Persisting variance in middle ear ventilation tube insertion in Auckland children: why ethnic disparity continues.

AIM: Insertion of ventilation tubes (VTs) is a common surgical treatment for recurrent and persistent otitis media, but surgical practice varies internationally. The current study explored variations in practice within New Zealand by examining VT insertion rates. The aim of the study was to determine time trends and current variations in VT insertion rates by ethnicity and district health board (DHB), with a focus on comparison of two DHBs in Auckland (Counties Manukau and Auckland DHB) to national average data. METHOD: Data for surgical procedures were analysed in the Atlas of Healthcare Variation domain, available via the Health Quality & Safety Commission website. Publicly funded events for New Zealand residents over a 10-year period (2009-2018) were examined for 0-4-year-olds. Individuals were assigned to their DHB of residence. VT rates for each DHB are presented per 1,000 population, with upper and lower confidence intervals calculated to the 95% level. RESULTS: There was a general decline in the rates of VT insertions for the 0-4-year-olds over the 2009-2018 decade. Analysis of the 2018 year showed variation by ethnicity and DHB. In CMDHB, ADHB and nationally, Asian and Pacific ethnic groups had the lowest rates of VT insertions compared to other ethnic groups. In CMDHB, the VT rates for Maori, Pacific and Asian children were less than half that of their respective groups in ADHB. The NZ European/Other ethnic group had the highest rates of VT insertions in CMDHB and nationally, but in ADHB, the rate for the NZ European/Other group was similar to that for Maori. CONCLUSION: These results are incongruent with evidence that Maori and Pacific children in New Zealand experience a greater burden of middle ear disease than NZ European children. The finding of persisting inequities in VT treatment for middle ear disease in 0-4-year-olds, with greatest impact on Pacific children, suggests that there may be a need for targeted middle ear screening for preschool children to detect pre-schoolers with ear disease, earlier than the 4-year-old B4 School Check.

Isolated Congenital Round Window Atresia: Report of 2 Cases.

Round window atresia (RWA) is an uncommon condition and can result in a conductive hearing loss. Two cases of nonsyndromal bilateral RWA in 2 members of the same family are reported. Both cases presented with a conductive hearing loss of 20 to 30 dB. High-resolution computed tomography scanning was used to diagnose the condition. The patients were rehabilitated with hearing aids. Review of the literature has shown disappointing results in hearing improvement with cochlear fenestration in an attempt to address this condition. Patients presenting with unexplained conductive hearing loss should be offered computed tomography scanning. The cases we report add to the literature to benefit future patients in preoperative counseling and better inform management.

The bacterial species associated with aspirated foreign bodies in children.

OBJECTIVE: Inhaled foreign bodies in children are common and may be complicated by secondary airway tract infection. The inhaled foreign body may act as carrier of infectious material and the aim of this study was to explore the bacterial species associated with aspirated foreign bodies in a cohort of children. METHODS: Retrospective case series of 34 patients who underwent rigid laryngobronchoscopy because of foreign body aspiration. Each patient had a sample taken from tracheobronchial secretions during the procedure. RESULTS: The average patient age was 31.2 months and the average hospital stay was 2.5 days. Of the foreign bodies 24 (71%) were organic in nature and 10 (29%) were non-organic. Twenty eight (82.3%) patients had mixed oropharyngeal flora organisms growth. Fifteen (44%) samples were positive for organisms other than oropharyngeal flora with the most common cultured organisms being: Streptococcus pneumonia (4/12%), Haemophilus influenza (4/12%), Moraxella catarrhalis (4/12%). Four samples (12%) grew a fungus; Candida albicans was cultured in 3 patients and Aspergillus glaucus was identified in one sample. Of the non-oropharyngeal organisms 7(47%) demonstrated antibiotic resistance with four having resistance to amoxycillin, two resistant to penicillin and one resistant to cotrimoxazole. CONCLUSION: Some children who present with aspirated foreign body may be complicated with secondary airway infection. Antibacterial treatment might be considered in some of these cases. The regimen of antibiotics should aim to cover oropharyngeal flora, S. pneumonia, H. influenza and Moraxella catarrhalis.

