Surgical management of vocal cord nodules in children: Trends and outcomes.

OBJECTIVES: Vocal cord nodules (VCNs) are the most common cause of dysphonia in school-aged children, with potential negative impacts on quality of life including diminished self-esteem and academic performance. The standard of care for VCNs is conservative management which ranges from voice hygiene to speech therapy with a focus on voice otherwise known as voice therapy, with surgical excision reserved for refractory cases. Thus, few studies have analyzed outcomes of surgical management of VCNs. The purpose of this study is to assess the prevalence and efficacy of surgical excision of VCNs when compared to speech therapy. METHODS: Children with VCNs seen at a single tertiary care institution between 2015 and 2020 were identified by ICD-9 code 478.5 and ICD-10 code J38.2. Demographics, objective voice assessment, intervention, and follow-up assessment data were reviewed. Frequencies, medians, and interquartile ranges were calculated. Time to resolution and improvement were assessed by Cox proportional hazards model. Univariate logistic regression was performed. A P value of <0.05 was considered statistically significant. RESULTS: Three hundred sixty-eight patients diagnosed with VCNs were identified. 169 patients received intervention for VCNs, with 159 (43.2 %) receiving speech therapy alone and 5 (1.4 %) receiving surgery alone. On bivariate analysis, there was no significant difference in demographic features between treatment groups, however speech therapy patients did have a longer follow-up time. 154 patients underwent objective voice assessment at the time of VCN diagnosis. Among these patients, 95 (61.7 %) received speech therapy and 59 (40.3 %) received no intervention. Speech therapy patients had significantly higher pVHI scores, however there was no significant difference in CAPE-V Overall Severity scores or computerized voice assessment analysis. On Cox proportional hazards analysis, surgical intervention was associated with faster resolution and faster improvement of dysphonic symptoms. On binary logistic regression, surgery was associated with a significantly greater proportion of patients reporting resolution of dysphonic symptoms, however there was no significant difference in proportion of patients reporting improvement of dysphonia. CONCLUSION: For most patients with VCNs, conservative measures such as voice hygiene and speech therapy remain first line, however certain patients may benefit from the rapid improvement and resolution of symptoms that surgical intervention may provide.

A review of dexamethasone as an adjunct to adenotonsillectomy in the pediatric population.

Although one of the most commonly performed surgical procedures in children and frequently performed as outpatient surgery, the postoperative course following tonsillectomy may include nausea, vomiting, poor oral intake, and pain. These problems may last days into the postoperative course. Although opioids may be used to treat the pain, comorbid conditions such as obstructive sleep apnea may mandate limiting the dose and the frequency of administration. Adjunctive agents may improve the overall postoperative course of patients and limit the need for opioid analgesics. Dexamethasone is a frequently administered intraoperatively as an adjunctive agent to decrease inflammation and pain, limit the potential for postoperative nausea and vomiting, and improve the overall postoperative course. The following manuscript reviews the use of dexamethasone to improve outcomes following tonsillectomy or adenotonsillectomy, discusses the controversies regarding its potential association with perioperative bleeding, and investigates options for dosing regimens which may maintain the beneficial physiologic effects while limiting the potential for bleeding.

Variation in Use of Tympanostomy Tubes: Impact of Privately Owned Ambulatory Surgery Centers.

OBJECTIVE: To determine whether privately owned ambulatory surgery centers (ASCs) increase pediatric tympanostomy tube use in their surrounding communities. STUDY DESIGN: We studied children <5 years of age who underwent outpatient tympanostomy tube placement in New York or Florida in 2010-2014. Data came from the Healthcare Cost and Utilization Project State Ambulatory Surgery Databases, which include all outpatient surgeries in these states. Population characteristics came from the US Census' American Community Survey. Weighted conditionally autoregressive models were used to assess the association between the zip code-level proportion of tympanostomy tube procedures performed in privately owned ASCs and the rate of tympanostomy tube use. RESULTS: In 2010-2014, 106 privately owned ASCs in Florida and 29 in New York performed tympanostomy tube placement in young children. After accounting for zip code-level urban/rural status, socioeconomic status (SES), and the proportion of residents of non-Hispanic white race, children residing in zip codes in the top tertile of privately owned ASC use in Florida had 52% greater tympanostomy tube use than children from zip codes in the bottom tertile (P < .001). In New York, high-SES zip codes with any use of privately owned ASCs had 2.6 times greater tympanostomy tube use than other high-SES zip codes (P < .001). This association was not present in low-SES areas. CONCLUSIONS: The presence of privately owned ASCs is associated with increased tympanostomy tube use in young children.

