Current Pediatric Tertiary Care Practices Following Adenotonsillectomy: An Update.

OBJECTIVE: Adenotonsillectomy is a common procedure performed in children, and the practice patterns at academic centers have been evolving with the publication of updated societal guidelines. In this study, we assess perioperative practice patterns at tertiary care children's hospitals for children undergoing adenotonsillectomy. METHODS: A cross-sectional 18-question survey distributed in July of 2022 recruited responses through August 25, 2022. The division chiefs of 70 pediatric otolaryngology groups at tertiary care children's hospitals across the United States and Canada were surveyed. Division chiefs submitted survey responses on behalf of the group practice patterns for children undergoing adenotonsillectomy. The main measure was survey responses from the division chiefs of pediatric otolaryngology reporting group practice. RESULTS: The survey response rate was 46%. Eighty-eight percent of groups reported an official adenotonsillectomy admission policy. Commonly reported admission criteria included age (93%) and obesity (59%). Eighty-eight percent of groups defined severe obstructive sleep apnea as apnea-hypopnea index ≥10. Only 41% of groups required a child to be observed sleeping on room air prior to ambulatory discharge. Ninety-seven percent of groups reported routinely obtaining preoperative polysomnography in a variety of clinical settings. CONCLUSIONS: Many children's hospitals report an official admission policy following adenotonsillectomy. Despite a decade passing since the initial publication of the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines, there remains great variability in the practice patterns for both preoperative polysomnography and postoperative monitoring and admission. These results highlight an opportunity for an improved unified approach to perioperative pediatric adenotonsillectomy practice. LEVEL OF EVIDENCE: 5 Laryngoscope, 2023.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy.

OBJECTIVES: There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision. STUDY DESIGN: Level III, retrospective case-control study. SETTING: A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware). METHODS: A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls. RESULTS: A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy. CONCLUSION: Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy?

IMPORTANCE: Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk. OBJECTIVE: The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk. DESIGN: Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018. SETTING: This study was completed at a tertiary-care pediatric referral center. PARTICIPANTS: 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital. EXPOSURES: Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk. MAIN OUTCOME(S) AND MEASURE(S): Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention. RESULTS: 1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage. CONCLUSIONS AND RELEVANCE: Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.

The Generalizability of the Clinical Assessment Score-15 for Pediatric Sleep-Disordered Breathing.

OBJECTIVE: The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion. METHODS: Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15. RESULTS: Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P < .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1. CONCLUSION: This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing. LEVEL OF EVIDENCE: 2B Laryngoscope, 130:2256-2262, 2020.

Systematic Review of Drug-Induced Sleep Endoscopy Scoring Systems.

Objective To systematically review the scoring systems used to report findings during drug-induced sleep endoscopy (DISE) for adults and children with obstructive sleep apnea. Data Sources PubMed, CINAHL, EBM Reviews, Embase, and Scopus databases. Review Methods This is a systematic review of all indexed years of publications referring to scoring of DISE for children and adults with obstructive sleep apnea. The type of DISE scoring system utilized was the primary outcome. PRISMA guidelines were followed to carry out this review; articles were independently reviewed by 2 investigators. All pediatric and adult studies that utilized ≥1 DISE grading systems were included. Results Of 492 identified abstracts, 44 articles (combined population, N = 5784) were ultimately included; 6 reported on children, 35 on adults, and 1 on children and adults. Twenty-one reporting methods were used in these studies, with the most common being the VOTE system (velum, oropharynx, tongue base, and epiglottis; 38.6%) and the Pringle and Croft classification (15.9%). The sites of obstruction most commonly included in a scoring system were the tongue base (62%), lateral pharynx/oropharynx (57%), palate (57%), epiglottis/supraglottis (38%), and hypopharynx (38%). Less commonly included sites were the larynx (29%), velum (23%), nose (23%), tongue (14%), adenoids (10%), and nasopharynx (10%). Conclusion There is no consensus regarding which scoring system should be utilized to report findings during DISE. The VOTE system and the Pringle and Croft classification were the most frequent scoring systems reported for patients undergoing DISE. Standardization of the reporting of DISE findings would improve comparability among studies.

Current Pediatric Tertiary Care Admission Practices Following Adenotonsillectomy.

