Pediatric cochlear implant explantation and reimplantation over a 32-year period.

OBJECTIVES: Cochlear implantation is indicated for pediatric patients with bilateral severe to profound sensorineural hearing loss. The literature reports large variability in cochlear implant (CI) device survival and rates of explantation and reimplantation. This retrospective chart review summarizes CI survival and rates of explantation and reimplantation in pediatric CI recipients at a Canadian tertiary pediatric hospital over 32 years. METHODS: A retrospective chart review of all pediatric patients who received a Cochlear Corporation® CI between April 1988 and June 2020 was undertaken. Rates of explantation/reimplantation were collected and categorized based on device type and reason for failure (medical, device, and inconclusive failure). Device survival analysis based on implant model was also completed utilizing Kaplan-Meier curves. RESULTS: 512 CIs were implanted over the 32-year period by four surgeons (77.1%, 18.16%, 4.49%, and 0.20%, respectively). Patient age ranged from seven months to 20.4 years. The overall explantation and reimplantation rate was 3.32% (17/512 implants), with seven as a result of device failure (1.37%), nine events of medical failure (1.76%), and one inconclusive failure (0.20%). Cumulative CI survival rates at 5, 10, 15, and 20 years were 98.15%, 96.33%, 95.53%, and 94.39%. CONCLUSION: The overall institutional CI failure, explantation, and reimplantation rates are lower than the average reported rates in the literature.

Patient reported outcome measures in unilateral aural atresia treated using a transcutaneous bone conduction implant (The Cochlear Baha Attract®).

OBJECTIVES: Unilateral aural atresia (UAA) is a congenital condition that is associated with maximal conductive hearing loss. The primary objective of this study was to assess the long-term compliance, complications, and quality of life of pediatric patients with UAA who had transcutaneous bone conduction hearing implants (TCBI). METHODS: Retrospective consecutive case series at a single centre between 2014 and 2018. Inclusion criteria consisted of UAA patients between 5 to 17 years-old receiving the Cochlear Baha Attract ® device. Demographic and audiologic data was extracted from charts. A prospective telephone survey was done, with patients and their families completing the Glasgow Children's Benefit Inventory (GCBI). Basic descriptive statistics, paired t-tests, and a univariate analysis were completed. RESULTS: Data was successfully collected from all 9 eligible children who received the Cochlear Baha Attract ® device for UAA (100%). The mean follow-up duration was 33 months after TBCI (9-60 months). The mean daily use was 7.7 h/day. Pure tone average and mean speech in noise scores were both significantly improved when comparing the unaided condition to the aided condition with TCBI (p < 0.001). The majority (89%) of patients had an improvement in GCBI; the median GCBI score was +14.6, indicating overall positive benefit. A linear regression showed no demographic variables were significant for mean daily use or GCBI scores. CONCLUSION: This preliminary study showed that patients with a TCBI for UAA had high long-term compliance and daily usage rates. TCBI improved the quality of life for the majority of patients and significantly improved hearing measures.

High frequency of otolaryngology/ENT encounters in Canadian primary care despite low medical undergraduate experiences.

Otolaryngology involves the treatment of patients with diseases and disorders of the ear, nose, throat (ENT), and related structures of the head and neck. Many medical students in Canada have limited experiences in ENT and a vast majority of these students go on to pursue a career as primary care physicians. Physicians at a primary care facility classified patient's visits as either being "ENT" related or not, to assess the amount of ENT related concerns they typically encounter. The data was collected separately in the summer and winter months to assess any seasonal variability. One in eight patient encounters presented with an ENT related concern. The percentage of ENT related symptom presentation visits in the pediatric population for both data collection periods (29%) was more than three times that of the adult population (9%). The rate of ENT symptom presentation in both adult and pediatric populations was not affected by seasonality. Primary care physicians will encounter new patients presenting with ENT related concerns quite frequently. This is especially true in the pediatric patient population. Increased ENT medical education is both necessary and essential for undergraduate medical students, residents, and primary care physicians.