Clinical Indices Can Standardize and Monitor Pediatric Care: A Novel Mechanism to Improve Quality and Safety.

OBJECTIVE: The Cancer Care Index (CCI), a single metric that sums the number of undesirable patient events in a given time frame (either preventable harm events or missed opportunities to provide optimal care), resulted in a 42% improvement in performance. Our objective was to test the index concept in other service lines to determine whether similar performance improvement occurred. STUDY DESIGN: Care indices were developed and introduced in 3 additional service lines: Nephrology (Chronic Kidney Disease Care Index; CKDCI), Pulmonology (Lung Transplantation Care Index; LTCI), and Otolaryngology (Tracheostomy Care Index; TCI). After reaching agreement on specific harms to be avoided and elements of optimal care that should be reliably delivered, these items were compiled into indices that were updated monthly. Reports included each element individually and the total for all elements. Baseline performance was calculated retrospectively for the previous year. RESULTS: Significant improvement in performance occurred in each program following implementation of the clinical indices. The CKDCI was decreased by 63.2% (P < .001), the LTCI was decreased by 89.5% (P < .001), and the TCI was decreased by 53.0% (P < .001). Surveyed staff indicated satisfaction with use of the metric. CONCLUSIONS: Clinical indices are useful for evaluating and managing the overall reliability of a program's ability to deliver optimal care, and are associated with improved clinical performance and satisfaction by service line staff when incorporated into a program's operation.

Tracheal extubation practices following adenotonsillectomy in children: effects on operating room efficiency between two institutions.

BACKGROUND: Adenotonsillectomy is one of the most commonly performed operative procedures in children. It is imperative to find the most efficient and cost-effective methods of practice to facilitate operating room management while maintaining patient safety. We investigated the efficiency of two different approaches of tracheal extubation in pediatric patients following adenotonsillectomy at two tertiary care pediatric hospitals with large surgical volumes. The primary aim of the study was to determine the difference in the operating room time according to the institutional practice of tracheal extubation in the postanesthesia care unit (PACU) as compared to the operating room. METHODS: After obtaining IRB approval, a retrospective chart review was performed over a 12-month period at two large, tertiary care children's hospitals including the first hospital, where patients undergo tracheal extubation in the operating room after completion of the surgical procedure and a second hospital, where patients are brought directly to the PACU and undergo tracheal extubation in the PACU by nurses, with immediate availability of the pediatric anesthesiology faculty. Patients ≤12 years of age undergoing adenotonsillectomy were eligible for inclusion in the study. Patients with significant cardiopulmonary disease or scheduled for recovery in the critical care unit were excluded. Patient demographics, total time in the operating room, surgical time, total time in the PACU, and, when applicable, time until tracheal extubation, were noted. RESULTS: The study cohort included 672 patients from the first hospital and 700 patients from the second hospital. Average operating room time was 17 min shorter at the first hospital than at the other, with most of the difference due to a reduction in the time between surgery end and transport from the operating room. PACU times were also 26 min shorter at the first hospital than at the second children's hospital. CONCLUSION: Tracheal extubation in the PACU is an efficient use of operating room time and resources.

Changes in intracuff pressure of cuffed endotracheal tubes while positioning for adenotonsillectomy in children.

