Credentialing and training advanced practice providers for advanced tertiary care pediatric otolaryngology: A curriculum for hospital and ambulatory practice.

OBJECTIVES: Inclusion of advanced practice providers (APPs) in hospital-based pediatric otolaryngology has been growing rapidly, aligning with a 70% increase in physician assistants in all surgical subspecialties in recent years. A post-graduate training program is developed to reflect these growing and changing responsibilities. METHODS: Curriculum development took place at one institution over eight years for 16 APPs following a standard Six Step Approach to medical curriculum: 1) Problem Identification and General Needs Assessment, 2) Targeted Needs Assessment, 3) Goals & Objectives, 4) Education Strategies, 5) Implementation, and 6) Evaluation and Feedback. This was integrated into an onboarding process for new hires and a continuing education plan for established providers. Gaps were identified throughout the process to improve education, skills required for competency, and readiness for independent practice. RESULTS: The curriculum incorporated a subset of goals and objectives from the familiar resident curriculum with significant differences in orientation and onboarding. A Clinical Competency Checklist was used initially for feedback and later to support credentialing after completion of the curriculum. A Procedure Rating Form was used for feedback and documentation of the number of performances required for credentialing. Self-Assessment was utilized to further identify readiness for independence and tailor additional education to meet practice needs. CONCLUSION: The curriculum and onboarding process presented can be used for any advanced practice provider joining an individual or team of pediatric otolaryngology providers. A standardized curriculum is helpful to the supervisors and trainees. Further collaboration between institutions and development of benchmarks will help ensure excellence in education and in care of pediatric otolaryngology patients.

IL-13 and IL-13-induced periostin levels are specifically decreased in patients following endoscopic sinus surgery for chronic rhinosinusitis.

BACKGROUND: Type 2 (T2) inflammation plays a pathogenic role in chronic rhinosinusitis (CRS). The effects of endoscopic sinus surgery (ESS) on T2 inflammation are unknown. OBJECTIVE: The aim of this study was to compare T2 inflammatory biomarkers from middle meatal (MM) mucus for distinguishing patients with CRS from CRS-free patients, identifying major phenotypes (CRS without nasal polyps [CRSsNP] and CRS with nasal polyps [CRSwNP]), assessing endotypic change, and establishing cross-sectional and longitudinal outcomes in patients undergoing ESS. METHODS: MM mucus samples were collected from patients with CRSsNP and patients with CRSwNP before and 6 to 12 months after ESS and compared with samples from CRS-free control patients. T2 biomarkers were evaluated both continuously and using threshold-based definitions of T2 endotype to identify relationships with patient-reported (based on the 22-Item Sinonasal Outcomes Test and Chronic Rhinosinusitis Patient-Reported Outcomes Measure) and clinician-reported (radiographic and endoscopic) severity. Linear mixed models were developed to analyze clinical variables associated with T2 biomarker levels. RESULTS: A total of 154 patients with CRS (89 with CRSsNP and 65 with CRSwNP) were enrolled, with a mean interval of 9 months between ESS and follow-up. An analysis of pre-ESS MM mucus samples revealed elevated levels of T2 mediators in patients with CRSwNP versus in patients with CRSsNP and CRS-free controls. Temporally stable correlations between levels of IL-13 and IL-5, levels of periostin and complement 5a, and levels of eosinophil cationic protein (ECP) and eotaxin-3 were observed. On this basis and on the basis of pathologic significance, levels of IL-13, periostin and ECP were further analyzed. After ESS, levels of IL-13 and periostin decreased significantly, whereas ECP levels remained unchanged. Across pre- and post-ESS evaluation, the T2 endotype was associated with radiographic severity but did not predict outcomes. CRSwNP status and African American race were associated with higher levels of IL-13 and periostin, whereas ECP level was higher in patients undergoing extensive surgery. CONCLUSION: ESS decreased levels of IL-13 and periostin in the middle meatus. T2 inflammation after ESS was correlated with patient- and clinician-reported severity across phenotypes. Pre-ESS T2 inflammation did not predict post-ESS outcomes.

Persistent discharge or edema after endoscopic sinus surgery in patients with chronic rhinosinusitis is associated with a type 1 or 3 endotype.