L'oto-rhino-laryngologie (ORL) concerne les maladies et les troubles de l'oreille, du nez, de la gorge et des structures connexes de la tête et du cou. De nombreux étudiants au Canada n'ont qu'une expérience limitée de cette spécialité alors que la grande majorité d'entre eux poursuivent une carrière de médecin de soins primaires. Les médecins d'un établissement de soins primaires ont classé les visites des patients afin de déterminer le volume de consultations en lien avec l'ORL. Les données ont été recueillies séparément pendant les mois d'été et d'hiver pour évaluer la variabilité saisonnière. D'après les données, une consultation sur huit était liée à la présence de symptômes ORL. Le pourcentage de consultations chez la population pédiatrique pour les deux périodes de collecte de données (29 %) était plus de trois fois supérieur à celui de la population adulte (9 %). La survenance de symptômes ORL n'était pas affectée par la saisonnalité, ni chez l'une ni chez l'autre. Les médecins de soins primaires voient assez souvent de nouveaux patients présentant des problèmes ORL, particulièrement des enfants. Un renforcement de l'enseignement de la médecine ORL est à la fois nécessaire et essentiel pour les étudiants en médecine de premier cycle, les résidents et les médecins de soins primaires.

Spontaneous Resolution of Ear Lidding in Newborns: A Prospective Observational Cohort Study.

ABSTRACT: Ear lidding is a cosmetic outer ear shape deformity commonly observed in newborns. Although lidding is considered a benign condition, psychological concerns such as bullying and depression have been observed in older children supporting correction of the condition. Nonsurgical correction of lidding using molding and splinting techniques has become increasingly popular, achieving successful outcomes in the majority of cases. Spontaneous resolution of the condition has also been reported in the literature however there is minimal prospective data available on the natural progression of ear lidding. In our case series of 11 closely followed newborns, we aimed to characterize the natural progression and resolution of lidding. Ten consecutive newborns participated in the observation plan and all 10 had complete spontaneous resolution of lidding within an average of 40 days. One other newborn's parents self-selected to have molding and splinting treatment. These results suggest that cosmetic treatment for less severe cases of ear lidding may be unnecessary as they have the potential to resolve on their own. Future research in this area could include controlled study designs and more work is needed to identify, which infants will require treatment. Our study may provide helpful reassurance to families and physicians that many newborns may see complete resolution of lidding without intervention.

Intranasal Dexmedetomidine increases the successful sedation of children with autism for out-patient auditory brainstem response hearing tests.

INTRODUCTION: The auditory brainstem response (ABR) hearing test can be challenging in children with autism spectrum disorder (ASD) due to the inherent behavioral challenges associated with this condition. To attempt to increase our success in sedating ASD patients, we added the use of intranasal Dexmedetomidine (Dexmed) to be used alone or with oral Chloral Hydrate (CH) in an ambulatory care setting, with monitoring by a specialist nurse. OBJECTIVES: To determine the success and safety of a protocol for ABR testing performed under sedation with intranasal Dexmed and oral chloral hydrate in ASD patients. To compare the success rate, the occurrence of adverse events and time needed to initiate ABR between Dexmed-CH protocol and previous CH-alone protocol in ASD patients. METHODS: Retrospective review. ASD patients in Dexmed-CH sedation protocol were age- and sex-matched to ASD patients who underwent CH-alone sedation protocol, for comparison. RESULTS: 74 ABR records in ASD children were included, 37 patients using Dex-CH protocol and 37 patients using CH-alone protocol. In the Dexmed-CH protocol group, Dexmed was used in 2 different ways: alone as a first choice in patients who refused to swallow CH (9/37), or combined with CH as a rescue (28/37). Under this sedation protocol, 89% of the attempted ABRs were completed successfully with no major adverse effects. In comparison, in ASD patients sedated using the protocol of CH-alone, the success rate significantly lower (69% vs. 89%). The time needed to initiate the test was not significantly different. CONCLUSION: The use of intranasal Dexmed by itself or in combination with CH was a safe and reliable method of performing sedated ABR in ASD patients. Modifying our previous oral CH protocol to include intranasal Dexmed, substantially improved our success rate of sedation in ASD patients in an ambulatory setting. This study may be of significant value to centers worldwide exploring alternatives to general anesthesia for ABR testing in ASD patients.