Long-standing inhaled foreign bodies in children: Characteristics and outcome.

OBJECTIVE: Aspirated foreign bodies in children present a potentially life-threatening condition and can be challenging to diagnose. This study aims to elucidate the characteristics and outcome of children with long-standing aspirated foreign bodies. METHODS: Retrospective case series of all cases of confirmed long-standing aspirated foreign bodies (LSAFB) between January 2003 to December 2015 in a single paediatric tertiary-level institution, defined as more than two weeks from choking episode or beginning of symptoms. RESULTS: Clinical files and operative records on 227 patients were screened and 35 children were confirmed to have been treated for LSAFB as per definition above. Median time to presentation was 4 weeks (mean 8.8 weeks). Eighty-six percent presented with cough and 51% with dyspnoea. Abnormal chest X-ray findings were found in 28 out 31 patients (90%). Organic foreign bodies (22) were more common than inorganic (14). Intraoperative granulation tissue was demonstrated in 89% of patients and in 46% of patients this was regarded as significant (defined as obstructing more than 50% of the involved airway lumen). Mean length of stay was 2.5 days. Nine patients (26%) had 11 respiratory complications; there were no mortalities. CONCLUSIONS: Paediatric LSAFB poses an uncommon diagnostic dilemma as there is often no witnessed history of aspiration event; and signs, symptoms and chest X-Ray findings are often non-specific. Laryngobronchoscopy is made more difficult by the presence of granulation tissue and the sequelae of prolonged non-treatment is a higher rate of chronic respiratory disease.

Pharmacokinetics and analgesic effectiveness of intravenous parecoxib for tonsillectomy ± adenoidectomy.

BACKGROUND: Few pharmacokinetic (PK) and pharmacodynamic (PD) data exist for COX-2 selective inhibitors in children. We wished to characterize the PKPD of parecoxib and its active metabolite, valdecoxib, in this population. METHODS: Children (n = 59) were randomized to parecoxib 0.25 mg·kg-1 , 1 mg·kg-1 , and 2 mg·kg-1 during tonsillectomy ± adenoidectomy. Samples (4-6 per child) were obtained from indwelling cannula over 6 h. A second group of inpatient children (n = 15) given 1 mg·kg-1 contributed PK data from 6 to 24 h. Pain scores and rescue medication for the first group were recorded postoperatively for up to 24 h. PK data were pooled with those (10 samples/24 h) from a published study of children (n = 38) who underwent surgery. A three-compartment parent and one-compartment metabolite model with first-order elimination was used to describe data using nonlinear mixed effects models. An EMAX model described the relationship between dose and rescue morphine equivalents during recovery. RESULTS: Parecoxib PK parameter estimates were CLPARECOXIB 19.1 L·h-1 ·70 kg-1 , V1PARECOXIB 4.2 L·70 kg-1 , Q2PARECOXIB 6.29 L·h-1 ·70 kg-1 , V2PARECOXIB 130 L·70 kg-1 , Q3PARECOXIB 6.02 L·h-1 ·70 kg-1 , and V3PARECOXIB 2.03 L·70 kg-1 . We assumed all parecoxib was metabolized to valdecoxib with CLVALDECOXIB 9.53 L·h-1 ·70 kg-1 and VVALDECOXIB 51 L·70 kg-1 . There was no maturation of clearance over the age span studied. There were no differences in pain scores between groups on waking, discharge, 12 h, or 24 h. There were no differences in analgesia consumption over 24 h between groups for tramadol, fentanyl, and morphine rescue use. Fentanyl and morphine consumption, expressed as morphine equivalents (0.13 mg·kg-1 ) in the 0.25 mg·kg-1 group, was greater than that observed in the 1 or 2 mg·kg-1 groups (0.095 mg·kg-1 ) in PACU. CONCLUSIONS: Parecoxib 0.9 mg·kg-1 in a 2-year-old, 0.75 mg·kg-1 in a 7-year-old, and 0.65 mg·kg-1 in a 12-year-old child achieves dose equivalence of 40 mg in a standard 70 kg person. Clearance maturation may occur in infants younger than the current cohort. Parecoxib doses above 1 mg·kg-1 add no additional analgesia.