BACKGROUND: Patients with chronic rhinosinusitis (CRS) may have persistence of polyps, discharge, or edema after endoscopic sinus surgery (ESS). Inflammation in CRS can be classified into three endotypes, with the presence of polyps associated with the type 2 endotype. Here, we evaluate the endotypic underpinnings of discharge or edema without polyps after ESS. METHODS: At a visit 6-12 months post ESS, patients underwent endoscopy and completed the CRS-PRO and SNOT-22. Luminex analysis of middle meatal mucus obtained at that visit was performed for IFN-γ, ECP, and IL-17a. Type 1, 2, and 3 endotypes were defined as greater than the 90th percentile expression of each marker, respectively, in controls. Wilcoxon rank-sum and chi-squared tests were used to compare cytokine levels and endotype prevalence between those with and without endoscopic findings. RESULTS: A total of 122 CRS patients completed a clinical exam (median: 8.2 months post ESS). Of the 122 patients, 107 did not have polyps on endoscopy. Of these 107 patients, 48 had discharge, 44 had edema, and 46 had neither discharge nor edema. Compared with those patients without any findings, patients with discharge or edema reported significantly worse severity as measured by CRS-PRO (10.5 vs. 7.0, p = 0.009; 12.0 vs. 7.0, p < 0.001; respectively), and had higher post-ESS IFN-γ, ECP, and IL-17a. Patients with discharge had higher prevalence of only T1 and T3 endotypes, while patients with edema had higher prevalence of only the T3 endotype. CONCLUSIONS: Post-ESS discharge or edema in the absence of polyps was associated with higher patient-reported outcome severity and was more strongly associated with type 1 or 3 inflammation.

A Near Miss of a Retropharyngeal Abscess with MRSA in a 5-Week-Old Boy Due to an Unusual Presentation.

A retropharyngeal abscess (RPA) in early childhood is not uncommon due to at-risk lymph nodes in this deep neck space and is typified by fever, odynophagia, and a constellation of respiratory manifestations. However, RPA is exceedingly rare in the neonatal subpopulation and not part of the usual differential diagnosis algorithm in this age range. Herein, we present a unique case of a previously healthy 5-week-old male infant with protracted "congestion" and difficulty in oral feeding, whose clinical course is confounded by intermittent, positional bradycardia and subsequent apnea. He was eventually diagnosed with a methicillin-resistant Staphylococcus aureus (MRSA) RPA, leading to concurrent vascular and airways compromise in the form of baroreceptor-mediated bradycardia from mass-effect carotid body compression. This clinical case is an important reminder that any infant with positional vital sign changes should prompt urgent and thorough investigation for extraordinary and otherwise uncommon pathophysiologic states. The case also highlights the power of multidisciplinary collaboration across multiple specialties and parental advocacy in unifying a diagnosis for rare pediatric illnesses.

Otologic complications of temporomandibular joint arthrocentesis due to arteriovenous fistula.

Arteriovenous fistula (AVF) is a rare sequela following arthrocentesis of the temporomandibular joint. This case report discusses a constellation of symptoms, findings, and appropriate management of a patient with a superficial temporal AVF. Several findings in this case, including vertigo, nystagmus, and hearing loss, have not been previously documented in the literature.

CRS-PRO and SNOT-22 correlations with type 2 inflammatory mediators in chronic rhinosinusitis.

