Longitudinal Analysis of Early Hearing Detection and Intervention Program Performance.

OBJECTIVES: Early hearing detection and intervention (EHDI) is a newborn hearing screening system created to detect infants with hearing loss (HL) and intervene to reduce language and communication impairment. Early hearing detection (EHD) consists of three sequential stages: identification, screening, and diagnostic testing. This study longitudinally reviews each stage of EHD in each state and proposes a framework to improve utilization of EHD data. DESIGN: A retrospective public database review was conducted, accessing publicly available data from the Centers for Disease Control and Prevention. Summary descriptive statistics were utilized to generate a descriptive study of EHDI programs in each U.S. state from 2007 to 2016. RESULTS: Data over 10 years from 50 states as well as Washington, DC were included in this analysis, creating up to 510 data points per analysis. Hundred percent (85 to 105) (median [min to max]) of newborns were identified by and entered EHDI programs. Ninety-eight percent (51 to 100) of identified infants completed screening. Of the infants who screened positive for HL, the proportion that received diagnostic testing was 55% (1 to 100). The overall proportion of infants who failed to complete EHD was 3% (1 to 51). Of the infants who fail to complete EHD 70% (0 to 100) are from missed screenings, 24% (0 to 95) are from missed diagnostic testing, and 0% (0 to 93) are from missed identification. Although there are more infants missed at screening, it was estimated, with limitations, that there is an order of magnitude more infants with HL among those who did not complete diagnostic testing compared with those who did not complete screening. CONCLUSIONS: Analysis demonstrates high completion rates at both identification and screening stages, whereas the diagnostic testing stage demonstrates low and highly variable completion rates. The low completion rates at diagnostic testing create a bottleneck in the EHD process and the large variability impedes the comparison of HL outcomes across states. Analysis also demonstrates that among all stages of EHD, whereas the largest number of infants are missed at screening, the largest number of children with HL are likely missed at diagnostic testing. Therefore, a focus by individual EHDI programs on addressing causes of low diagnostic testing completion rates would yield the greatest increase in the identification of children with HL. Potential causes of low diagnostic testing completion rates are further discussed. Finally, a new vocabulary framework is proposed to facilitate further study of EHD outcomes.

Effect of Cleft Palate Repair Timing on Inpatient Complication Rate: Review of a National Database.

OBJECTIVES: Timing of cleft palate repair is controversial. We aim to assess whether timing of cleft palate repair affects rates of inpatient complications, length of stay (LOS), and cost of stay. METHODS: The Healthcare Cost and Utilization Project Kids' Inpatient Database 2009 was queried for all admissions with a primary diagnosis of cleft palate during which cleft palate repair was performed as a primary procedure. Age 6 months or less was termed "early" repair, while age >6 months was termed "standard" repair. Patients age >3 years old, inpatient stays >30 days, and those stays in which a cleft lip repair was performed were excluded. Logistic regressions were used to model the probability of complications. Generalized linear models and a natural log link function were used for LOS and hospital charges, using SAS 9.4. RESULTS: We included 223 early and 1482 standard repair patients. Early repairs were exclusively performed in urban hospitals (P < 0.001). Eighty-nine patients experienced a total of 100 complications, including respiratory failure (N = 53), airway obstruction (N = 18), and oropharyngeal hemorrhage (N = 13). We found no significant difference in complication rate or total hospital charges in the 2 groups. The earlier repair group had a slightly longer LOS (P = 0.048). CONCLUSION: Over 85% of United States cleft palate repairs are performed after 6 months of age. All early repairs were performed at urban hospitals, and had slightly longer LOS. There was a 5.1% overall complication rate. Available data revealed no significant difference in complication rates between early repair and standard repair groups. LEVEL OF EVIDENCE: 3b.

Rising Costs of Otic Drops: Review of a National Database.

