Risk Factors for Multiple Hemorrhages Following Tonsil Surgery in Children.

OBJECTIVES/HYPOTHESIS: Although much is known about the incidence and risk factors for hemorrhage after tonsil surgery, the incidence and factors related to multiple episodes of hemorrhage are not well examined. Our objective was to identify risk factors that may contribute to multiple hemorrhages following tonsil surgery in children. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review was conducted of pediatric patients who experienced one or more hemorrhages following tonsillectomy/tonsillotomy, with or without adenoidectomy, between 2010 and 2016 at a single, tertiary-care hospital. Risk factors for multiple hemorrhages were examined using a multivariable logistic regression model. RESULTS: Among the 11,140 patients who underwent tonsil surgery, 452 patients experienced one or more hemorrhages; 32 of these had multiple episodes of hemorrhage (7.1% of all patients with bleeds/0.3% of all patients). Older age (≥12 years: adjusted odds ratio [OR]: 3.13; 95% confidence interval [CI]: 1.47-6.68) and high body mass index for age (≥85th percentile: adjusted OR: 2.26; 95% CI: 1.06-4.85) were significantly associated with an increased risk of multiple hemorrhages in the multivariable model. Medical comorbidities, indications for surgery, surgical technique, intraoperative blood loss, and perioperative medications were not associated with multiple episodes of bleeding. CONCLUSIONS: Multiple hemorrhages after tonsillectomy/tonsillotomy are uncommon. The risk of a second PTH after an initial episode is 7.1%, almost double the risk of a bleed after the initial tonsil surgery. Age > 12 years and high BMI for age may be associated with increased risk of rebleeding. After an initial bleed, increased surveillance may be warranted, particularly for patients with risk factors. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2765-2770, 2019.

Patient-reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation.

OBJECTIVE: The primary objective of this project was to retrospectively investigate the relationship between patient-reported and physiologic swallowing measures after chemoradiation therapy for head neck cancer (HNC). METHODS: Adult patients who underwent chemoradiation therapy for HNC and presented for videofluoroscopic swallow study were reviewed retrospectively. Surgically treated patients were excluded. Patient perception of swallowing-related outcomes was assessed via the MD Anderson Dysphagia Inventory (MDADI) on the same day that physiologic measures of swallow function were obtained. Using vidoefluoroscopic data, the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale yielded measures of safety (DIGEST-S: penetration/aspiration) and efficiency (DIGEST-E: residue). Statistical analysis for correlation coefficients was performed. RESULTS: Thirty patients met the inclusion criteria. The oropharynx was the most commonly affected site (70.0%), followed by the larynx (16.7%). The median radiation dose was 72 grays (Gy), and participants were assessed a mean of 4.6 (range 0-12) years following completion of treatment. There was no correlation between the MDADI and the DIGEST-E score (Pearson rho = -0.045, P = 0.812), DIGEST-S score (Pearson rho = 0.075, P = 0.695), or summary DIGEST grade (Pearson rho = 0.046, P = 0.810). MDADI scores did not change significantly with increasing time since radiation (P = 0.375), whereas the DIGEST-E scores, DIGEST-S score, and summary DIGEST grades worsened over time (P = 0.007, P = 0.002, and P = 0.0005, respectively). CONCLUSION: Assessment of swallowing physiology showed that function worsened after chemoradiation therapy, but this did not correlate with patient-reported quality-of-life measures. Reduced patient awareness of swallow dysfunction years after completion of chemoradiation has implications for management of dysphagia in the face of physiologic decline. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2059-2064, 2019.

Systems Science: A Primer on High Reliability.

In the 21st century, most medical care is not delivered by a single physician but rather, by a team. A team is a type of system, a set of people and things interacting together for a defined aim. The discipline of systems science concerns itself with how complex teams or organizations function. The application of systems science has had a major positive impact on safety and quality in such diverse disciplines as auto manufacturing, airline safety, and nuclear power generation. A modest understanding of how systems science applies to medical care can help improve safety and quality of care.

Sequential Imaging in Patient With Suspected Menière's Disease Identifies Endolymphatic Sac Tumor.