The 22-item Sino-Nasal Outcome Test (SNOT-22) and 12-item Patient Reported Outcomes in Chronic Rhinosinusitis (CRS-PRO) instrument are validated patient-reported outcomes measures in CRS. In this study we assess the correlation of these with type 2 (T2) biomarkers before and after endoscopic sinus surgery (ESS). METHODS: Middle meatal mucus data were collected and the SNOT-22 and CRS-PRO were administered to 123 patients (71 CRS without nasal polyps [CRSsNP], 52 CRS with nasal polyps [CRSwNP]) with CRS before and 6 to 12 months after undergoing ESS. Interleukin (IL)-4, IL-5, IL-13, and eosinophilic cationic protein (ECP) were measured using a multiplexed bead assay and enzyme-linked immunoassay. Pre- and post-ESS SNOT-22 and CRS-PRO were compared with T2 biomarkers. RESULTS: Before ESS neither PROM correlated with any biomarker. After ESS, CRS-PRO showed a correlation with 2 mediators (IL-5 and IL-13: p = 0.012 and 0.003, respectively) compared with none for the SNOT-22. For CRSwNP patients, pre-ESS CRS-PRO and SNOT-22 correlated with IL-4 (p = 0.04 for both). However, after ESS, CRS-PRO correlated with 3 biomarkers (IL-5, IL-13, and ECP: p = 0.02, 0.024, and 0.04, respectively) and SNOT-22 with 2 biomarkers (IL-5 and IL-13: p = 0.038 and 0.02, respectively). There were no significant relationships between any of the T2 biomarkers pre- or post-ESS among patients with CRSsNP. Exploratory analyses of the subdomains showed the SNOT-22 rhinologic and CRS-PRO rhinopsychologic subdomains correlated better with the T2 biomarkers. On individual item analysis, IL-13 correlated significantly post-ESS with 8 of 12 items on the CRS-PRO vs 6 of 22 items on the SNOT-22. CONCLUSION: The CRS-PRO total score showed a significant correlation with T2 biomarkers especially when assessed post-ESS and among CRSwNP patients.

Use of intraoperative frontal sinus mometasone-eluting stents decreased interleukin 5 and interleukin 13 in patients with chronic rhinosinusitis with nasal polyps.

BACKGROUND: Mometasone-eluting stents (MES) have demonstrated improvement in short-term endoscopic outcomes and reduce short- to medium-term rescue interventions. Their effect on the local inflammatory environment, longer-term patient-reported outcomes, and radiographic severity have not been studied. METHODS: Middle meatal mucus and validated measures of disease severity were collected before and 6 to 12 months after endoscopic surgery in 52 patients with chronic rhinosinusitis with nasal polyps (CRSwNPs). Operative findings, type 2 mediator concentrations, intraoperative variables, and disease severity measures were compared between those who did and those who did not receive intraoperative frontal MES. RESULTS: A total of 52 patients with CRSwNPs were studied; 33 received frontal MES and were compared with 19 who did not. Pre-endoscopic sinus surgery (ESS) middle meatus (MM) interleukin (IL) 13 and eosinophil cationic protein (ECP) were higher in the stented group (p < 0.05), but pre-ESS clinical measures of disease severity were similar as were surgical extent and post-ESS medical management. Intraoperative eosinophilic mucin was more frequent in the stented group (58% vs 11%, p = 0.001). IL-5 (p < 0.05) and IL-13 (p < 0.001) decreased post-ESS in the stented group, but this was not observed in the nonstented group. Post-ESS IL-4 and IL-13 were higher in the nonstented vs stented group (p < 0.05 for both). CONCLUSION: Although patients who received intraoperative frontal MES had significantly higher pre-ESS MM IL-13 and ECP, patients who received frontal MES had lower concentrations of IL-4 and IL-13 than those who did not at a median of 8 months post-ESS. However, these changes did not correspond to significantly different measures of symptomatic or radiographic disease severity.

Prevalence and Risk Factors for Multifocality in Pediatric Thyroid Cancer.