OBJECTIVES: US prescription drug prices have increased substantially during the past decade and now account for approximately 17% of total US health expenditures. Otic drop prices are of particular interest given their common use in otolaryngologic clinical practice. We hypothesized that otic drop prices increased at a rate significantly higher than the overall inflation rate. We considered potential causes for otic drop price fluctuations during this period and whether they could be correlated with corporate restructuring events. METHODS: Publicly available data on otic antibiotic drop pricing was assessed from 2012 to 2020 and were correlated with contemporaneous publicly available information about corporate and political events. RESULTS: CiproHC (Alcon Laboratories, Inc., Fort Worth, TX, US), Ciprodex (Alcon Laboratories, Inc., Fort Worth, TX, US), Cortisporin-TC (Endo Pharmaceuticals, Dublin, Ireland), Coly-Mycin S (JHP Pharmaceuticals, LLC, Rochester, MI, US), generic neomycin-polymixin-HC otic drop, ciprofloxacin otic drop, and ofloxacin otic had overall change in cost between January 2014 and January 2020 of 69.9%, 63%, 268.9%, 219.5%, 232.5%, 13%, and 62.4%, respectively. Generic ofloxacin otic drop showed the most price fluctuation, temporarily rising 945% from July 2015 to its peak price of $26/mL in October 2016. CONCLUSION: Otic drop prices have been volatile, with overall price increases higher than overall inflation. Drug pricing is not transparent, making it difficult for prescribers and patients alike to be cost conscious when choosing the best therapy. We outline six factors that contribute to high US medication prices and also highlight two examples of otic drops that underwent significant price fluctuation during the studied period. LEVEL OF EVIDENCE: V Laryngoscope, 131:E1069-E1075, 2021.

Obesity as a Possible Risk Factor for Pediatric Sensorineural Hearing Loss.

OBJECTIVES/HYPOTHESIS: Childhood hearing loss impacts linguistic, academic, social, and psychologic development, and may have lasting implications for future workforce performance. Current evidence for obesity as a pediatric sensorineural hearing loss (SNHL) risk factor is intriguing but equivocal. We hypothesized that obesity is associated with a higher risk of SNHL. We additionally examined whether underweight is associated with a higher risk of SNHL. STUDY DESIGN: Retrospective database review. METHODS: A single-institution audiologic database from 2015 to 2020 was queried for audiograms with type-A tympanograms from children aged 5 to 18 years old. Comorbidities known to be associated with hearing loss were excluded. We then examined both for sub-clinical (≥15 dB) high- or low-frequency hearing loss, and for clinical (≥21 dB) hearing loss, with the aim of examining the association between obesity and SNHL. Multivariable logistic regression was performed to adjust for age, gender, diabetes mellitus, attention deficit hyperactivity disorder, and autism. RESULTS: A total of 3,142 children were included. Obesity was not associated with risk of SNHL (adjusted OR 0.82; 95% CI: 0.60, 1.12). Underweight children had a higher risk of SNHL than normal weight children (adjusted OR 1.78; 95% CI: 1.08, 2.95). Autism was significantly associated with increased risk of sub-clinical SNHL only (adjusted OR 2.00; 95% CI 1.34, 2.98). CONCLUSIONS: No association was found between obesity and pediatric SNHL. Underweight children may represent a higher-risk population for SNHL. There appears to be an increasing risk of SNHL as children approach adolescence. Further study of systemic risk factors for SNHL is indicated. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1416-1419, 2021.

Update on Recurrent Respiratory Papillomatosis.

Recurrent respiratory papillomatosis (RRP) remains a challenging disease afflicting children and adults, resulting in an estimated $120 million per year in United States healthcare-related costs, with annual costs per patient approaching $60,000. Although the prevalence of RRP has declined, RRP remains the most common benign laryngeal neoplasm in children. RRP is unique in its high rate of multisite recurrence, its high burden on patient quality of life, and its high associated healthcare costs. This article summarizes current understanding of the natural history and quality of life burden of RRP, and basic science advancements in prevention and treatment.

Stridor in the Newborn.

Stridor in the newborn period may result from numerous causes, both congenital and acquired. Its presentation is diverse, and understanding the subtleties of that diversity is the key to determining the likely cause of the stridor, as well as the urgency for specialist evaluation. This article presents a framework for evaluating the quality of stridor in the newborn, as well as a review of the characteristics of stridor associated with entities commonly encountered in the neonatal airway.

Managing the Child with Persistent Sleep Apnea.

Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA.

Longitudinal Analysis of "Window Shade" Tympanoplasty Outcomes for Anterior Marginal Tympanic Membrane Perforations.

OBJECTIVES: Although many techniques have been proposed for the repair of tympanic membrane perforations, few address the unique challenges presented by anterior marginal perforations. In these circumstances, traditional underlay and overlay techniques are often complicated by issues including blunting of the anterior tympanomeatal angle, graft lateralization, delayed healing, and reduced graft take rates. The "window shade" tympanoplasty technique described in this paper incorporates several aspects of the underlay and overlay techniques to address these issues. STUDY DESIGN AND SETTING: A retrospective chart review was conducted at an academic medical center, of all patients who underwent window shade tympanoplasty from 1994 to 2016 by a single surgeon. PATIENTS: A total of 412 patients aged 6 to 76 years old were included in the study. Patients who had undergone concomitant ossicular chain reconstruction were excluded from the hearing outcome portion of the analysis. MAIN OUTCOME MEASURES: Any patients observed to have residual postoperative perforations within the first 6 months after surgery were considered to have graft failure. Complications such as otorrhea, serous otitis media, epithelial pearls, and post-auricular infection were tabulated. Air-bone gap closure was also assessed. RESULTS: Postoperative outcomes of 412 patients were assessed including graft take rate, complication rates, and air-bone gap closure. The graft take success rate was 94.2%. Overall complication rate was 4.6%. 82.6% of patients achieved air-bone gap closure within 10 dB. CONCLUSIONS: The results of this study further reinforce the success of the window shade technique in repairing anterior marginal tympanic membrane perforations.

