Intraoperative and postoperative findings in children with myringotomy tubes (MT) undergoing cochlear implantation (CI).

OBJECTIVE: To evaluate and compare children undergoing cochlear implantation (CI) with myringotomy tubes (MT) placed preoperatively or intraoperatively to those without MT . METHODS: This was a retrospective review of pediatric patients undergoing CI between 2015 to 2020 at a tertiary care pediatric hospital. CI patients with and without MT were reviewed for the following outcomes: intraoperative findings, intraoperative and postoperative complications, and surgical time. Descriptive and bivariable statistical analysis was performed. RESULTS: 192 cochlear implant surgeries were included: 116 without MT tubes and 76 with a history of MT. Twenty-six patients had MT present at the time of CI surgery. No statistical difference existed between patients with MT (CI + MT group) and those without MT (CI - MT group) with regard to intraoperative complications (P = 0.760) and intraoperative findings (P = 0.545). MT association with total post-operative complications (GEE) showed no statistical significance (OR 2.45, 95% CI 0.83-7.22, P-value 0.105). CI + MT patients were significantly more likely to have inflamed middle ear mucosa at time of surgery (P = 0.003). CI + MT patients did not have a longer length of surgery compared to the CI - MT group (3.47 h vs 3.3 h, respectively, P = 0.342). CONCLUSION: Our data confirms it is safe to perform CI in ears with myringotomy tubes, although the surgeon should be aware of possibly encountering increased middle ear inflammation during the surgery.

Bullying, Peer Victimization, and Quality of Life in Pediatric Hearing Loss Patients: A Pilot Study.

OBJECTIVE: The primary objective of this pilot study is to describe the impacts of bullying and peer victimization (BPV) in children with hearing loss. STUDY DESIGN: Prospective clinical survey study. METHODS: This pilot study enrolled children between 8 and 18 years who were administered validated surveys at an outpatient clinic between July 2020 and March 2022. Surveys included health-related quality of life questionnaires (PedsQL and EQ-5D-Y), along with bullying and peer victimization questionnaires ("My Life in School" and the multidimensional peer victimization scale). Responses were scored with multivariate analysis. Clinical histories and active ICD-10 codes were also collected. RESULTS: About 105 patients were recruited with a mean age of 13.1 years (SD = 3.15) and hearing loss (n = 30) among the top otolaryngological diagnoses. When surveying patients with hearing loss, 50.0% (n = 15) actively used a hearing aid device. Children (ages 8-12 years) with hearing loss reported a significantly lower psychosocial health-related quality of life than their peers without hearing loss (P = .007), though this was not the case for adolescents (ages 13-18 years) with hearing loss (P = .099). These trends did not change significantly before or after students resumed in-person classes. Children who wore hearing aids did not report a different BPV level than their peers. CONCLUSION: In this small sample of school-aged children, any hearing loss, even with mild severity, was associated with diminished health-related quality of life; however, this was unrelated to hearing aid use. Wearing a hearing aid did not appear to be linked to higher bullying and peer victimization rates. Along with further studies on BPV with larger sample sizes, the findings in this study may help physicians counsel parents and children on the psychosocial aspects of hearing loss treatment and guide care decisions. LEVEL OF EVIDENCE: 3.

Pediatric cochlear implants and myringotomy tubes: a systematic review.

OBJECTIVE: To evaluate the intraoperative findings and post-operative complications associated with patients who have current or history of myringotomy tubes undergoing a cochlear implantation. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were followed. Studies from Pubmed, Cochrane, Embase, Web of Science, and Scopus were included. Studies were independently screened and analyzed by 2 reviewers. Publications assessing pediatric patients with current or history of myringotomy tubes at time of cochlear implantation were reviewed. Discrepancies were resolved by a team of 4 reviewers. RESULTS: 172 studies were screened, 15 met inclusion criteria, and 12 were incorporated into the study. All 12 of the studies were retrospective cohort studies. Meta-analysis showed no significant relationship between intraoperative findings at time of cochlear implantation (presence of effusion, granulation tissue, edematous middle ear tissue) and myringotomy tube insertion (p = 0.63). Additionally, there was no significant relationship between current or history of myringotomy tube and acute otitis media episode after CI (p = 0.25). CONCLUSION: There was no association noted between perioperative outcomes of pediatric cochlear implantation and myringotomy tube. This information will be helpful for surgeons planning to perform cochlear implantation in the pediatric population.