Importance: Current guidelines recommend total thyroidectomy for the majority of pediatric thyroid cancer owing to an increased prevalence of multifocality. However, there is a paucity of information on the exact prevalence and risk factors for multifocal disease-knowledge that is critical to improving pediatric thyroid cancer management and outcomes. Objective: To determine the prevalence and risk factors for multifocal disease in pediatric patients with papillary thyroid carcinoma (PTC). Design, Setting, and Participants: This multicenter retrospective cohort study included patients 18 years or younger who underwent thyroidectomy for PTC from 2010 to 2020 at 3 tertiary pediatric hospitals and 2 tertiary adult and pediatric hospitals in the US. Main Outcomes and Measures: Demographic and clinical variables, including age, family history of thyroid cancer, autoimmune thyroiditis, prior radiation exposure, cancer predisposition syndrome, tumor size, tumor and nodal stage, PTC pathologic variant, and preoperative imaging, were assessed for association with presence of any multifocal, unilateral multifocal, and bilateral multifocal disease using multiple logistic regression analyses. Least absolute shrinkage and selection operator analysis was performed to develop a model of variables that may predict multifocal disease. Results: Of 212 patients, the mean age was 14.1 years, with 23 patients 10 years or younger; 173 (82%) patients were female. Any multifocal disease was present in 98 (46%) patients, with bilateral multifocal disease in 73 (34%). Bilateral multifocal disease was more accurately predicted on preoperative imaging than unilateral multifocal disease (48 of 73 [66%] patients vs 9 of 25 [36%] patients). Being 10 years or younger, T3 tumor stage, and N1b nodal stage were identified as predictors for multifocal and bilateral multifocal disease. Conclusions and Relevance: This large, multicenter cohort study demonstrated a high prevalence of multifocal disease in pediatric patients with PTC. Additionally, several potential predictors of multifocal disease, including age and advanced T and N stages, were identified. These risk factors and the high prevalence of multifocal disease should be considered when weighing the risks and benefits of surgical management options in pediatric patients with PTC.

Hypocalcemia prevention and management after thyroidectomy in children: A systematic review.

INTRODUCTION: Hypocalcemia is the most common complication following thyroidectomy in children. Guidelines to manage post-thyroidectomy hypocalcemia are available for adults, but not children. The objective of this review was to identify practices related to hypocalcemia prevention and management in pediatric patients. METHODS: We identified studies examining the prevention and management of hypocalcemia in pediatric patients post-thyroidectomy within PubMed, EMBASE, Web of Science and Cochrane databases. Three independent reviewers screened citations and reviewed full-text papers. RESULTS: A total of 15 studies were included, representing 1552 patients. The overall study quality was weak with lack of randomization and inconsistent outcome reporting. The pooled incidence of hypocalcemia from the 15 studies was 35.5% for transient hypocalcemia and 4.2% for permanent hypocalcemia. All studies discussed post-operative hypocalcemia treatment, with most patients requiring admission for intra-venous calcium therapy. One study described a protocol discharging asymptomatic patients on calcitriol and calcium. Three studies discussed preoperative calcium supplementation in patients at risk of hypocalcemia. No studies examined routine use of calcium and/or vitamin D supplementation to prevent post-operative hypocalcemia. CONCLUSION: A significant number of children undergoing thyroidectomy develop hypocalcemia. Despite this high incidence, our systematic review demonstrates significant practice variation surrounding post-thyroidectomy hypocalcemia prevention and management in children. LEVEL OF EVIDENCE: III (systematic review of studies of which some were case-control studies (III) and some were case series (IV)).

Definitive surgical management for second branchial cleft fistula: a case series.

BACKGROUND: Second branchial cleft fistulae are rare pediatric anomalies managed with surgical excision and, in certain cases, ipsilateral tonsillectomy to prevent postoperative recurrence or wound infection. Limited information is available in the published literature regarding surgical techniques to maximize patient outcomes and minimize recurrence. Our objective was to describe outcomes for the largest series of branchial cleft fistulae excised using a uniform technique based on embryologic principles. METHODS: We conducted a retrospective analysis of pediatric patients who underwent surgery for second branchial cleft fistula using a uniform technique developed by the senior surgeon between 2006 and 2018 at a tertiary care pediatric hospital. The technique involves dissection to the level of the greater cornu of the hyoid bone as the point of transection, which is the landmark for the base of the tonsillar fossa. Data collected included age at surgery, initial presentation, laterality of fistula tract, final pathology, and follow up data. Measured outcomes included fistula recurrence, wound infection, and other complications. RESULTS: Of 67 patients, 28 (42%) were male and 10 (15%) had bilateral fistulae, for a total of 77 tracts excised. After a median follow up of 31 months, there were no recurrences and one wound infection that was treated successfully with oral antibiotic therapy. No patients underwent tonsillectomy. CONCLUSION: Effective management of second branchial cleft fistulae can be challenging. We present the largest cohort of results using a uniform surgical technique performed at a single center that obviates the need for tonsillectomy, and thus represents a less morbid and effective approach with no evidence of recurrence.