Mastoid pressure dressing - Current practice amongst Canadian pediatric cochlear implant surgeons.

OBJECTIVES: Mastoid pressure dressing (MPD) has routinely been used following major ear surgery, such as cochlear implant (CI) surgery, to prevent postoperative wound complications. To date, controlled studies have suggested no difference in the incidence of wound complications following MPD use. However, there is a variation in the practice of MPD usage across pediatric CI surgeons. In this study, we aimed to identify the most common type of postoperative dressing management after pediatric cochlear implantation and the factors in the decision-making process for post-surgical care amongst Canadian pediatric CI surgeons. METHODS: Canadian Otolaryngologists who perform pediatric CI surgery were identified (n = 18) and contacted via email to complete a short online questionnaire regarding current post-operative head dressing practice following CI surgery. Descriptive statistics were used to analyze the response data. RESULTS: The participants provided an approximate number of CI's they performed in 2016. 100% of the recipients completed the survey. Approximately 376 CI's were completed in 2016 with an average of 21 CI's per surgeon. 61% of participants routinely used MPDs following surgery justified by reasons such as wound protection, institutional standard of care, and physician's original training practice. CONCLUSION: There is no clear consensus on the use of MPDs amongst Canadian pediatric CI surgeons. Since the current evidence in the literature suggests no difference in wound complication incidence post-surgery with MPD use, a change in postoperative dressing management to non-use in those that employ this practice may be justified. Eliminating the usage of a MPD may also have potential economic benefits. Further prospective controlled studies may be warranted.

The use of video glasses improved learning of tonsillectomy and adenoidectomy surgery: A randomized controlled trial.

OBJECTIVE: One of the most common challenges in surgical education for trainees is gaining practical experience through observing procedures in the operating room. Due to the nature of some procedures, a narrow surgical view severely limits the learning experience. Video glasses are new devices that offer the potential to project the primary surgeon's exact view to learners in real-time, allowing for an enhanced operative learning experience. STUDY DESIGN: Single center randomized prospective trial. SETTING: Tertiary care pediatric hospital. PARTICIPANTS: Using block randomization, medical students and surgical residents observed either a tonsillectomy or adenoidectomy, either directly at table-side or by real-time video feed from the surgeon's video glasses projected to a screen in the operating room, in random order. Participants then completed a survey comparing aspects of their learning experience viewing the procedure through the video feed in comparison to direct observation. MAIN OUTCOME MEASURES: Evaluating the hypothesis that video glasses provided an improved overall learning experience and a realistic simulation of the open surgical procedures tested. RESULTS: 23 trainees participated in the study. Survey results demonstrated that the overall learning experience with the use of video glasses was significantly improved when compared to direct visualization (average Visual Analog Scale (VAS) score 82/100 vs. 64/100, p = 0.021). Video glasses were shown to be superior when comparing the view of the surgical field (83/100 vs. 54/100 on VAS, p < 0.001) and the ability to identify anatomical structures (79/100 vs. 56/100 on VAS, p = 0.001). The ease of following surgical steps with video glasses was also shown to be better than by direct visualization (81/100 vs. 69/100 on VAS, p = 0.039). All participants stated that video glasses closely simulated the learning environment of the real-life open procedure. CONCLUSION: This study showed that the use of video glasses was beneficial for surgical education and a realistic tool for learners at varying levels of training. Video glasses may significantly improve the learning experience for procedures with a narrow field of view.

Improving vaccination uptake in pediatric Cochlear implant recipients.