BACKGROUND: When using cuffed endotracheal tubes (cETTs), changes in head and neck position can lead to changes in intracuff pressure. AIM: The aim of this study was to assess the combined effect of neck extension, shoulder roll placement, and Crowe-Davis retractor use during adenotonsillectomy on the intracuff pressure of cETTs in children. METHODS: Patients <18 years of age undergoing adenotonsillectomy under general anesthesia following the placement of a cETT were included in the study. After inflation of the cuff to seal the trachea, using the leak test, baseline intracuff pressure was recorded and then continuously monitored. After neck extension, placement of a shoulder roll, insertion of the Crow-Davis retractor, suspension from a Mayo stand, and positioning for surgery, the intracuff pressure was recorded again. RESULTS: The study cohort included 84 patients, ranging in age from 0.9 to 17 years (5.7 ± 3.9 years). In 46 patients (54.8%), the intracuff pressure increased from baseline after positioning for adenotonsillectomy. In 12 of these patients (14.3%), the intracuff pressure was >30 cm H2O. The intracuff pressure decreased in 28 patients (33.3%), while no change was noted in 10 patients (11.9%). Overall, the general trend was an increase in intracuff pressure from 15.9 ± 7.8 cm H2O to 18.9 ± 11.6 cm H2O. CONCLUSION: Both increases and decreases in the intracuff pressure may occur following positioning of the pediatric patient for adenotonsillectomy. An increase in intracuff pressure may result in a higher risk of damage to the tracheal mucosa. A decrease in the intracuff pressure can result in an air leak resulting in inadequate ventilation, increased risk of aspiration, and even predispose to airway fire if oxygen-enriched gases are used. Continuous intracuff pressure monitoring or rechecking the intracuff pressure after positioning for adenotonsillectomy may be indicated.

Oropharyngeal oxygen and volatile anesthetic agent concentration during the use of laryngeal mask airway in children.

BACKGROUND: The laryngeal mask airway is increasingly used as an airway adjunct during general anesthesia. Although placement is generally simpler than an endotracheal tube, complete sealing of the airway may not occur, resulting in contamination of the oropharynx with anesthetic gases. Oropharyngeal oxygen enrichment may be one of the contributing factors predisposing to an airway fire during adenotonsillectomy. The current study prospectively assesses the oropharyngeal oxygen and volatile anesthetic agent concentration during laryngeal mask airway use in infants and children. METHODS: Following the induction of general anesthesia and placement of a laryngeal mask airway, the oropharyngeal gas sample was obtained by placing a 14-gauge catheter attached to the gas sampling tube into the oropharynx above the laryngeal mask airway. The oropharyngeal concentration of the oxygen and the anesthetic agent were recorded for five breaths during both spontaneous ventilation (SV) and positive pressure ventilation (PPV). RESULTS: The study included 238 patients. The oropharyngeal concentration of sevoflurane was >50% of the inspired sevoflurane concentration during SV in 10 of 238 (4.2%) patients and during PPV in 135 of 238 (56.7%) patients. Similarly, during SV and PPV, the oropharyngeal oxygen concentration was >21% in 30 of 238 (12.6%) patients and in 188 of 238 (79%) patients, respectively. Significantly, we also noticed that the oropharyngeal oxygen concentration exceeded 50% in 5 of 238 (2.1%) patients during SV and in 139 of 238 patients (58.4%) patients during PPV. CONCLUSIONS: With the use of a laryngeal mask airway and the administration of 100% oxygen, there was significant contamination of the oropharynx during both PPV and SV. The oropharyngeal concentration of oxygen was high enough to support combustion in a significant number of patients. The use of a laryngeal mask airway does not ensure sealing of the airway and may be one risk factor for an airway fire during adenotonsillectomy.

The relationship between head and neck position and endotracheal tube intracuff pressure in the pediatric population.