Comparison of the seventh and eighth edition american joint committee on cancer oral cavity staging systems.

OBJECTIVE: For the first time in 30 years, the eighth edition of the American Joint Committee on Cancer (AJCC) Staging Manual offers major changes in the staging of oral cavity cancer. We evaluated the predictive ability of the new staging system for oral cavity cancer to validate these changes and hypothesized that the new system would improve prognostic accuracy. METHODS: We conducted a retrospective cohort study of patients with oral cavity squamous cell carcinoma in the National Cancer Data Base from 2009 to 2013 and applied the seventh and eighth edition staging AJCC staging systems to all patients. Stage-specific overall survival was calculated using the Kaplan-Meier method and concordance indices to measure the system's prognostic accuracy. RESULTS: We identified 39,361 patients with a median follow-up of 27.1 months (range 0.1-80.4 months). In the seventh edition, there were 43.0%, 15.0%, 10.6%, and 25.7% of patients with pathologic stage I, II, III, and IV disease, respectively. After restaging based on eighth edition pathological guidelines, 10.0% of patients were upstaged (38.1%, 18.1%, 14.2%, and 25.2%, respectively, with stage I, II, III, and IV disease, respectively). The survival concordance index improved from the seventh to eighth edition for pathological staging (concordance index 0.699 and 0.704, respectively) and for clinical staging (concordance index 0.714 and 0.715, respectively). CONCLUSION: We provide validation of the new AJCC staging system for oral cavity cancer. Eighth edition AJCC staging guidelines upstage a substantial number of patients with greater depth of invasion or extranodal extension. This resulted in slightly improved prognostication. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:2351-2360, 2018.

Pediatric thyroid nodules: A single center experience.

OBJECTIVES: 1. Analyze our center's experience with thyroid nodules. 2. Evaluate the efficacy of fine needle biopsy. 3. Compare our experience with the 2015 ATA guidelines. METHODS: IRB approved retrospective chart review from July 1993-July 2014 at a tertiary pediatric institution. Patients under age 21 with documented thyroid nodules who underwent fine needle aspiration, and/or thyroidectomy were included. RESULTS: 126 patients were identified. 84.1% (n = 106) were female. Age range was 12 months-20 years. The average age was 13.3 ± 4.1 years. The nodules ranged from 0.5 cm to 6 cm 53.9% (n = 68) had a fine needle biopsy done. 42.6% (n = 29) fine needle biopsies were benign, 26.5% (n = 18) were non-diagnostic, 13.2% (n = 9) were classified as "atypia", 0.09% (n = 6) were consistent with thyroiditis, and 0.09% (n = 6) were suspicious for papillary carcinoma. 78.6% (n = 99) underwent surgery. 7 patients with "benign" needle biopsies underwent surgery: all had follicular adenoma. 7 patients with "atypia" needle biopsies underwent surgery: one patient had papillary thyroid cancer. 8 patients with non-diagnostic needle biopsies underwent surgery: one patient had papillary thyroid cancer. All the patients with needle biopsy suspicious for papillary carcinoma had papillary carcinoma on final pathology. 99 patients underwent surgery: 14.1% (n = 14) had papillary carcinoma and 2% (n = 2) had medullary carcinoma. CONCLUSION: Our review of pediatric thyroid nodules at our institution supports data previously reported. 84% of identified patients were female, supporting previous data that nodules are more prevalent in the female population. Of the 126 patients identified, 12.7% had thyroid carcinoma, supporting the 7-25% range described in previous literature. Our institution showed a high positive predictive value of FNA for papillary thyroid carcinoma.

Pediatric epidermoid cysts masquerading as ranulas: A case series.

Pediatric neck masses represent a variety of differential diagnoses. A common pathology in pediatric cystic neck tumors include ranulas, mucus retention cysts due to salivary gland obstruction. Epidermoid cysts are lesions infrequently encountered in the pediatric population and may appear similarly to ranulas on computed tomography imaging. MRI more easily differentiates these masses, and should therefore be the preferred imaging modality. Due to their distinct intraoperative management, ranulas and epidermoid cysts should be distinguished preoperatively through proper workup.