The qualitative experiences of otolaryngologists with genetic services in pediatric hearing loss evaluation.

Genetic testing is one of the most high-yield diagnostic tests in the evaluation of pediatric sensorineural (SNHL) hearing loss, leading to a genetic diagnosis in 40-65% of patients. Previous research has focused on the utility of genetic testing in pediatric SNHL and otolaryngologists' general understanding of genetics. This qualitative study examines otolaryngologists' perceptions about facilitators and barriers when ordering genetic testing in the workup of pediatric hearing loss. Potential solutions for overcoming barriers are also explored. Eleven (N = 11) semi-structured interviews were conducted with otolaryngologists in the USA. Most participants were currently practicing in a southern, academic, urban setting and had completed a pediatric otolaryngology fellowship. Insurance was one of the main barriers to testing, and increased genetics provider accessibility was the most frequently cited solution to increase utilization of genetic services. Difficulty acquiring insurance coverage and unfamiliarity with the genetic testing process were the most common reasons otolaryngologists referred patients to genetics clinics for genetic testing, as opposed to ordering testing themselves. This study suggests that otolaryngologists recognize the importance and utility of genetic testing, but a lack of genetics-specific skills, knowledge, and resources makes it difficult for them to facilitate testing. Multidisciplinary hearing loss clinics that include genetics providers may increase the overall accessibility of genetic services.

Sustaining standardized opioid prescribing practices after pediatric tonsillectomy.

INTRODUCTION: Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes. METHODS: A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure. RESULTS: From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28). CONCLUSION: An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.

Patient and physician satisfaction with telemedicine in pediatric otolaryngology.

OBJECTIVES: 1) Evaluate the caregiver-perceived benefits and barriers of a tertiary pediatric otolaryngology telemedicine service using the validated Telemedicine Satisfaction Questionnaire (TSQ); 2) Explore the provider's perception and experience on the current telemedicine platform using a modified Physician Satisfaction Questionnaire (PSQ). METHODS: Caregivers of patients ≤18 years of age who received telemedicine services from May 4 to June 18, 2020 (duration of telemedicine use) were eligible for this study. Caregivers were contacted via telephone and given the option to answer the TSQ over the phone, receive a link via email, or decline participation. Providers were administered the modified PSQ as an anonymous, self-report online instrument on the 2 nd week of telemedicine implementation. The study authors were excluded from the PSQ. RESULTS: 58/148 caregivers completed the TSQ. The TSQ questions were grouped into three categories: quality of care, similarity to in-person care, and perception of the interaction. Caregivers felt the most satisfied with the perception of the interaction (mean response 4.84, SD 0.08, p < 0.05). With the PSQ, providers had less favorable responses when compared to the TSQ across all categories (p < 0.05 for all categories) but did report satisfaction for the perception of the interaction (mean response 3.37, SD 0.85). CONCLUSION: Our study demonstrates further evidence that the telemedicine may provide positive benefits. Caregivers were supportive of this service due to its convenience. Providers felt confident using this service, but they also felt the care provided was different from that in the clinic. Improvement in the telemedicine platforms and associated technology for physical exams may help improve the quality of telemedicine care, and similarity to in-person care.

Effects of Age on Delayed Facial Palsy After Otologic Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVES: To report 4 cases of delayed facial palsy (DFP) after pediatric middle ear (ME) surgery and systematically review and analyze the associated literature to evaluate the effects of age on DFP etiology, management, and prognosis. METHODS: Systematic review of PubMed, Cochrane Library, and Embase for articles related to DFP after cochlear implantation (CI) was performed. These articles were assessed for level of evidence, methodological limitations, and number of cases. Meta-analysis was performed to assess the effects of age on DFP incidence. Furthermore, a comprehensive list of all pediatric DFP cases after otologic surgery was assembled through a multi-institutional retrospective review and systematic review of the literature. RESULTS: Twenty-nine articles fit the criteria for inclusion in the meta-analysis. The incidence of DFP after CI was 0.23% and 1.01% for pediatric and adult cases, respectively. This difference was statistically significant (P < .001, odds ratio 4.36). Twenty-three cases, adding to the 4 presented herein, were suitable for a comprehensive list. The mean age was 6.9 years. Average postoperative day of paresis onset was 5.4, with an average maximum House-Brackmann grade of 3.5. All patients obtained full facial recovery after an average of 23.5 days. CONCLUSIONS: The systematic review demonstrates that DFP after pediatric CI is rare and occurs at a significantly lower rate than in adults, further supporting the viral reactivation hypothesis of DFP. The prognosis for pediatric DFP after otologic surgery is excellent, with a high rate of full recovery in a short time frame. However, steroid administration can be considered. LEVEL OF EVIDENCE: IIa.