BACKGROUND: An Infectious Disease vaccine specialist joined our institution's Cochlear Implant Team in 2010 in order to address the high percentage of non-compliance to immunization prior to surgery identified previously from an internal review. The purpose of this study was to (1) review the immunization status of cochlear implant recipients in 2010-2014, (2) assess if introducing a vaccine specialist made a significant change in vaccination compliance and (3) elucidate any barriers to vaccination compliance. METHODS: Retrospective chart review and a telephone survey. Medical records of 116 cochlear implant recipients between 2010 and 2014 were reviewed. A telephone survey was conducted to obtain the current vaccination status in children who required post-operative vaccinations with incomplete records on chart review and, if applicable, the reason for non-compliance. RESULTS: Between 2010 and 2014, 98% of children were up-to-date at the time of surgery, compared to 67% up-to-date at the time of surgery between 2002 and 2007. 27 children were included in our post-operative immunization analysis. 29.6% (8/27) failed to receive necessary vaccinations post-surgery. Pneumovax-23, a vaccine for high-risk patients (such as cochlear implant candidates) was missed in all cases. CONCLUSION: Pre-operative vaccination for cochlear implant recipients improved dramatically with the addition of a vaccine specialist. However, a significant proportion of patients requiring vaccinations post-surgery did not receive them. The main reason for non-compliance was due to parents being unaware that their children required this vaccine postoperatively by being "high-risk". Although improvement was demonstrated, a communication gap continued to impede the adequacy of vaccination uptake in pediatric cochlear implant recipients following surgery at age 2 when the high-risk vaccine was due.

Detection of abnormally shaped ears by a trained non-specialist allows for early non-surgical intervention.

INTRODUCTION: Many children are born with abnormally-shaped ears, including protruding ears or unusually-shaped outer ears. While the majority are benign, these may cause significant issues with self-esteem and bullying in childhood. Early molding can resolve some of these abnormalities, avoiding the need for future corrective surgery. However, newborns with these abnormalities are rarely identified early, within the first few days of life, when molding is most effective. In this study, we investigate whether a trained non-specialist can correctly identify ear shape abnormalities in newborns. METHODS: A non-specialist (medical student) was trained on normal and abnormal ear anatomy using photographs and descriptions. Newborns <72 h of age were recruited from maternity wards. Newborns' ears were photographed and these images were assessed independently by two specialists and the non-specialist. External ear shape was classified as either normal or abnormal based on pre-determined criteria. RESULTS: A total of 661 ears of 334 newborns were photographed and assessed. High inter-rater agreement was achieved with a kappa statistic of 0.863 (SE 0.078). The non-specialist detected abnormally-shaped ears with a sensitivity and specificity of 90.9% and 91.1% respectively. CONCLUSIONS: Our study illustrates that non-specialist can be trained to accurately detect newborn ear abnormalities, providing a cost-effective means of ensuring that these children's health care needs are met in a timely fashion. Specifically, we recommend the integration of ear shape assessment into currently established programs such as the newborn hearing screening program.

Prevalence and ethnic variation of pre-auricular sinuses in children.

OBJECTIVES: Pre-auricular sinus (PAS) describes a congenital ear malformation presenting as a pit or sinus that may become infected, often requiring antibiotics and/or surgical excision. Although the presentation of PAS in otolaryngology clinics is not uncommon, there is limited epidemiological data regarding this malformation in children. Some evidence also suggests a potential ethnic variation in prevalence rates and potential heritability patterns within families, however these have yet to be proven. This study is the first to use pediatric population level data to investigate prevalence rate, ethnic variation, and to explore the unproven hypotheses of a genetic basis of PAS. METHODS: In this prospective cross-sectional study, we enrolled 1106 subjects (mean age=6.8, male-to-female ratio=1.15:1) between June and September 2014. Subjects were recruited from B.C. Children's Hospital in Vancouver, Canada. Inclusion criteria was children <18 years of age; exclusion criteria was those seeking care for PAS. Subjects were visually inspected for the presence of PAS by clinical observers followed by verbal questionnaire (demographics, self-identified ethnicity, family history of PAS, chronic medical conditions). Data analysis utilized Pearson Chi-Square Test to determine the potential ethnic variation, and odds ratios of family history were used to determine a potential genetic basis. RESULTS: 26 (7 bilateral, 19 unilateral) of 1106 subjects were positive for PAS (2.4%). Using Pearson Chi-Square Test, a significant ethnic variation was found to exist (χ(2) (6,N=1106)=22.80, p<0.0001), with Asians having the highest prevalence (6.6%), followed by African Americans (4.5%), Middle Easterners (3.4%), First Nations (2.0%), and Caucasians (1.2%). None were found in South Asians (n=124) or Latin Americans (n=18). Subjects with positive family history of PAS had greater likelihood of having PAS (OR=16.7, 95% CI=7.3-38.5, p<0.0001). There was also stronger association between family history and bilateral PAS (OR=26.5, 95% CI=5.8-121.7, p<0.0001) compared to unilateral PAS (OR=12.2, 95% CI=4.6-32.5, p<0.0001). CONCLUSIONS: This was the largest pediatric population level study to date, and showed the prevalence of PAS was 2.4% in this pediatric population, whose ethnic diversity was representative of B.C.'s community. A significant ethnic variation existed and associations between family history and PAS suggested a potential genetic basis, particularly with bilateral PAS.