IMPORTANCE: Pediatric adenotonsillectomy is a frequently performed procedure. Few studies have examined perioperative practice patterns for children undergoing adenotonsillectomy. OBJECTIVE: To assess current group practice patterns associated with the perioperative care of children undergoing adenotonsillectomy for sleep-disordered breathing at tertiary care children's hospitals following the release of the 2011 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guidelines. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey was distributed to the chiefs of 72 pediatric otolaryngology divisions at tertiary care children's hospitals in the United States and Canada from March 25 to April 16, 2014. MAIN OUTCOMES AND MEASURES: Internet-based survey responses from the chiefs of pediatric otolaryngology at tertiary care children's hospitals in the United States and Canada, who responded regarding group, rather than individual, practices. RESULTS: Of the 72 surveys sent, 48 responses (67%) were received. Twenty-one respondents (44%) reported that their group has no official admission policy for children with sleep-disordered breathing. Seventy-three percent (29 of 40) reported using some measure of obesity as a criterion for postoperative admission. The AAO-HNS polysomnography criteria for severe obstructive sleep apnea were used by 40% of respondents (16 of 40) as admission criteria, whereas 15% (6 of 40) used the American Academy of Pediatrics criteria for severe obstructive sleep apnea. Seventy-three percent (29 of 40) reported requiring a child to be asleep while breathing room air without oxygen desaturation before discharge to home. An established minimum time for observation was reported by 43 of the respondents (90%). Institution size or volume of adenotonsillectomies performed did not affect the results. CONCLUSIONS AND RELEVANCE: Many tertiary care children's hospitals in the United States do not have an official admission policy to guide adenotonsillectomy care. Even for institutions that do have an official admission policy, the policies are not universally aligned with the AAO-HNS clinical practice guidelines. These survey results demonstrate an opportunity to improve quality and safety regarding admission policy practice patterns after pediatric adenotonsillectomy.

Postoperative nonsteroidal anti-inflammatory drugs and risk of bleeding in pediatric intracapsular tonsillectomy.

OBJECTIVES: In light of current FDA guidelines on opioid use in children, we sought to determine the risk of post-tonsillectomy hemorrhage (PTH) in children who received ibuprofen with acetaminophen versus those who received narcotic with acetaminophen for postoperative pain control. METHODS: This was an IRB-approved retrospective chart review of patients at a tertiary-care pediatric center. The medical records of 449 children who received acetaminophen and ibuprofen following intracapsular tonsillectomy with or without adenoidectomy were reviewed (NSAID group) and compared with medical records of 1731 children who underwent intracapsular tonsillectomy and received acetaminophen with codeine or hydrocodone with acetaminophen postoperatively (narcotic group). Main outcome measure was the incidence of PTH requiring return to the operating room. Secondary outcome measures included incidence of primary PTH, secondary PTH, and postoperative evaluation in the emergency department or readmission for pain and/or dehydration. RESULTS: Incidence of PTH requiring return to the operating room was higher in the NSAID group (1.6%) compared with the narcotic group (0.5%), P=0.01. Incidence of primary PTH was significantly higher in the NSAID group (2%) versus the narcotic group (0.12%), P<0.0001. Incidence of secondary PTH was 3.8% in the NSAID group and 1.1% in the narcotic group (P<0.0001). CONCLUSION: Use of ibuprofen after intracapsular tonsillectomy in children is associated with statistically significant increase in PTH requiring return to the operating room, as well as an increase in overall rates of both primary and secondary PTH. Ibuprofen provides pain control that is at least equivalent to narcotic and is not associated with respiratory depression. Further study of ibuprofen use in the post-tonsillectomy patient is warranted.

Pediatric Tympanostomy Tube Removal Technique and Effect on Rate of Persistent Tympanic Membrane Perforation.

IMPORTANCE: Tympanostomy tube removal is a commonly performed pediatric procedure. Few studies have evaluated whether removal technique influences the likelihood of the tympanic membrane (TM) to heal. OBJECTIVE: To determine whether the technique used for tympanostomy tube removal affects the likelihood of persistent TM perforation healing in children. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series with medical chart review in a tertiary care pediatric health system of 247 children undergoing tympanostomy tube removal (341 ears) between 2010 and 2013 by 1 of 4 different techniques: (1) tube removal only; (2) freshening TM perforation edges; (3) performing patch myringoplasty; or (4) both freshening edges and performing patch myringoplasty. MAIN OUTCOMES AND MEASURES: Rate of persistent TM perforation after tympanostomy tube removal using the different removal techniques. Secondary outcomes included associations between persistent TM perforation and patient and tympanostomy tube characteristics. RESULTS: The overall persistent TM perforation rate was 10% (34 of 341 ears). Tube removal technique did not significantly influence likelihood for the TM to heal: perforations persisted in 11 of 97 ears (11%) with tube removal only, 6 of 68 ears (9%) with freshened TM perforation edges, 7 of 57 (12%) with patch myringoplasty, and 10 of 119 (8%) with both edges freshened and patch myringoplasty (P = .81). The mean (SD) age of patients with a persistent perforation at the time of tympanostomy tube removal was 8.5 (3.9) years vs 6.5 (3.2) years for those without a persistent perforation (P = .01). In patients with trisomy 21, there was a significantly higher rate of persistent TM perforation (OR, 8.65; 95% CI, 2.13-34.74; P = .002). Short-acting tubes were found to have a significantly lower rate of persistent TM perforation (13 of 194; 7%) than longer-acting tubes (9 of 41; 22%) (OR, 0.26; 95% CI, 0.09-0.71; P = .002). CONCLUSIONS AND RELEVANCE: No reduction in persistent TM perforation rate was found following tympanostomy tube removal if TM edges were freshened and/or a patch myringoplasty was performed. Increased pediatric age, longer-acting tympanostomy tubes, and history of trisomy 21 may negatively influence likelihood of closure.