Bullying and Children who are Deaf or Hard-of-hearing: A Scoping Review.

OBJECTIVE/HYPOTHESIS: The goal of this scoping review is to evaluate and synthesize the published research regarding bullying and children who are deaf or hard-of-hearing (DHH). STUDY DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR) statement was used as the guideline for conducting this review. METHODS: This review included studies assessing pediatric (0-21 years) DHH children. Seventy records underwent the initial title-abstract screening, 33 underwent full-text review, and 23 studies met inclusion criteria. During the data extraction process, an additional six were excluded, resulting in a total of 17 evaluated studies. RESULTS: Of the 17 studies assessed, nine compared peer victimization of DHH children and their hearing peers. Of those, seven studies reported that hearing loss (HL) is significantly associated with increased victimization. Two studies found that HL is significantly associated with decreased bullying perpetration. Notably, bullying in DHH children was not associated with a visible sign of disability, such as a hearing assistive device. Rather, variables such as educational setting, parental, and peer support are more likely to mediate bullying in this population. CONCLUSIONS: DHH children have a higher risk of peer victimization and may bully others less often than their hearing peers. Studies described the health consequences of bullying in children who are DHH, including sleep issues and anxiety. These consequences may have implications for the patients' overall HL management. Additional research regarding bullying interventions and prevention in this population should be conducted. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1884-1892, 2021.

Social Isolation and Loneliness in the Hearing-Impaired Pediatric Population: A Scoping Review.

OBJECTIVE: To review existing publications in order to evaluate the effect of hearing loss on social isolation and loneliness in the pediatric population. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) guidelines were followed. Eight databases were searched. Studies were independently screened and analyzed by two reviewers. Publications were included if pediatric hearing-impaired individuals and social isolation or loneliness were studied. Discrepancies were resolved by a team of five reviewers. RESULTS: Thirty-three studies were included in this review. Sixty percent of studies (12/20) found that hearing loss was related to loneliness and 64.7% found that children with hearing loss experienced more social isolation (11/17). The Asher Loneliness and Dissatisfaction Questionnaire was commonly used to assess loneliness. No commonly used tool for assessing social isolation was found. Six articles found that school type was not associated with loneliness. Difficulty communicating was the most mentioned factor leading to loneliness and social isolation. Frequent recommendations to improve social integration included facilitating interactions with the hearing-impaired and educating the nonhearing-impaired to normalize the disability. CONCLUSION: The majority of studies found that hearing impairment results in a higher prevalence of social isolation and loneliness. However, an association cannot be definitively claimed due to the lack of uniform assessment tools. This review emphasizes the need for standardized methods to assess loneliness and social isolation and highlights methods to improve social integration for the hearing impaired. Laryngoscope, 131:1869-1875, 2021.

The Pediatric Sinus Staging System: A Computed Tomography-Based Approach to Grading Pediatric Sinus Disease.

OBJECTIVES/HYPOTHESIS: Pediatric chronic rhinosinusitis (CRS) is a prevalent disease with few objective measurements available to predict which patients will require surgical intervention. The Lund-Mackay (LM) score for computed tomography (CT) scans is one objective data point available for the adult population; however, a dedicated scoring system in the pediatric population has not been popularized. We present a Pediatric Sinus Staging System (PSSS) that considers both opacification and the varying developmental stages of each sinus. STUDY DESIGN: Retrospective chart review. METHODS: We analyzed CT scans of pediatric patients with a diagnosis of CRS. Both LM and PSSS scores were calculated for each scan. Groups were formed based on treatment outcomes and included patients who were treated successfully with medical therapy and/or adenoidectomy (med/adenoid), patients who required functional endoscopic sinus surgery (FESS), and patients who required revision FESS. RESULTS: Overall, 76 patient scans were reviewed. PSSS values were significantly less than LM for the control group (P = .001) and significantly higher for patients with cystic fibrosis (P = .027) and with CRS with polyps (P = .001). The ideal cutoff for PSSS to distinguish between med/adenoid and single FESS treatment with a sensitivity 90.6% and specificity of 50.0% was ≥2. CONCLUSIONS: The PSSS gives a more descriptive score by accounting for the opacification and pneumatization of each sinus. Our current results show similar values between PSSS and LM scores, which suggests internal validity. In addition, a PSSS score of ≥2 may help physicians better counsel families on the likelihood of requiring FESS. Further investigation is needed to fully validate the PSSS. LEVEL OF EVIDENCE: 3b Laryngoscope, 131:E642-E648, 2021.