BACKGROUND: Over the past few years, there has been a change in clinical practice with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in pediatric patients. These changes have led to concerns regarding unsafe intracuff pressures in pediatric patients, which may result in postoperative morbidity. To avoid these issues, it is generally suggested that the intracuff pressure be maintained at ≤30 cmH2 O. The current study prospectively assesses the changes in intracuff pressure related to alterations in head and neck position in pediatric patients. METHODS: Patients less than 18 years of age, undergoing surgery, requiring endotracheal intubation with a cuffed ETT were eligible for inclusion. No alteration in the technique of anesthetic induction or maintenance was required for the study. Following endotracheal intubation and inflation of the cuff with the head and neck in a neutral position, the intracuff pressure was measured. The intracuff pressure was then subsequently measured with the head turned to the right, head turned to the left, head and neck flexed, and head and neck extended. RESULTS: A total of 200 patients were included in the study resulting in a total of 1000 intracuff pressure readings. When compared to the neutral position, the intracuff pressure increased in 545 instances (68.1%) with changes in position of the head and neck. An increase in intracuff pressure was noted more frequently and to the greatest degree with head and neck flexion. The pressure decreased in 153 instances (19.1%), most frequently with neck extension. CONCLUSION: Significant changes in the intracuff pressure occur with changes in head and neck position. In several cases, this resulted in a significant increase in the intracuff pressure. For prolonged cases with the head and neck turned from the neutral position, the intracuff pressure should be measured following patient positioning to ensure that the intracuff pressure is within the clinically recommended range.

A technique to measure the intracuff pressure continuously: an in vivo demonstration of its accuracy.

OBJECTIVE: A major concern with the use of cuffed endotracheal tubes (cETT) in children is hyperinflation of the cuff which may compromise tracheal mucosal perfusion. To measure the intracuff pressure (CP), we devised a method using the transducer of an invasive pressure monitoring device. The objective of the study was to test the accuracy and validity of this device for instantaneous and continuous CP monitoring. METHODS: The study was conducted in 2 phases. In Phase 1 (200 pediatric patients), after inflation of the cuff, the CP was measured using the standard manometer and the transducer simultaneously. In Phase 2 (20 pediatric patients), the transducer was left connected to the pilot balloon of the ETT to obtain a continuous CP reading and the standard manometer was used to measure the CP at 5-min intervals. Statistical analysis included a Bland-Altman comparison and linear regression analysis. RESULTS: In Phase 1, linear regression analysis demonstrated an R2 value of 0.9956. The bias was 0.30 cmH2O, the precision was 0.75 cmH2O, and the 95% level of agreement (LOA) ranged from -1.16 to 1.77 cmH2O. In Phase 2, the linear regression analysis revealed an R2 value of 0.9846. The bias was 0.28 cmH2O, the precision was 0.7 cmH2O, and the 95% LOA ranged from -1.1 to 1.66 cmH2O. CONCLUSION: Our study demonstrates that when cETTs are used in the pediatric population, the transducer of the invasive pressure monitoring device can be used reliably to measure the CP at the time of inflation and continuously thereafter.

Comparing recurrence between cautery techniques in pediatric epistaxis.

OBJECTIVE: To compare the risk of recurrent epistaxis between children treated with silver nitrate (SN) in the office or electrocautery (EC) in the operating room (OR). METHODS: Patients aged 2-18 diagnosed with epistaxis (ICD R04.0) in 2018 and treated with SN or EC were retrospectively reviewed. Epistaxis laterality, history of nasal trauma, and personal or family history of a bleeding disorder were recorded. Patients with prior cautery or epistaxis secondary to a procedure were excluded. Recurrence was defined as initial encounter after cautery with documented epistaxis. Patients were followed up into 2022 to track onset of recurrence. Time to recurrence between SN and EC was compared with hazard curves with predictors for recurrence analyzed via Cox's proportional hazard regression. RESULTS: Among 291 patients cauterized for epistaxis, 62 % (n = 181) received SN compared to 38 % (n = 110) who underwent EC. There was significantly higher risk of recurrence when treated with SN compared to EC (Hazard ratio 2.45, 95 % CI: 1.57-3.82, P < 0.0001). Median time to recurrence was not statistically different between techniques (6.39 months (SN) (IQR: 2.33, 14.82) vs. 4.11 months (EC) (IQR: 1.18, 20.86), P = 0.4154). Complication rates were low for both groups (1.16 % (SN) vs. 0 % (EC), P > 0.05). CONCLUSION: Among patients with epistaxis, risk of recurrence is significantly higher in those cauterized with SN compared to EC. Time to recurrence is not significantly different between cautery techniques.

