecialty Fellowships.

OBJECTIVES: To examine otolaryngology resident interest in subspecialty fellowship training and factors affecting interest over time and over the course of residency training STUDY DESIGN: Cross-sectional study of anonymous online survey data. SETTING: Residents and fellows registered as members-in-training through the American Academy of Otolaryngology-Head and Neck Surgery. SUBJECTS AND METHODS: Data regarding fellowship interest and influencing factors, including demographics, were extracted from the Section for Residents and Fellows Annual Survey response database from 2008 to 2014. RESULTS: Over 6 years, there were 2422 resident and fellow responses to the survey. Senior residents showed a statistically significant decrease in fellowship interest compared with junior residents, with 79% of those in postgraduate year (PGY) 1, 73% in PGY-2 and PGY-3, and 64% in PGY-4 and PGY-5 planning to pursue subspecialty training (P < .0001). Educational debt, age, and intended practice setting significantly predicted interest in fellowship training. Sex was not predictive. The most important factors cited by residents in choosing a subspecialty were consistently type of surgical cases and nature of clinical problems. CONCLUSIONS: In this study, interest in pursuing fellowship training decreased with increased residency training. This decision is multifactorial in nature and also influenced by age, educational debt, and intended practice setting.

Efficacy of a Human Papillomavirus Vaccination Educational Platform in a Diverse Urban Population.

IMPORTANCE: Human papillomavirus (HPV) is a preventable disease that plays a causative role in a significant proportion of malignant neoplasms of the head and neck. Inner-city populations are at risk for HPV-related oropharyngeal cancer, are least likely to receive HPV vaccination, and report a lack of information regarding HPV. OBJECTIVE: To determine whether an educational platform affects knowledge, attitudes, and practices regarding HPV vaccination in an inner-city community. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study, conducted from March 1 to December 31, 2014, surveyed 128 participants at multiple inner-city community centers regarding their knowledge of, attitudes toward, and practices regarding HPV vaccination before and after a brief educational presentation. No eligible individuals refused to participate in the educational session. Surveys were excluded from analysis if they were incomplete. INTERVENTIONS: Participants completed two 20-question surveys separated by a 15-minute educational session on HPV-related disease, including a short PowerPoint presentation. MAIN OUTCOMES AND MEASURES: Presence of statistically significant differences in survey scores before and after the educational session. RESULTS: Eighty-six participants met eligibility criteria (61 male [70.9%]; 68 with a high school education [79.1%]). Baseline knowledge of HPV, its causal association with cancer, and the existence of a vaccine against HPV were poor: of a total composite score of 20, the mean knowledge score before the educational session was 9.69. Participants' self-rated knowledge regarding HPV disease and vaccination improved significantly as a result of the educational session; the absolute increase in mean knowledge composite score from before the educational session to after the session was 3.52 (17.6%) (95% CI, -2.87 to 9.92; P < .01). Attitudes regarding government involvement in vaccination did not change as a result of the educational session (composite attitudes score before the educational session, 16.57 of 28; score after the session, 15.22; P = .98). Participants' intent to vaccinate their children increased significantly following the educational presentation: before the presentation, 34 respondents (40%) intended to have their children vaccinated; after the presentation, 60 (70%) intended to do so (P = .002). CONCLUSIONS AND RELEVANCE: Lack of knowledge regarding HPV vaccination and unwillingness to undergo vaccination contribute to low rates of HPV vaccination within urban populations. Community-based educational sessions successfully teach the link between HPV and various cancers, provide information regarding the risks and benefits of vaccination, and increase participants' willingness to vaccinate their children against HPV. Attitudes regarding government involvement in health programs are resistant to change.

Clobetasol's Influence on the Management and Cost of Skin Overgrowth Associated with the Bone-Anchored Hearing Aid.