Hearing preservation with a slim modiolar cochlear implant in a pediatric cohort.

OBJECTIVES: Recent cochlear implant (CI) electrodes are designed to be atraumatic to inner ear structures. Studies in adults have demonstrated improved hearing preservation rates with the CI532/632 electrode, but none have examined this in children. Our objective is to describe the hearing preservation rate with CI532/632 in pediatric patients and determine factors that influence hearing preservation. METHODS: We conducted a retrospective cohort study of children undergoing CI over a three-year period. Inclusion criteria were: CI with the 532/632 electrode, presence of pre-operative low frequency hearing defined by pure tone average (PTA) of ≤80 dB at 250 Hz or at the average of 250 and 500 Hz, and post-operative unaided audiometry. Other data collected included demographics, otologic history, imaging, and surgical details. RESULTS: A total of 13 patients and 15 ears were included. Hearing was preserved in 10/15 (66%) ears at an average follow-up of 6 months, similar to that reported in the adult literature. Patients with preserved hearing post-operatively were more likely to have a positive family history of hearing loss. There was a trend towards patients with anatomic inner ear abnormalities being more likely to lose hearing after CI, but this was not statistically significant. Pre-operative thresholds were not predictive of hearing preservation. Patients with preserved hearing had a significantly smaller shift in thresholds after cochlear implantation. Therefore, hearing preserved and non-preserved groups differed more by the magnitude of change in threshold, rather than their preoperative threshold. Other factors such as age, sex, surgeon, and surgery duration were not associated with hearing preservation. CONCLUSION: This study describes low frequency hearing preservation after pediatric CI532/632 implantation. The hearing preservation rate in our cohort was consistent with that reported in the adult literature. Our data suggest that preoperative thresholds do not solely determine which patients will go on to experience hearing preservation. We believe this will aid surgeons with patient-specific device selection and counseling potential pediatric CI recipients with preserved hearing.

Rapid telemedicine implementation in the context of the COVID-19 pandemic in an academic pediatric otolaryngology practice.

OBJECTIVE: To describe the implementation of telemedicine in a pediatric otolaryngology practice during the coronavirus disease 2019 (COVID-19) global pandemic. METHODS: A descriptive paper documenting the development and application of telemedicine in a tertiary academic pediatric otolaryngology practice. RESULTS: A total of 51 established patients were seen via telemedicine within the first 2 weeks of telemedicine implementation. Seven (7) patients were no shows to the appointment. The median patient age was 5 years old, with 55% male patients. Common diagnoses for the visits included sleep disordered breathing/obstructive sleep apnea (25%) and hearing loss (19.64%). Over half (50.98%) of visits were billed at level 4 visit code. DISCUSSION: The majority (88%) of visits during the first 2 weeks of telemedicine implementation in our practice were completed successfully. Reasons that patients did not schedule telemedicine appointments included preference for in person appointments, and lack of adequate device at home to complete telemedicine visit. Limitations to our telemedicine practice included offering telemedicine only to patients who had home internet service, were established patients, and English-speaking. Trainees were not involved in this initial implementation of telemedicine. CONCLUSIONS: COVID-19 has driven the rapid adoption of telemedicine in outpatient medicine. Our group was able to institute an effective telemedicine practice during this time.

The use and cost-effectiveness of intraoperative navigation in pediatric sinus surgery.