Z-Form Extracellular DNA in Pediatric CRS May Provide a Mechanism for Recalcitrance to Treatment.

OBJECTIVES: We examined sinus mucosal samples recovered from pediatric chronic rhinosinusitis (CRS) patients for the presence of Z-form extracellular DNA (eDNA) due to its recently elucidated role in pathogenesis of disease. Further, we immunolabeled these specimens for the presence of both members of the bacterial DNA-binding DNABII protein family, integration host factor (IHF) and histone-like protein (HU), due to their known role in converting common B-DNA to the rare Z-form. METHODS: Sinus mucosa samples recovered from 20 patients during functional endoscopic sinus surgery (FESS) were immunolabelled for B- and Z-DNA, as well as for both bacterial DNABII proteins. RESULTS: Nineteen of 20 samples (95%) included areas rich in eDNA, with the majority in the Z-form. Areas positive for B-DNA were restricted to the most distal regions of the mucosal specimen. Labeling for both DNABII proteins was observed on B- and Z-DNA, which aligned with the role of these proteins in the B-to-Z DNA conversion. CONCLUSIONS: Abundant Z-form eDNA in culture-positive pediatric CRS samples suggested that bacterial DNABII proteins were responsible for the conversion of eukaryotic B-DNA that had been released into the luminal space by PMNs during NETosis, to the Z-form. The presence of both DNABII proteins on B-DNA and Z-DNA supported the known role of these bacterial proteins in the B-to-Z DNA conversion. Given that Z-form DNA both stabilizes the bacterial biofilm and inactivates PMN NET-mediated killing of trapped bacteria, we hypothesize that this conversion may be contributing to the chronicity and recalcitrance of CRS to treatment. LEVEL OF EVIDENCE: NA Laryngoscope, 134:1564-1571, 2024.

Visual outcomes following orbital decompression for orbital infections.

OBJECTIVE: To analyze the visual outcomes and sequelae of endonasal intervention for orbital infections. INTRODUCTION: Orbital infections pose a serious threat to vision in the pediatric population and can result in complications such as blindness, diplopia, intracranial involvement, and death. [1] Orbital decompression by endonasal intervention is a common treatment to address a variety of orbital infections including orbital cellulitis, orbital abscesses, and subperiosteal abscesses. [2] The outcomes of visual sequelae such as loss or limitation of visual acuity, extraocular movements, and increased intraocular pressure following orbital decompression via endonasal intervention have not been sufficiently investigated in the current literature. METHODS: This retrospective cohort study was performed at our tertiary care pediatric hospital using data from 69 patients aged 0-18 years who were admitted between 2008 and 2018. Data was extracted from the electronic medical record system. RESULTS: Following endoscopic sinus surgery, symptoms of orbital infection improved throughout the cohort. Improvement in visual acuity is demonstrated by a statistically significant decrease in the average logMAR value in both the right and left eye (P = 0.002 and P = 0.028 respectively). There was also a significant improvement to normal values postoperatively for patients who initially presented with abnormal tonometry, extraocular movement, and the appearance of eyelids and eyelashes. CONCLUSION: There is no decline or loss of vision with otolaryngology surgical intervention for orbital cellulitis in our cohort. This retrospective chart review demonstrates the efficacy of surgical intervention on overall visual outcomes following endonasal intervention for orbital infections such as orbital cellulitis, orbital abscesses, and subperiosteal abscesses.

Local Allergen-Specific IgE Production in Turbinate Tissue of Pediatric Patients.