BACKGROUND: Management of the skin/abutment interface in patients with bone-anchored hearing aids (BAHAs) can occasionally be a challenge. Even with the most compliant patients and the most intensive home/office treatment regimens, painful triamcinolone injections and revision surgery can become necessary. Such treatments can be associated with an inordinate cost burden. To our knowledge this research provides the first objective comparison of cost and patient outcomes after the introduction of topical 0.05% clobetasol cream for the care of the skin/abutment interface in patients with BAHAs. METHODS: Thirty-three patients were managed with the traditional algorithm (local wound care, triamcinolone injection, and revision surgery). Nineteen patients were managed with the contemporary algorithm in which 0.05% topical clobetasol cream was added to the traditional treatment regimen. RESULTS: Common postoperative skin reactions were comparable in the traditional vs contemporary treatment groups: granulation tissue (53.8% vs 56.3%), soft-tissue overgrowth (30.8% vs 18.8%), and both granulation tissue and soft-tissue overgrowth (15.4% vs 25.0%). The addition of clobetasol cream was associated with a marked decrease in the invasive treatment endpoints in the contemporary vs traditional treatment groups: triamcinolone injections (0.0% vs 12.1%) and surgical revision (0.0% vs 9.1%). The difference in cost for managing soft-tissue overgrowth at the abutment site was substantial, with the traditional treatment group averaging $2,773.25 per patient and the contemporary treatment group averaging $47.94 per patient (P<0.021) according to 2013 estimates and values. CONCLUSION: Clobetasol use during early postoperative care of a BAHA implant dramatically decreases cost and improves treatment outcomes by reducing the need for invasive postoperative procedures to treat common postoperative skin reactions.

The efficacy of mitomycin and stenting in choanal atresia repair: a 20 year experience.

OBJECTIVE: To determine the efficacy of topical mitomycin and stenting in patients that have undergone endoscopic repair of choanal atresia. METHODS: Retrospective review of 37 endoscopic operations on pediatric patients for choanal atresia. RESULTS: Twenty-six sides were operated on in 17 patients; 37 total operations were performed. All 17 patients were repaired endoscopically with 1 patient requiring transpalatal revision surgery. Eight patients (47%) had a unilateral atresia and 9 (53%) were bilateral. Eleven total sides (42%) were treated initially with mitomycin. Eighteen percent of those sides required post-operative dilation vs. 40% of the sides not treated with mitomycin (p=0.39) and no patient in the mitomycin group required revision surgery compared to 20% of patients not treated with mitomycin (p=0.24). Significantly fewer sides in the mitomycin group (9%) developed granulation vs. those treated without (53%) (p=0.03). The average number of procedures performed (1.18 vs. 2.53; p=0.002) was significantly fewer in those patients treated with mitomycin vs. not. A greater amount of sides in the stent group developed granulation tissue (50% vs.0%; p=0.023). The average number of procedures performed was significantly greater in those patients treated with a stent (2.33 vs. 1.12; p=0.008). The average time spent in the hospital was significantly shorter (7.09 vs. 2.33 days; p=0.02) in those patients treated without stenting. CONCLUSION: Topical mitomycin is efficacious as an adjuvant therapy as it was associated with the formation of less granulation tissue, a lower rate of restenosis and fewer surgeries. Stenting was associated with significantly more procedures, greater formation of granulation tissue and longer overall hospital stays. However, consideration should be given toward stent placement in all neonates for the prevention of post-operative airway obstruction. LEVEL OF EVIDENCE: 2c.

Persistent oro-nasal fistula after primary cleft palate repair: minimizing the rate via a standardized protocol.

OBJECTIVES: Multiple methods are described for cleft palate repair. Similarly, a wide range of postoperative oro-nasal fistula rates are described, depending on technique and series examined. We describe long-term outcomes and fistula rates for primary cleft palate repair for a single surgeon using a standardized protocol. Furlow palatoplasty was used for clefts limited to the soft palate, and two-flap palatoplasty was used for clefts involving both the hard and soft palate. METHODS: Retrospective review of prospectively gathered data. RESULTS: Eighty-two patients underwent cleft palate repair within the study period. Average age at time of repair was 1.69 years (range 0.47-12.1 years), 19 patients had cleft palate as a part of a known genetic syndrome, and male:female ratio was 1.05:1. Overall fistula rate requiring repair was 5.5%, and fistula development was not significantly associated with type of cleft repair or use of AlloDerm in the repair. CONCLUSIONS: A very low rate of oro-nasal fistula and good postoperative outcomes were achieved utilizing this protocol for cleft palate repair. It is effective both in isolated cleft palate, as well as in more complicated syndromic patients. It is possible that significant associations between repair technique and fistula rate exist that were not elucidated in this study as a result of the small number of oro-nasal fistulas.