OBJECTIVES/HYPOTHESIS: There are consensus statements about when to use intraoperative navigation (IN) in adult sinus surgery. However, no corresponding guidelines exist for pediatrics. Our objectives included: 1) assess the demographic and operative factors associated with IN use and 2) calculate the cost-effectiveness of IN use. STUDY DESIGN: Retrospective chart review. METHODS: One hundred nineteen pediatric patients undergoing sinus surgery between 2003 and 2016 were reviewed. Demographic and surgical factors were collected from medical records. Costs associated with use of IN were gathered from billing records. RESULTS: Of the 119 patients, 60 underwent sinus surgery with navigation (wIN) and 59 underwent surgery without navigation (sIN). Children in the wIN group had more complex surgeries with more sinuses opened (P = .008). Individual attending surgeon and presence of trainee were associated with increased use of IN (P < .001 for both). IN resulted in a median of 31.5 minutes longer surgical time (P < .001). IN had an incremental cost/effectiveness ratio (ICER) of $22,378 for each year without revision surgery for patients with acute disease. However, for patients with chronic disease, the probability of undergoing a second surgery was the same between wIN and sIN groups, and navigation was not cost-effective (ICER of -$3,583). CONCLUSIONS: IN use did not decrease complications or rates of revision surgery. It was used primarily as an educational tool or to increase confidence in intraoperative identification of landmarks. However, the use of IN added surgical time and was not cost-effective. Further research must be completed to determine when IN is indicated in pediatric sinus surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

Patient Positioning During In-Office Otologic Procedures Impacts Physician Ergonomics.

OBJECTIVE: The purpose of this study was to evaluate the impact of patient positioning on physician ergonomics during in-office otologic procedures. A previous simulation study suggested that placing patients supine during in-office otology procedures is ergonomically favorable. This study aims to substantiate these findings during the routine care of patients in an otolaryngology practice setting. STUDY DESIGN: Observational study. SETTING: Outpatient otology clinic within tertiary care facility. STUDY SUBJECTS: Two neurotology attending physicians. INTERVENTIONS: Physicians performed cerumen removal procedures in the office with patients either in the seated position (n = 24) or supine position (n = 24). MAIN OUTCOME MEASURES: The rapid upper limb assessment (RULA), a validated instrument that measures body positioning with a focus on the upper arm, was used to measure ergonomic positioning. RULA scores correlate occupational body positioning with a numeric representation of musculoskeletal injury risk ranging from 1 (minimal risk) to 7 (very high risk). RESULTS: Overall median RULA scores were 4.5 (medium risk) with patients in the seated position, and 2 (low risk) with patients in the supine position (p < 0.0001). Similarly, RULA scores were significantly lower with patients in the supine position when each physician was evaluated independently (p < 0.0001, for both). CONCLUSIONS: Placing patients in a supine position for cerumen removal results in more favorable ergonomic positioning for the physician, thus reducing risk for work-related musculoskeletal disorders. This suggests that physicians should consider placing patients in the supine position for in-office otologic procedures. Further study is needed to investigate optimal ergonomic positioning for other common otolaryngology procedures.

Prognostic Factors of Pediatric Revision Ossicular Chain Reconstruction.

OBJECTIVE: Ossicular chain reconstruction (OCR) is a surgical method used to repair conductive hearing loss. In children, up to 40% of OCRs will require revisions. In this study, our aims were to validate improvement in hearing outcomes following revision OCR and identify prognostic factors for successful revision OCRs. DESIGN: Retrospective review at the Children's Hospital of Pittsburgh from 2003 to 2014. SETTING: Tertiary referral center. PATIENTS: Pediatric patients undergoing multiple OCRs who had demographic, operative, and pre- and postoperative audiogram data. Patients included in our study had ≥ 2 OCR procedures to the same ear. Forty-three of 123 patients met inclusion criteria. MAIN OUTCOME MEASURES: Pre- and postoperative audiograms were used to compare the changes in pure-tone averages (PTA), speech recognition thresholds, and air-bone gaps following OCR surgeries. RESULTS: Revision OCRs significantly improved PTA, speech recognition thresholds, and air-bone gaps (p values= 0.003, 0.004, 0.005, respectively) and seven patients (14%) had return of normal hearing (PTA < 25 dB). Cholesteatoma at the time of first revision was associated with additional OCR revisions (hazard ratio [HR]: 10.3; p=0.013), while patients who had canal wall down or no mastoidectomy during first OCR revision were less likely to require additional revision compared with patients who had canal wall up mastoidectomy (HR: 0.170, p = 0.041 versus canal wall down; HR: 0.242, p = 0.041 versus no mastoidectomy). CONCLUSIONS: Revision OCR(s) are an acceptable method to improve residual conductive hearing loss following primary OCR surgery in pediatric patients. Patients with cholesteatoma and canal wall up at the time of revision OCR have increased chances of requiring further revision.