Pneumococcal vaccine impact on otitis media microbiology: A New Zealand cohort study before and after the introduction of PHiD-CV10 vaccine.

UNLABELLED: We compared the microbiology of middle ear fluid (MEF) in two cohorts of children having ventilation tube (VT) insertion; the first in the era of 7-valent Streptococcus pneumoniae conjugate vaccine (PCV7) and the second following introduction of the ten-valent pneumococcal vaccine (PHiD-CV10). METHODS: During 2011 (Phase 1) and again in 2014 (Phase 2) MEF and NP samples from 325 children and 319 children were taken at the time of VT insertion. A matched comparison group had NP swabs collected with 137 children (Phase 1) and 154 (Phase 2). Culture was performed on all NP and MEF samples with further molecular identification of Haemophilus species, serotyping of S. pneumoniae, and polymerase chain reaction (PCR) testing on all MEF samples. RESULTS: In Phase 2 immunisation coverage with ⩾3 doses of PHiD-CV10 was 93%. The rate and ratios of culture and molecular detection of the 3 main otopathogens was unchanged between Phase 1 and Phase 2 in both MEF and NP. Haemophilus influenzae was cultured in one quarter and detected by PCR in 53% of MEF samples in both time periods. S. pneumoniae and Moraxella catarrhalis were cultured in up to 13% and detected by PCR in 27% and 40% respectively of MEF samples. H. influenzae was the most common organism isolated from NP samples (61%) in the children undergoing VT surgery whilst M. catarrhalis (49%) was the most common in the non-otitis prone group. 19A was the most prominent S. pneumoniae serotype in both MEF and NP samples in Phase 2. Of Haemophilus isolates, 95% were confirmed to be non-typeable H. influenzae (NTHi) over both time periods. CONCLUSION: Following implementation of PHiD-CV10 in New Zealand, there has been no significant change in the 3 major otopathogens in NP or MEF in children with established ear disease. For these children non-typeable H. influenzae remains the dominant otopathogen detected.

The starship children's hospital tonsillectomy: A further 10 years of experience.

OBJECTIVES/HYPOTHESIS: Tonsillectomy as a day-stay procedure remains controversial, although it is an established procedure in New Zealand. We reviewed our last 10 years' experience. METHODS: A prospective audit was used to determine unplanned conversion from day-stay to overnight hospital admission rates and the incidence of postoperative complications. RESULTS: There were 5,400 tonsillectomies performed over the 10-year study period (January 2004-January 2015); 71% as outpatients. The unplanned conversion rate to overnight stay was 0.4%. The median age of day-stay patients was 6.5 years (range 13 months-15 years) compared with those admitted for overnight stay (5 years; range 8 months-15 years). The primary postoperative bleed rate was 0.5% (confidence interval [CI] 0.3%-0.7%), and the combined primary and secondary posttonsillectomy bleed rate was 4.3% (CI 3.8%-5.0%). The rate of patients returning with postoperative complications within 1 month of surgery was 6.3% (CI 5.6%-7.0%). CONCLUSION: Day-stay tonsillectomy in the pediatric population is safe when performed using the described guidelines in a facility with appropriate resources. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:E416-E420, 2016.

What is behind the ear drum? The microbiology of otitis media and the nasopharyngeal flora in children in the era of pneumococcal vaccination.