Retropharyngeal phlegmon in Rosai Dorfman disease.

Rosai Dorfman disease (RD), also known as sinus histiocytosis with massive lymphadenopathy (SHML), is a benign histiocytic proliferative condition of unsubstantiated etiology that most often presents as bilateral painless cervical lymphadenopathy. Head and neck manifestations of RD are diverse but most commonly present as massive cervical lymphadenopathy. Interestingly, a retropharyngeal fluid collection has never been described as a sequelae of RD. Our objective is to present a novel case of a 9-year old female with RD that suffered from recurrent retropharyngeal phlegmon and to discuss diagnostic and treatment recommendations for this disease process.

Lund-mackay staging system in cystic fibrosis: a prognostic factor for revision surgery?

BACKGROUND: Cystic fibrosis (CF) is an autosomal recessive genetic disease that affects approximately 30,000 people in the United States. Mucus in CF patients can be exceptionally viscous, leading to progressive cycles of inflammation and infection. The most widely accepted staging system used to score sinus computed tomography (CT) scans is the Lund-Mackay Score (LMS). METHODS: To determine if a significant correlation exists between LMS and the need for revision sinus surgery in a patient population with CF, we performed a retrospective review of 32 patients with CF who were referred to the Tulane Otolaryngology Clinic from 2005 to 2011 and received a CT scan of the paranasal sinuses. CT scans were graded in a blinded manner by the institution's neuroradiologist using the LMS system. RESULTS: We found no statistically significant difference in the raw or scaled LMSs between patients receiving revision surgery (n=9) and patients receiving a single surgery (n=23). CONCLUSIONS: CT scans are vital for preoperative planning, but they are not a useful tool for risk stratification. More specifically, application of the LMS is not relevant in identifying which CF patients with chronic rhinosinusitis will be at risk for revision surgeries.

Improving outcomes in a high-output pediatric otolaryngology practice.

OBJECTIVES: To identify factors associated with efficient operating room work flow on high volume pediatric otolaryngology days and the effects on provider and perceived parent satisfaction. METHODS: Retrospective review was performed of a sample of 20 days with greater than 10 cases per day performed by a pediatric otolaryngologist operating in 2 rooms. Turnover time and complications were the main outcome measures. Providers from otolaryngology and anesthesia that participated in these days were surveyed regarding efficiency, safety, and satisfaction. RESULTS: 223 cases were performed over 20 operative days. The average turnover time was significantly longer in "major" surgeries (p=0.03), cases with multispecialty involvement (p=0.01), cases requiring intubation (p<0.001), and in cases where a fellowship trained pediatric anesthesiologist (p=0.01) or CRNA was present (p<0.001). When comparing "fast" (<25min average turnover) operative days vs. "slow" (>25min average turnover) days, presence of a non-fellowship trained anesthesiologist (p<0.001), and the presence of an anesthesiology resident (p=0.03) were significantly associated with "fast" days, while the presence of a CRNA was associated with "slow" days (p<0.001). A significantly greater proportion of patients required intubation on "slow" turnover days vs. "fast" days (p=0.13). Only one complication was observed (0.4%). 48 providers were surveyed with a 63% response rate. Reported satisfaction amongst providers was significantly greater on days with at least 10 cases (p=0.047) and on days with turnover times of 25min or less (p<0.001). Pre-operative nursing evaluation/preparation of the patient, inter-provider communication and delays in room cleaning/setup were identified most often as causative factors responsible for delays in turnover. CONCLUSIONS: High-operative volume operating days are common in pediatric otolaryngology and can be safely performed in an efficient manner. Appropriate scheduling and high-level communication between providers is needed to ensure success on these days. Identified areas of potential inefficiency can be a starting point for work flow optimization practices.

Clinical practice guideline: tinnitus.

OBJECTIVE: Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient's quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome. PURPOSE: The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers. ACTION STATEMENTS: The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.

Clinical practice guideline: tinnitus executive summary.

The American Academy of Otolaryngology--Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tinnitus. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 13 recommendations developed address the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the impact of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.