A retrospective review of the progression of pediatric vocal fold nodules.

IMPORTANCE: To our knowledge, the rate of change in the size of pediatric vocal fold nodules (VFNs) has not been investigated. Improved understanding of the factors that affect change in VFN size may help to better guide treatment decisions and counselling of families. OBJECTIVE: To characterize the rate of change in the size of pediatric VFNs over time and to identify which factors affect increased rates of improvement. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of 67 children evaluated in a voice clinic between 2002 and 2011 with a primary diagnosis of VFNs. EXPOSURE: No treatment or behavioral modification only (n = 19) vs targeted voice therapy with or without the treatment of associated conditions (gastroesophageal reflux and allergic rhinitis) (n = 45) vs surgical intervention (n = 3). MAIN OUTCOMES AND MEASURES: Change in VFN grade (graded according to a previously validated scale based on size) over time. RESULTS: Sixty-seven patients with a median (range) age of 6.0 (3.8-20.6) years were analyzed. Median (range) follow-up was 25 (1-119) months. The rate of change in VFN grade over time was significantly associated with large baseline VFN size (P < .001) and targeted voice therapy with or without the management of associated conditions or surgery (P = .01); the association with postpubescent age was not significant (P = .09). The rate of change in VFN grade was not significantly different at 1 and 3 years postbaseline (P = .33). CONCLUSIONS AND RELEVANCE: Baseline VFN size, treatment, and patient age are important in predicting the rate of improvement in nodule size over time. Rate of change in VFN size is a gradual decrease that is steady over time. This information can be used to help guide treatment decisions and counsel families of children with VFNs regarding expectations for improvement. Additional study is needed to evaluate whether the same factors that influence nodule size similarly influence parental perception of voice and expert perceptual voice analysis.

c-Met expression in tall cell variant papillary carcinoma of the thyroid.

BACKGROUND: Tall cell variant papillary carcinoma of the thyroid demonstrates unusually aggressive clinical behavior compared with the usual form of papillary thyroid carcinoma. The proto-oncogene c-met encodes a tyrosine kinase receptor known to influence cell invasion. This current study examined c-Met expression in tall cell variant tumors compared with other types of papillary thyroid carcinoma and benign thyroid disease. METHODS: c-Met expression in 60 archived thyroid specimens was evaluated by immunohistochemical staining. RESULTS: Tall cell variant specimens expressed significantly greater levels of c-Met than other forms of papillary thyroid carcinoma and benign thyroid disease (P < 0.0001). c-Met expression was significantly different for the following pairs of histologies: tall cell variant versus usual papillary carcinoma of the thyroid (P < 0.0001), tall cell variant versus follicular variant papillary thyroid carcinoma (P < 0.0001), tall cell variant versus benign thyroid (P < 0.0001), and usual papillary carcinoma of the thyroid versus benign thyroid (P = 0.005). In addition, for all types of papillary carcinomas evaluated, c-Met expression was significantly higher in specimens with extracapsular spread (P = 0.01) and skeletal muscle invasion (P = 0.02), and approached significance for specimens with lymphatic invasion (P = 0.06). After adjusting for extracapsular spread, c-Met expression was still found to be associated significantly with tall cell histology (P < 0.0001). CONCLUSIONS: c-Met expression is a significant marker for tall cell variant papillary carcinoma of the thyroid and its invasive behavior. This finding may explain the unusually aggressive behavior of this tumor and suggests a role for c-Met in the early identification of patients with tall cell variant thyroid disease.