Factors influencing hearing outcomes in pediatric patients undergoing ossicular chain reconstruction.

OBJECTIVE: Ossicular chain disruption in children leads to conductive hearing loss. Few studies have focused on factors influencing successful results in pediatric ossicular chain reconstruction (OCR). We aim to determine whether demographic or surgical factors affect hearing outcomes in pediatric OCR. METHODS: We conducted a retrospective chart review of 120 patients undergoing OCR at our institution, a tertiary care hospital, between 2003 and 2014, with median length of follow-up of 2.2 years (range 0.1-9.3 years). Pediatric patients (<18 years old at time of surgical procedure) who had current procedural terminology (CPT) codes of OCR, and available pre- and post-operative audiograms were included in the study. Demographic information, surgical details, and pre- and post-operative pure-tone averages (PTA), speech reception thresholds (SRT), and air-bone gaps (ABG) were recorded from clinic notes, audiograms and operative reports. Differences between PTA, SRT and ABG pre- and post-operatively, as well as demographic and surgical factors, were evaluated using Wilcoxon rank-sum tests. Factors influencing revision were evaluated using Log-rank tests. RESULTS: A total of 120 patients (123 ears) were included. 35.8% of cases were revised, most commonly due to displaced prostheses. 28.5% of surgeries resulted in normal hearing (PTA ≤25 dB) post-operatively. Post-operative SRT and ABG were significantly better in patients with partial ossicular replacement prosthesis (PORP) compared with those with total ossicular replacement prosthesis (TORP) (p = 0.016, 0.027). Titanium prostheses resulted in better post-operative PTA and larger changes in PTA compared with all other materials (p = 0.034, p = 0.038). CONCLUSIONS: In our experience, children with titanium prostheses had better hearing outcomes than those with other materials, and children with PORP had better hearing outcomes than those with TORP.

Novel Application of Steroid Eluting Stents in Choanal Atresia Repair: A Case Series.

PURPOSE: To describe the application of mometasone furoate eluting sinus stent technology in the treatment of choanal atresia (CA) in the hopes of preventing postsurgical stenosis. METHODS: We analyzed 3 consecutive patients aged 4 days to 16 years undergoing repair of CA at a tertiary pediatric hospital. Mometasone furoate eluting sinus stents were placed intraoperatively. Postoperative need for revision surgery as well as routine surveillance endoscopy were used to determine success of surgery. RESULTS: Three patients of varying age and etiology underwent successful repair of choanal atresia/stenosis. The steroid eluting sinus stent was deployed successfully in all 3 cases. There was no identifiable restenosis in any of the 3 patients with 12-month follow-up. There were no complications noted throughout the follow-up period. CONCLUSIONS: Choanal atresia is a rare disorder that can prove difficult in postsurgical management. In our case series, mometasone furoate eluting stents were effective and safe for the management of this disease process. Further prospective studies are needed to determine the exact safety profile, long-term consequences, and efficacy of steroid eluting sinus stents in the pediatric population.

Optimizing Positioning for In-Office Otology Procedures.

Objective Surgeons often report musculoskeletal discomfort in relation to their practice, but few understand optimal ergonomic positioning. This study aims to determine which patient position-sitting versus supine-is ergonomically optimal for performing otologic procedures. Study Design Observational study. Setting Outpatient otolaryngology clinic setting in a tertiary care facility. Subjects and Methods We observed 3 neurotologists performing a standardized simulated cerumen debridement procedure on volunteers in 2 positions: sitting and supine. The Rapid Upper Limb Assessment (RULA)-a validated tool that calculates stress placed on the upper limb during a task-was used to evaluate ergonomic positioning. Scores on this instrument range from 1 to 7, with a score of 1 to 2 indicating negligible risk of developing posture-related injury. The risk of musculoskeletal disorders increases as the RULA score increases. Results In nearly every trial, RULA scores were lower when the simulated patient was placed in the supine position. When examined as a group, the median RULA scores were 5 with the patient sitting and 3 with the patient in the supine position ( P < .0001). When the RULA scores of the 3 neurotologists were examined individually, each had a statistically significant decrease in score with the patient in the supine position. Conclusion This study indicates that patient position may contribute to ergonomic stress placed on the otolaryngologist's upper limb during in-office otologic procedures. Otolaryngologists should consider performing otologic procedures with the patient in the supine position to decrease their own risk of developing upper-limb musculoskeletal disorders.