Effect of Local Anesthetic Injections on Subjective Pain Scales in Pediatric Tonsillectomies: A Meta-analysis.

OBJECTIVE: To assess the effect of local anesthetic injection on subjective pain scores for pediatric tonsillectomies on postoperative days (PODs) 0 and 1. DATA SOURCES: A comprehensive literature search was conducted with the PubMed, Embase, Web of Science, and Scopus databases. REVIEW METHODS: A 2-researcher team following the PRISMA guidelines performed a systematic review and meta-analysis. Studies with original data and a saline injection control arm were selected. Corresponding authors were contacted for missing data. The collated data were analyzed with RevMan version 5.4 (Review Manager; Cochrane Collaboration). Random effects modeling and standard mean difference were utilized to control for heterogeneity. Surgical technique subgroup analysis was performed. RESULTS: A total of 319 publications were identified, and 8 articles with 13 experimental arms (627 participants) were selected for meta-analysis. Local anesthetic injection was compared with placebo with saline injection. The standard mean difference for POD 0 pain was -0.81 (95% CI, -1.16 to -0.46; P < .00001) in favor of local anesthetic. The standard mean difference for POD 1 was -1.13 (95% CI, -1.48 to -0.78; P < .00001) in favor of local anesthetic. Subgroup analysis by surgical technique showed a less robust effect for cautery excision (-1.01 [95% CI, -1.37 to -0.66]) vs cold excisional technique (-1.19 [95% CI, -1.64 to -0.74]), with or without cautery-based hemostasis. CONCLUSIONS: A local anesthetic injection during a pediatric tonsillectomy reduces postoperative pain on POD 0 and 1. Further analysis on total narcotic use and postoperative complications would benefit surgeon decision making.

Volumetric analysis of the aging auditory pathway using high resolution magnetic resonance histology.

Numerous shown consequences of age-related hearing loss have been unveiled; however, the relationship of the cortical and subcortical structures of the auditory pathway with aging is not well known. Investigations into neural structure analysis remain sparse due to difficulties of doing so in animal models; however, recent technological advances have been able to achieve a resolution adequate to perform such studies even in the small mouse. We utilize 12 members of the BXD family of recombinant inbred mice and aged separate cohorts. Utilizing novel magnetic resonance histology imaging techniques, we imaged these mice and generated high spatial resolution three dimensional images which were then comprehensively labeled. We completed volumetric analysis of 12 separate regions of interest specific to the auditory pathway brainstem nuclei and cortical areas with focus on the effect of aging upon said structures. Our results showed significant interstrain variation in the age-related effect on structure volume supporting a genetic influence in this interaction. Through multivariable modeling, we observed heterogenous effects of aging between different structures. Six of the 12 regions of interests demonstrated a significant age-related effect. The auditory cortex and ventral cochlear nucleus were found to decrease in volume with age, while the medial division of the medial geniculate nucleus, lateral lemniscus and its nucleus, and the inferior colliculus increased in size with age. Additionally, no sex-based differences were noted, and we observed a negative relationship between auditory cortex volume and mouse weight. This study is one of the first to perform comprehensive magnetic resonance imaging and quantitative analysis in the mouse brain auditory pathway cytoarchitecture, offering both novel insights into the neuroanatomical basis of age-related changes in hearing as well as evidence toward a genetic influence in this interaction. High resonance magnetic resonance imaging provides a promising efficacious avenue in future mouse model hearing loss investigations.

Cochlear ribbon synapse maturation requires Nlgn1 and Nlgn3.

Hearing depends on precise synaptic transmission between cochlear inner hair cells and spiral ganglion neurons through afferent ribbon synapses. Neuroligins (Nlgns) facilitate synapse maturation in the brain, but they have gone unstudied in the cochlea. We report Nlgn3 and Nlgn1 knockout (KO) cochleae have fewer ribbon synapses and have impaired hearing. Nlgn3 KO is more vulnerable to noise trauma with limited activity at high frequencies one day after noise. Furthermore, Nlgn3 KO cochleae have a 5-fold reduction in synapse number compared to wild type after two weeks of recovery. Double KO cochlear phenotypes are more prominent than the KOs, for example, 5-fold smaller synapses, 25% reduction in synapse density, and 30% less synaptic output. These observations indicate Nlgn3 and Nlgn1 are essential to cochlear ribbon synapse maturation and function.

nPEP protocol implementation and evaluation at a local US Crisis Center.

Non-occupational Post-Exposure Prophylaxis for HIV (nPEP) is recommended by the CDC for isolated exposures that pose "substantial risk" for HIV transmission. To combat multiple barriers to nPEP utilization, a comprehensive program was developed through the local community sexual assault provider. The purpose of this study was to evaluate nPEP protocol implementation. A retrospective chart review was conducted of all sexual assault victims seen during a six-month period, and all patients who accepted nPEP were selected for follow-up phone interviews. 157 patients presented during the study period. Mean time to care was 32.4hrs, with 126/157 (80%) presenting ≤72hrs. 114/157 (73%) patients were offered nPEP by providers. 67/114 (59%) patients accepted, with the most common reason for declining being needing more time to decide. 10/13 (77%) patients able to be contacted reported completing nPEP, with side-effects cited as the most common noncompletion reason. 9 reported side effects and 4 received recommended follow-up HIV testing. 83/99 (84%) patients clearly eligible by chart review were offered nPEP, suggesting good adherence to CDC guidelines. Most patients contacted completed nPEP despite side-effects, suggesting good adherence. Our findings demonstrated multiple points status post-sexual assault to potentially improve the nPEP process.