OBJECTIVES: The objective of this study is to compare serum allergen-specific IgE to IgE levels in nasal tissue taken from the inferior turbinates of pediatric patients undergoing turbinate reduction. METHODS: Twenty-six pediatric patients were recruited at the time of turbinate reduction surgery. At the time of recruitment, parents of patients completed the validated 22 item Sinonasal Outcome Test (SNOT-22) to describe symptoms prior to surgery. A sample of turbinate tissue was taken during turbinate reduction and blood was collected. Tissue and serum IgE were measured and differences in the group characteristics were evaluated using Chi-square tests for binary variables and Wilcoxon-Mann-Whitney tests for continuous variables. Student's t test was used to assess differences in means of total SNOT-22 scoring between the groups, and Wilcoxon-Mann-Whitney tests were used again for the rest of the SNOT-22 analysis. RESULTS: Levels of IgE in the serum were compared to levels in the turbinate tissue from all patients for each individual allergen. Every allergen except Alternaria displayed significant correlation between the serum and turbinate IgE levels. Additionally, each allergen except Alternaria and oak tree resulted in a strong correlation (r > .7) based on the correlation coefficients. Levels of Alternaria were found to be poorly correlative between serum and turbinate tissue, and significance was not achieved (r = -.346, P = .11). CONCLUSION: Certain allergen-specific IgE antibodies in the nasal mucosa seem to be highly associated with those in the serum, based upon the significant correlations we found between the two.

Dynamic Volumetric Computed Tomography Angiography is an Effective Method to Evaluate Tracheomalacia in Children.

OBJECTIVE: Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV-CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference-standard of rigid bronchoscopy. METHODS: Children who had undergone DV-CTA and bronchoscopy in one-year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as >50% collapse of the tracheal cross-sectional area in exhalation. Pearson correlation was used for comparison. RESULTS: Over a 19-month period, we identified 32 children (median age 8 months, range 3-14 months) who had undergone DV-CTA and bronchoscopy within a 90-day period of each other. All studies were unsedated and free-breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV-CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p < 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p < 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia. CONCLUSION: For most children, DV-CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:410-416, 2023.

Near-Total Ear Avulsion Repaired With Primary Closure and Hyperbaric Oxygen: A Case Series and Review of the Literature.

INTRODUCTION: Near-total ear avulsion is a rare and challenging problem to repair with many techniques described; primary repair is an attractive option but is not always successful. Healing may be augmented with postoperative hyperbaric oxygen therapy (HBOT), but this technique is under-reported, and an ideal regimen is not known. The study objective is to discuss the role of HBOT in the management of ear avulsion by reviewing 2 unique cases. METHODS: Case report and review of the literature. A Pubmed search using the terms ear avulsion and postoperative hyperbaric oxygen was performed. RESULTS: Two pediatric patients presented with near-total avulsion of the auricle after suffering a dog bite. Various management options were discussed including observation, primary repair, post-auricular cartilage banking, graft reconstruction with periauricular tissue or rib cartilage, or microsurgical replantation. The decision was made to perform primary reattachment, followed by adjuvant hyperbaric oxygen therapy (HBOT). The patients achieved favorable esthetic results and continue to maintain the function of the reattached ear. Photo documentation was obtained throughout the process. DISCUSSION: There is no consensus on the management of near-total ear avulsion. Primary repair is ideal from a cosmetic and ease-of-operation standpoint but does not always yield viable tissue. The use of postoperative HBOT is an attractive option that may boost success rates, but the ideal HBOT regimen is unknown. These cases represent a successful application of this innovative technique in a pediatric patient.

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.

Medical Student Mentorship in the COVID-19 Era.