AIM: This study aims to describe the microbiology of middle ear fluid (MEF) in a cohort of children vaccinated with Streptococcus pneumoniae conjugate vaccine (PCV7) having ventilation tube insertion. Nasopharyngeal (NP) carriage of otopathogens in these children is compared with children without history of otitis media. METHODS: Between May and November 2011, MEF and NP samples from 325 children aged <3 years were collected in three major centres in New Zealand at the time of ventilation tube insertion. An age-matched non-otitis-prone comparison group of 137 children had NP samples taken. A questionnaire was completed by both groups. RESULTS: Immunisation coverage with at least one dose of PCV7 was 97%. Haemophilus influenzae was cultured in 19.4% of MEF and was polymerase chain reaction (PCR) positive in 43.4%. S. pneumoniae and Moraxella catarrhalis were cultured in <10% of MEF samples but were PCR positive for 23.1% and 38.7%, respectively. H. influenzae was the most common organism isolated from NP samples (60%) in the grommet group, while M. catarrhalis (56%) was the most common in the non-otitis prone group. S. pneumoniae was more commonly found in the nasopharynx of children with ear disease (41% vs. 29%). 19F was the most prominent S. pneumoniae serotype in NP samples of both groups, but no serotype dominated in MEF. Ninety-five per cent of H. influenzae isolates were confirmed to be non-typeable H. influenzae. CONCLUSION: In this cohort of children with established ear disease requiring surgical intervention, non-typeable H. influenzae is the dominant pathogen in both the nasopharynx and MEF.

The incidence of acute otitis media in New Zealand children under five years of age in the primary care setting.

INTRODUCTION: Acute otitis media (AOM) is a common childhood infection. Baseline data are required to evaluate potential changes in the epidemiology of AOM with new public health measures. AIM: To estimate the incidence of AOM in children under five years of age in primary care in New Zealand. METHODS: Using a cohort study design, consultation notes from 1 November 2008 to 31 October 2009 from 63 primary care facilities were analysed for new and recurrent episodes of AOM, complications, antimicrobial use and outcome. RESULTS: There were 19 146 children in the sample. The raw incidence of AOM was 273 per 1000 children (27.3%; 95% CI 216-330). Of the 3885 children, 2888 (74%) had one episode of AOM and 152 (4%) of these children developed recurrent AOM. Incidence declined with age. There was no difference in incidence between Maori, Pacific and 'Other' ethnicities. Antibiotics were used to treat 2653 (51%) AOM episodes and 113 (4.3%) of these children re-presented within three days of antibiotic therapy for persistent symptoms. Tympanic membrane perforation was the only complication noted, observed in 62 (1%) episodes. DISCUSSION: These data indicate that AOM is an important and frequent childhood infection in New Zealand. The show a significant decline in the use of antibiotics to manage AOM in concordance with accepted best practice. The complication rate of AOM is likely under-represented. This study enables future research into the effectiveness of current and future immunisations and changing management practices in New Zealand.

Vitamin D and tonsil disease--preliminary observations.

OBJECTIVE: To estimate the prevalence of 25(OH) vitamin D deficiency in children undergoing (adeno)tonsillectomy. METHODS: From 1st November 2008 to 20th December 2008, 33 children aged from 4 to 16 and resident in Auckland, New Zealand (latitude 36° 52' S) undergoing (adeno)tonsillectomy for difficulty breathing/sleep apnoea and/or recurrent tonsillitis had 25(OH) vitamin D, iron and zinc levels measured. RESULTS: Of the 32 patients who had 25(OH) vitamin D levels measured, 15.6% were vitamin D deficient (25(OH) vitamin D<50nmol/L), and 78% had levels, <75nmol/L. 25(OH) vitamin D level was inversely correlated with Fitzpatrick skin type (Spearman's rho=-0.713, p<0.01), body mass index (BMI) (Spearman's rho=-0.434, p=0.013) and tonsil size (Spearman's rho=-0.417, p=0.017). However regression modeling demonstrated that only Fitzpatrick skin type (ß=-0.687, p=0.001) and BMI (ß=-0.256, p=0.044) were significant predictors of vitamin D levels (R(2)=0.572). CONCLUSIONS: Seventy-eight percent of Auckland children undergoing (adeno)tonsillectomy had a 25(OH) vitamin D level<75nmol/L, a level which is associated with an increased incidence of upper respiratory tract infection. Low 25(OH) vitamin D levels were related to a darker skin, increased BMI and larger assessed tonsil size. The association of larger tonsil size with lower 25(OH) vitamin D status needs further evaluation but offers a potential explanation why black and Hispanic children are more likely than white children to have (adeno)tonsillectomy for snoring or obstructive sleep apnoea.

Middle ear disease in children with cleft palate: protocols for management.