OBJECTIVE: The standard evaluation of patients with suspected Menière's disease (MD) includes initial imaging to rule out tumors of the temporal bone. Few guidelines, however, advocate sequential imaging. We propose that sequential imaging may reveal other etiologies of auditory and vestibular symptoms as demonstrated in a patient with an endolymphatic sac tumor that was originally diagnosed Menière's after initial imaging. PATIENTS: One patient with MD and initially unremarkable imaging. Repeat imaging several years after diagnosis after additional symptoms demonstrated interval development of an endolymphatic sac tumor (ELST). INTERVENTIONS: Resection of endolymphatic sac tumor. MAIN OUTCOME MEASURES: 1) Audiometry, 2) temporal bone imaging, and 3) otopathology RESULTS:: A 45-year-old man with diagnosis of asymmetric sensorineural hearing loss and intermittent vertigo underwent temporal bone magnetic resonance imaging that did not demonstrate any causative lesions. After an episode of sudden sensorineural hearing loss 4 years after initial presentation, repeat imaging was obtained. Magnetic resonance imaging and surgical resection confirmed diagnosis of ELST. The patient had no history of von Hippel-Lindau disease. CONCLUSIONS: A patient with a longstanding diagnosis of MD demonstrated interval development of an ELST. While ELSTs are rare, the study raises the question regarding whether interval imaging is indicated in patients with MD.

Vertical Phase Difference and Glottal Efficiency in Musical Theater and Opera Singers.

OBJECTIVE: The objectives of this study were to (1) determine the relationship between vertical phase difference (VPD) and glottal efficiency (GE) in singers and (2) to compare VPD and GE between musical theater and opera singing styles. METHODS: Five opera and three musical theater singers (Mean age = 25.3, 100% male) performed a series of vocal tasks at two pitches (low pitch C#3, 133 ± 5 Hz; high pitch C#4, 277 ± 5 Hz) for three levels of loudness (soft, baseline, and loud), while undergoing flexible distal chip videostroboscopy. Aerodynamic and acoustic information for each vocal task was recorded using the Phonatory Aerodynamic System. VPD was qualitatively measured via visual-perceptual judgments of repeated comparison tests, where a blinded rater was asked to select the video in which the subject demonstrated the greatest VPD. Aerodynamic data were analyzed for differences in GE. RESULTS: Qualitative visual-perceptual analysis indicated that increased magnitude of VPD was correlated with tasks involving increased loudness or higher pitch. GE was similarly correlated with increased loudness or higher pitch. GE was minimally correlated with subglottal pressure at high pitch. CONCLUSION: This prospective study reveals novel human subject evidence that VPD may correlate with GE. Future studies will further explore the implications of VPD with respect to GE, subglottal pressure, and laryngeal mechanics.

Factors associated with singers' perceptions of choral singing well-being.

OBJECTIVES: Choral singing is a popular vocational pastime across cultures. The potential health benefits associated with choral singing, including positive effect on well-being, are a topic of interest in health research. However, anecdotal reports from voice professionals suggest that the unique demands of choral singing may enforce unhealthy singing habits. This study explores suboptimal vocal behaviors that are sometimes associated with choral singing, which include singing outside comfortable pitch range, singing too loudly, and singing too softly for blend. METHOD: The relationships between suboptimal choral singing habits, vocal warm-ups (WUs), vocal fatigue, and singing-related well-being were assessed via a 14-item Likert-based response format questionnaire. Participants consisted of 196 attendees of the international World Choir Games. The final study group consisted of 53 male and 143 female international amateur singers aged 10-70. RESULTS: Results indicated a positive correlation between vocal fatigue and suboptimal singing behaviors (r = 0.34, P < 0.0001). Participants who did not engage in suboptimal singing behavior experienced increased singing-related well-being (r = -0.32, P < 0.0001, N = 141). Vocal WUs were not related to vocal fatigue or singing well-being. Substantially, more participants from this demographic preferred choir over solo singing (X²[1, N = 196] = 22.93, P < 0.0001). CONCLUSION: Suboptimal choral singing behaviors may result in vocal fatigue and reduction of choral singing well-being and should therefore be considered when examining the effect of choral singing on singing-related well-being and health. Future research will compare the amateurs' perceptions of choral singing with perceptions from professional singers and will look at determinants of choral singing well-being.