Symptomatic Congenital Cytomegalovirus Infection Is Underdiagnosed in British Columbia.

Records were reviewed from all infants tested for congenital cytomegalovirus infection in British Columbia, Canada from 2006 to June 2014. Fourteen of 701 infants, or approximately 4.2 per 100,000 live births, had a positive test, indicating that >90% of expected symptomatic congenital cytomegalovirus infection cases were not diagnosed using clinician-initiated testing.

Maternal thoughts of harm in response to infant crying: an experimental analysis.

Ninety-eight mothers of healthy firstborn infants 0 to 6 months old were randomly assigned to listen to 10-min of infant crying or infant cooing while continuously rating subjective feelings of frustration. Participants completed pre-test measures of depressed mood, empathy, and trait anger and post-test measures of infant-related harm thoughts, negative and positive emotions, and urge to comfort and to flee. Twenty-three (23.5 %) participants endorsed unwanted thoughts of active harm (e.g., throwing, yelling at, shaking the infant). Women in the cry condition were more likely than women in the coo condition to report thoughts of harm. Women in the cry condition who endorsed thoughts of harm reported higher frustration levels over the 10 min of crying, higher levels of post-test negative emotions, and stronger urges to flee the infant but not stronger urges to comfort the infant. Trait anger and personal distress empathy predicted the occurrence of unwanted thoughts of infant harm, whereas negative mood did not. Unwanted, intrusive, infant-related thoughts of harm may be triggered by prolonged infant crying, are predicted by personal distress empathy and a tendency to experience anger, and are associated with higher frustration, negative emotions, and the urge to escape the infant.

Publication rate of abstracts presented at the Canadian society of otolaryngology- head and neck surgery annual meetings: a five year study 2006-2010.

BACKGROUND: To determine the rate of publication in a peer-reviewed journal for all oral presentations made at the Canadian Society for Otolaryngology- Head and Neck Surgery's Annual Meetings from 2006-2010. METHODS: All abstracts were searched by keywords and authors' names in Medline via PubMed and Google Scholar. Authors of presented abstracts not found to be published were contacted directly for further information. RESULTS: 50.5% of presented abstracts (n = 198) were subsequently published with an average time to publication of 21 months. For those abstracts found not to be published 74.6% (n = 167) of authors responded with further information about their research, 66% (n = 89) of abstracts with author response that were not published were never submitted for publication. Authors' main reasons for not publishing were that the research was still in process (34%, n = 21) or that a resident or fellow working on the project "had moved on" (26%, n = 16). CONCLUSION: The publication rate for the Canadian Society for Otolaryngology- Head and Neck Surgery's Annual Meetings from 2006-2010 is within the range reported by other conferences and specifically other Canadian conferences in different specialties; however, roughly half of presentations went on to be published. The main barrier to publication was bringing projects to the submission stage and not rejection by journals. Resources such as more time for research or personnel to coordinate projects may result in a greater rate of project completion.

Maternal frustration, emotional and behavioural responses to prolonged infant crying.