Anesthetic injections and analgesia use in pediatric post-tonsillectomy patients: A meta-analysis and systematic review.

OBJECTIVE: To assess the effect of local anesthetic injection on post-operative analgesia and complications for pediatric tonsillectomies on post-operative day (POD) 0 and 1. METHODS: A 2-researcher team following the PRISMA guidelines performed a systematic review and meta-analysis. The databases Pubmed.gov, Embase, Web of Science, and Scopus were used. Studies written with original data utilizing a saline injection control arm were selected. Corresponding authors were contacted for missing data, which was used when possible. The collated data was analyzed with Review Manager (RevMan) Version 5.4., The Cochrane Collaboration, 2020. Surgical technique subgroup analysis was performed. RESULTS: 319 publications were identified and 8 articles with 12 total experimental arms (529 participants) were selected. Local anesthetic injection was compared to saline injection. The standard mean difference for time until first analgesic was 0.68 min [0.26, 1.09](P = 0.001) in favor of local anesthetic. The odds ratio (OR) for patients receiving one or more narcotic doses on POD 0 was 0.22 [0.06, 0.84](P = 0.03) in favor of local anesthetic. CONCLUSIONS: Use of an intraoperative anesthetic injection during pediatric tonsillectomy can help improve initial recovery as it delays the need for narcotic medication and may reduce postoperative narcotic usage on POD 0 and 1. In addition, a local anesthetic does not increase the risk of postoperative bleeding or dehydration.

Management of Peritonsillar Abscess Within a Local Emergency Department: A Quality Analysis Study.

OBJECTIVE: Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck, affecting thousands of people annually with high treatment costs. The purpose of this project was to determine how in-network emergency departments (EDs) adhere to generally accepted guidelines regarding diagnosis and management of potential PTAs. METHODS: The authors performed a retrospective chart review to identify patients with PTA in five EDs in one year. Information pertaining to diagnostic tests, treatment, and airway status was also collected. Descriptive analysis was used to assess if EDs were consistent with generally accepted guidelines. RESULTS: Six hundred twenty-one patient records were identified and 140 were included in final analysis. Out of 140 patients, 71 were admitted for inpatient management and 23 were admitted for observation. Of the 46 patients diagnosed and discharged from the ED, 61% received a computerized tomography (CT) scan and only 39% had PTA drainage performed. Four (3%) patients received a point of care ultrasound and a CT scan and no patient received only an ultrasound. Out of all patients, 116/140 received a CT scan and 22 received drainage in the ED. The remainder of these patients either had drainage performed by an otolaryngologist or had no drainage performed. Of the 94 patients admitted for inpatient or observation, 84 received a CT scan and six received drainage by an ED physician. Only 62% of patients were given a penicillin derivative and 29% were given clindamycin, which has no Gram-negative coverage. CONCLUSION: One-third of PTA patients were managed within the ED, far less than similar studies. Of these, over 50% received a CT scan and less than 50% had PTA drainage. PTA drainage can improve patients' symptoms and antibiotic effectiveness. The majority of patients were prescribed a penicillin derivative with or without another antibiotic.

To Tube, or Not to Tube: Comparing Ventilation Techniques in Microlaryngeal Surgery.

OBJECTIVES/HYPOTHESIS: The objective of this study was to compare ventilation techniques utilized in microlaryngeal surgery. STUDY DESIGN: Retrospective cohort study. METHODS: Two-hundred surgeries performed from May 1, 2018 to March 1, 2020 and stratified as intubated, intermittently intubated (AAIV) or apneic. Patient demographics, comorbidities, anesthetic agents, intraoperative parameters/events, and complications were studied and compared across the three groups using inferential analyses. RESULTS: Median body mass index in the AAIV group was significantly higher (33 vs. 29; P = .0117). Median oxygen nadirs were lower in AAIV cases (81% vs. 91-92%) while CO2 peak measurements were lower (33 mmHg vs. 48 mmHg) in the fully apneic cohort which were significantly shorter cases (P < .0001). CO2 peak measurements were comparable between AAIV and intubated cohorts (median 48.5 mmHg vs. 48.0 mmHg). Median apnea times were significantly prolonged by 2-5.5 minutes using nasal cannula and THRIVE/Optiflow in fully apneic cases when compared to no supplementary oxygenation (P = .0013). Systolic blood pressures following insertion of laryngoscope were higher (159.5 vs. 145 mmHg) and postoperative diastolic pressures were lower (68.5 vs. 76.5 mmHg) in fully apneic cases than intubated cases. No differences existed between frequencies of complications. CONCLUSIONS: This study compares intubated, intermittently apneic, and fully apneic surgeries. No statistically significant differences were noted in comorbid conditions. While intraoperative hemodynamic fluctuations were more pronounced in the fully apneic cohort, and oxygenation distributions were lower in the AAIV cohort, no significant differences existed between events and complications. Apneic techniques are as safe and effective as traditional intubation. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2773-2781, 2021.