OBJECTIVE: There is wide international variation in the protocols used for middle ear disease management in cleft palate patients. Ventilation tube (grommet) insertion may occur routinely at the time of palatoplasty or selectively on a separate occasion if symptomatic middle ear disease develops. The audiological and otologic outcomes of cleft palate patients were studied in a single institution over a timeframe in which both protocols were utilised. METHODS: This was a retrospective study of 234 cleft palate patients who underwent palatoplasty from 1990 to 2005 at Middlemore Hospital, Auckland, New Zealand. Data on hearing loss, middle ear disease, and tympanic membrane abnormalities was collected from clinical notes. Audiological data was obtained from pure tone audiogram reports. RESULTS: Forty-five patients had routine grommets inserted concurrent with palatoplasty and 189 patients were managed conservatively with selective grommet insertion if indicated. Grommets were subsequently required in 79 (41.8%) of these 189 patients. There was no difference in the incidence of persistent conductive hearing loss, but recurrent middle ear disease, tympanic membrane abnormalities, and the total number of grommet insertions were significantly higher in the routine grommet group. Poorer outcomes were noted in patients who had undergone a greater number of grommet insertions. CONCLUSION: No significant deterioration in audiological outcomes and better otologic outcomes were found in cleft palate patients undergoing selective grommet insertion compared to routine grommet insertion. It is recommended that ventilation tube placement occur in patients selected on the basis of symptomatic infection or significant hearing loss.

Pediatric tracheotomy: 17 year review.

OBJECTIVE: To study the outcomes, complications, and indications for pediatric tracheotomies performed at a major tertiary care children's hospital, Starship Children's Hospital in Auckland, New Zealand, over the period 1987-2003. METHODS: A retrospective review of hospital records from 1987 to 2003 was conducted to assess all pediatric patients who had undergone tracheotomies. RESULTS: A total of 122 tracheotomies (119 surgical, 3 percutaneous) were performed on patients less than 16 years of age. Upper airway obstruction (including craniofacial dysmorphism, n=40, and subglottic stenosis, n=18) was the most common indication for surgery (n=86; 70%) with a lesser number (n=36; 30%) requiring tracheotomy for prolonged ventilation. The median age at tracheotomy was 4.5 months in patients with upper airway obstruction and 16 months in those requiring prolonged ventilation. Decannulation was carried out successfully in 92 patients (75%), although 6 (6.5%) subsequently required recannulation. The overall complication rate was 51% (n=62). Early postoperative complications occurred in a total of 9 (7.4%) patients, including difficulties with ventilation in intensive care due to inadequate seal or tube position in 5 (4.1%), and accidental decannulation in 3 (2.5%). Late complications included localized granulation in most patients, for which 15 (12.3%) required intervention whilst under a routine planned general anesthetic. Major vascular erosion was not encountered in any patient, although 5 (4.1%) required intervention for minor bleeding associated with granulation tissue. Suprastomal collapse occurred in 13 patients (10.7%); but did not affect their subsequent decannulation, although 2 (1.6%) developed tracheotomy-related subglottic stenosis. Closure of tracheocutaneous fistulas was required in 16 (13.1%) decannulated patients. Only 2 patients (1.6%) died from tracheotomy-related complications, with an overall mortality rate of 14%. CONCLUSIONS: Pediatric tracheotomies performed at Starship Children's Hospital between 1987 and 2003 were associated with a low incidence of procedure-related mortality and morbidity and successful decannulation in most cases. The majority of procedures were performed to treat upper airway obstruction, most commonly caused by craniofacial dysmorphism or subglottic stenosis.

A rare tracheal lesion.

We report a potentially life-threatening tracheal lesion that caused postextubation stridor in a child following dental surgery. The child developed a cough, dysphonia, stridor, and respiratory distress hours after his operation. Standard therapy for postextubation stridor was ineffective. A lateral neck X-ray suggestive of subglottic pathology prompted an endoscopy. This revealed a fibrinous membrane that was attached to the anterior trachea and required mechanical ablation. The child made an uneventful recovery. This lesion has not been reported in children before and we believe that it is important in the differential diagnosis of postextubation stridor as it requires specific therapy.