Prolonged inconsolable crying bouts in the first months of life are frustrating to parents and may lead to abuse. There is no empirical description of frustration trajectories during prolonged crying, nor of their emotional predictors or emotional and behavioural sequelae. Frustration responses and their relationships were explored in an analogue cry listening paradigm. Without knowing how long it would last, 111 postpartum mothers were randomized to listen to a 10-min audiotape of infant crying or cooing while continuously recording frustration on a visual analogue 'slider' scale. The listening bout was preceded by questionnaires on negative mood, trait anger and empathy and followed by questionnaires on the reality of the cry sound, positive and negative emotions, soothing strategies, coping strategies and urges to comfort and flee. Individual frustration trajectories were modelled parametrically and characterized by frustration maximum, rate of rise, inflections and harmonicity parameters. As hypothesized, the modal response was of gradually increasing frustration throughout. However, there were marked individual differences in frustration trajectories. Negative mood, trait anger and empathy did not predict modal or modelled individual trajectories. However, frustration responses were significantly related to post-listening emotions and behavioural ratings. In particular, prolonged crying generated highly ambivalent positive and negative emotional responses. In summary, maternal frustration generally increased as the crying bout progressed; however, frustration trajectories were highly individual and emotional responses were highly ambivalent in terms of positive and negative emotions generated. Some emotional and behavioural responses were associated with specific trajectory parameters of frustration responses.

Proteomic biomarkers of recovered heart function.

AIMS: Chronic heart failure is a costly epidemic that affects up to 2% of people in developed countries. The purpose of this study was to discover novel blood proteomic biomarker signatures of recovered heart function that could lead to more effective heart failure patient management by both primary care and specialty physicians. METHODS AND RESULTS: The discovery cohort included 41 heart transplant patients and 20 healthy individuals. Plasma levels of 138 proteins were detected in at least 75% of these subjects by iTRAQ mass spectrometry. Eighteen proteins were identified that had (i) differential levels between pre-transplant patients with end-stage heart failure and healthy individuals; and (ii) levels that returned to normal by 1 month post-transplant in patients with stable heart function after transplantation. Seventeen of the 18 markers were validated by multiple reaction monitoring mass spectrometry in a cohort of 39 heart failure patients treated with drug therapy, of which 30 had recovered heart function and 9 had not. This 17-protein biomarker panel had 93% sensitivity and 89% specificity, while the RAMP® NT-proBNP assay had the same specificity but 80% sensitivity. Performance further improved when the panel was combined with NT-proBNP, yielding a net reclassification index relative to NT-proBNP of 0.28. CONCLUSIONS: We have identified potential blood biomarkers of recovered heart function by harnessing data from transplant patients. These biomarkers can lead to the development of an inexpensive protein-based blood test that could be used by physicians to monitor response to therapy in heart failure, resulting in more personalized, front-line heart failure patient management.

Electronic and paper diary recording of infant and caregiver behaviors.

OBJECTIVES: To assess (1) preference of parental use of an electronic diary (e-diary) over a paper diary to record continuous infant and caregiver behaviors over 7 days; (2) whether e-diary recordings would differ in systematic ways from those obtained by paper diaries, and (3) frequency of diary entries when parents provide entries when convenient. METHODS: Mothers of normal newborns were randomized at 5 weeks infant age to a paper diary first (n = 34) or e-diary first (n = 35) group. With 3 days between, mothers completed 7-day recordings on both the paper Baby's Day Diary and an analogous personal digital assistant e-diary for infant (sleep, awake alert, feeding, fussing, crying, inconsolable crying) and caregiver (carrying/holding, moving) behaviors, and completed post diary ease-of-use ratings and poststudy preference ratings. RESULTS: Mothers found e-diaries less bothersome but similarly disruptive and enjoyable to paper diaries. At study end, more found e-diaries easier to use, less bothersome and more efficient. E-diary behaviors were consistently more frequent, but rarely different in duration, then paper diary behaviors. Time-stamped e-diary entries (1) generally declined across weeks, (2) were higher if e-diaries were used first, and (3) settled at a modal 2 to 3 entries/day by the second week. CONCLUSIONS: For behavioral recording of infant and caregiver behaviors, mothers generally expressed more approval for e-diaries than paper diaries, but neither was considered onerous. E-diaries consistently report more frequent but similar durations of behaviors. If recording when convenient, daily diary entries trend toward 2 to 3 entries a day. The e-diary results provide convergent evidence that paper diary recordings of common infant and caregiver behavior durations provide good estimates of durations, but that behavioral frequencies may be underestimated.