Impact of montelukast and fluticasone on quality of life in mild pediatric sleep apnea.

OBJECTIVES: Research has shown improvement in apnea-hypopnea index in children with mild obstructive sleep apnea treated with anti-inflammatory medications. Data on quality of life outcomes in children receiving these medications is lacking. We aim to assess quality of life in children with mild obstructive sleep apnea treated with montelukast and fluticasone. METHODS: Children between 3 and 16 years old with mild sleep apnea (apnea-hypopnea index > 1 and ≤ 5) presenting to a pediatric otolaryngology clinic were recruited prospectively and treated with 4 months of montelukast and fluticasone. Subjects' caregivers completed the OSA-18, a validated quality of life survey, at baseline and 4 months. Children with ongoing obstruction at follow-up underwent adenotonsillectomy. RESULTS: Thirty-one patients were included. Mean (SD) age was 6.8 (3.9) years. Most subjects (54.8%) were black and 48% were obese. Mean (SD) apnea-hypopnea index of the subjects was 2.8 (1.0). The mean (SD) baseline OSA-18 score was 60.2 (18.5), indicating a moderate impact of sleep disturbance on quality of life. Following treatment, there was significant improvement (p < 0.005) in mean OSA-18 score. Four children discontinued montelukast due to behavioral side effects. Seven children (22%) underwent adenotonsillectomy after failing medical therapy. Demographic factors such as obesity [OR 0.63 (0.11, 3.49)] and apnea hypopnea index [OR 1.38 (0.59, 3.66)] failed to predict which children would respond to anti-inflammatory medications. CONCLUSIONS: Children with mild obstructive sleep apnea treated with montelukast and fluticasone experience significant improvements in quality of life. Further research is needed to determine optimal duration of therapy.

Recurrent respiratory papillomatosis: update 2018.

PURPOSE OF REVIEW: Recurrent respiratory papillomatosis (RRP) is the most common as well as the costliest benign airway neoplasm in the United States [Ivancic et al. (2018). Laryngoscope Investig Otolaryngol 3:22; Derkay (1995). Arch Otolaryngol Head Neck Surg 121:1386]. In addition, it is potentially deadly, with risk of airway obstruction as well as a 3-7% risk of malignant conversion [Schraff et al. (2004). Arch Otolaryngol Head Neck Surg 130:1039]. This review highlights exciting advancements over the past 1-2 years in scientific understanding of the pathophysiology, epidemiology, natural history, prevention, and treatment of this difficult disease. RECENT FINDINGS: Recent studies have yielded the following findings: The primary quality of life reduction that patients perceive is voice-related; the membranous vocal folds are the most frequently involved anatomic subsite in adult-onset RRP; there may be a correlation between laryngopharyngeal reflux, herpes simplex virus type 2, and adult-onset RRP; there has been a decline in RRP incidence in Australia following the implementation of a national vaccination program; addition of educational audiovisual aids assists in vaccine acceptance rates; preventive vaccination can be used as treatment for pediatric as well as adult RRP patients with demonstrable effects on antibody titers and reoperation rates; calreticulin-linked DNA vaccines show promise in reducing the growth rate of human papilloma virus (HPV)11 E6/E7-expressing tumors in mice; injection of bevacizumab is associated with no adverse tissue affects; systemic bevacizumab is effective as a treatment for severe uncontrolled disease; pegylated interferon treatment is effective in select severe pediatric RRP disease; and finally, increased rates of programed death 1 T-lymphocyte infiltration and programed death-ligand 1 expression are seen on both papilloma and infiltrating immune cells. SUMMARY: RRP is declining in incidence but remains a challenging disease to treat with great costs to patients, families, and the healthcare system. As the disease continues to be better understood, new frontiers are opening in treatment, particularly for severe or poorly controlled disease. Until the disease can be eradicated, it remains a vital area of research to help prevent new cases and treat afflicted patients.