Background: The Covid-19 pandemic led to a reduction of in-person, guided mentorship due to social distancing and an emphasis on virtual meetings. The effect of these changes on medical students' experiences and specialty choice has yet to be studied in a large-scale manner. Objective: To determine the perspective of third- and fourth-year medical students regarding the impact of the COVID-19 pandemic on mentorship. Design: The authors distributed a modified Likert scale questionnaire (score: 1-10) to assess responses. Participants: Third- and fourth-year medical students at two large US allopathic medical schools. Main Measures: Responses to each survey item were analyzed to characterize the impact of the COVID-19 pandemic on mentorship relationships in medical school. A score of 1-5 was considered "disagree" and a score of 6-10 was considered "agree." Key Results: A total of 144 responses were collected with a response rate of 16.2%. Overall, 80.6% (n = 116) of respondents agree that the COVID-19 pandemic has had a negative impact on their medical school experience. Nearly half (41.0%, n = 59) expressed concern over the lack of mentorship opportunities, and 66.0% (n = 95) reported that the pandemic has made it more difficult to form or maintain connections with their mentors. Importantly, 43.6% (n = 61) of respondents reported that having close mentoring relationships reduced the impact of the pandemic on their medical training. While many respondents (79.9%, n = 114) did not change career plans due to the pandemic, most students are concerned about evaluating prospective residency programs (88.9%, n = 128). Notably, M3s have much lower confidence than M4s in their ability to choose a specialty (5.9 vs. 8.2, p = 6.43e - 08). Conclusions: This investigation illustrates the concerns that medical students have regarding access to mentorship opportunities due to the COVID-19 pandemic. We hope that these findings encourage medical schools to evaluate and expand their current mentorship programs. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01838-4.

A Case of an Infantile Lingual Leiomyomatous Hamartoma.

Lingual leiomyomatous hamartomas are rare lesions of the tongue with largely unknown mechanisms of formation. These lesions are often asymptomatic, though they may present with symptoms, particularly relating to swallow function. Workup should include imaging of the head and neck, and diagnosis should be made histologically. Treatment is surgical excision. This case is a report of a 4-week-old female who presented for evaluation of an asymptomatic 1 × 1 cm dorsal midline tongue mass discovered at birth. The patient was monitored until the age of 9 months, at which time the mass was surgically excised. The patient had an uncomplicated postoperative course. Pathological analysis yielded a diagnosis of leiomyomatous hamartoma.

Assessing the use of telehealth for the surgical management of recurrent otitis media.

OBJECTIVE: To compare the incidence of middle ear effusion (MEE) at the time of bilateral tympanostomy tube insertion (BTI) for recurrent acute otitis media (rAOM) patients initially seen in-office or via telehealth. METHODS: After obtaining IRB approval from Nationwide Children's Hospital, a total of 524 patients evaluated for rAOM were retrospectively reviewed after being divided into two cohorts: those seen via a telehealth visit from April to June of 2020 (n = 140), and those seen via an in-person visit from April to June of 2019 (n = 384). Recommendation for BTI was captured for each patient following their visit. Clinical characteristics documented at the time of the visit, such as history of intramuscular (IM) antibiotic use and hearing or speech concerns were also captured to determine whether both telehealth and in-person cohorts were similar in clinical presentation. For BTI patients, the presence or absence of MEE in either ear at the time of BTI was recorded. Patients with cleft palate or prior BTI were excluded. RESULTS: 51.43% (72/140) of patients in the telehealth cohort were recommended for BTI. Of those recommended, 87.50% (63/72) underwent BTI. Of these, 31.75% (20/63) had a MEE at the time of BTI. In the in-office cohort, 69.01% (265/384) of patients were recommended for BTI. Of those recommended, 92.83% (246/265) underwent BTI. Of these, 69.92% (172/246) had a MEE at the time of BTI. CONCLUSION: There were significantly less middle ear effusions in the telehealth cohort compared to the in-office cohort (p < 0.0001). It is well understood that telehealth is limited in its physical exam capabilities. It is possible that the use of telehealth for the surgical management of rAOM may lead to more procedures on patients without MEE.

Recognition and Management of Nonaccidental Esophageal Perforation.

Nonaccidental trauma is a common pediatric concern that often goes unrecognized. Although most patients present with bruising, burns, fractures, and head trauma, it is critical that physicians be able to diagnose and treat atypical presentations such as pharyngeal and esophageal trauma. In this report, we describe the presentation and management of a 5-week-old girl with an inflicted esophageal perforation.