Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study.

OBJECTIVE: Evaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH). METHODS: Based on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA. RESULTS: The incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not. CONCLUSION: Treatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication. LEVEL OF EVIDENCE: 4.

Prevention of post-operative pediatric tracheotomy wounds: A multidisciplinary team approach.

OBJECTIVE: Tracheotomy-related pressure wounds have been reported as high as 29%. All advanced stage (stage 3 or 4) wounds are reported by hospitals, and CMS will no longer reimburse healthcare costs to manage them. We present the results of an intensive, multidisciplinary wound prevention strategy starting in the operating room at the time of tracheotomy placement. METHODS: Prospective analysis of a tracheostomy wound care protocol at an academic, tertiary-care pediatric hospital from September 2012 to February 2016. Participants include all patients having undergone tracheostomy placement followed by protocoled daily dressing changes until the first tracheostomy tube change by team consisting a senior level otolaryngology resident or pediatric otolaryngology fellow, certified wound care specialist, respiratory therapist, and bedside nurse. RESULTS: Post-operative tracheostomy-related wound data from 3 years prior to clinical intervention was obtained and compared to the intervention cohort. From March 2010-August 2012, 161 tracheotomy procedures were performed with 36 (22.4%) subsequent pressure wounds; 31% of these were stage 3 or 4 wounds. After multidisciplinary protocol implementation, there have been 121 additional tracheotomy procedures with reduction to 12 (9.9%) total tracheotomy-related wounds (p = 0.0064) and none (0%) were stage 3 or 4 (p = 0.0014). All stage 1 and 2 wounds were identified early, underwent appropriate intervention, and avoided further progression. CONCLUSIONS: This protocol was successful in the elimination of all tracheostomy-related advanced stage, hospital-acquired pressure injuries and led to prompt identification of early stage wounds post-operatively.

Quantification of hearing loss in patients with posterior semicircular canal dehiscence.

CONCLUSION: Patients with posterior semicircular canal dehiscence (PSCD) have low frequency conductive hearing loss similar to patients with superior semicircular canal dehiscence (SSCD) secondary to a pathologic third window. OBJECTIVES: PSCD can result in conductive hearing loss, but the magnitude of this hearing loss remains to be quantified. Patients with SSCD have been shown to have low frequency conductive hearing loss. The underlying pathophysiology of hearing loss from PSCD and SSCD is similar and related to a pathologic third window. METHOD: A PubMed search was completed for a meta-analysis of patients with PSCD. Articles with quality audiograms were obtained. Air conduction thresholds for ears with posterior semicircular canal dehiscence were compared to the opposite ear as well as normal control data. RESULTS: Eight articles with 21 patients with PSCD and quality audiograms were included. Two patients had bilateral PSCD and one of those was excluded because hearing thresholds were at the limit of the audiometer. Patients with posterior semicircular canal dehiscence have statistically significant lower air conduction thresholds in frequencies at and below 2000 Hz.

Using the maxillary-nasal angle to evaluate congenital nasal pyriform aperture stenosis.

IMPORTANCE: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of nasal airway obstruction in newborns. The decision to operate is made clinically. Although pyriform aperture width is used for diagnosing CNPAS, it does not fully characterize stenosis of the nasal cavity. OBJECTIVE: To determine the utility of additional metrics for evaluating CNPAS. DESIGN, SETTING, AND PARTICIPANTS: The medical records of 13 patients with CNPAS treated from 2007 through 2012 at a single tertiary pediatric facility were retrospectively examined. Data on patient demographic characteristics, known genetic abnormalities, and hospital courses were extracted. Computed tomographic images were evaluated for pyriform aperture width; maxillary-nasal angle (MNA), defined as the angle between the anterior maxilla and anterior-posterior nasal axis; and choanal width. INTERVENTIONS: Medical management and surgical management. MAIN OUTCOMES AND MEASURES: Pyriform aperture width, MNA, and choanal width. RESULTS: Six of 13 patients underwent medical management, and 7 patients underwent surgical treatment. For patients who were managed medically as compared with those managed surgically, the evaluation revealed a larger pyriform aperture width (median [interquartile range {IQR}], 5.6 [5.4-6.1] vs 4.6 [4.5-4.7] mm; P = .03) and MNA (median [IQR], 70° [63°-73°] vs 59° [59°-64°]; P = .048) but no significant difference in choanal width (median [IQR], 11.0 [9.6-12.2] vs 11.9 [10.3-11.9] mm; P = .76). CONCLUSIONS AND RELEVANCE: The MNA, when used in conjunction with pyriform aperture width, provides additional pertinent information to supplement clinical decision making in the evaluation of patients with CNPAS. These measurements may be helpful in identifying patients who should undergo surgical intervention, although additional studies would be required to allow predictive use of the MNA.

Quantification of hearing loss associated with superior semi-circular canal dehiscence.

INTRODUCTION: Superior semi-circular canal dehiscence (SSCD) is a known cause of hearing loss. This study quantifies hearing loss in SSCD ears in a frequency-specific fashion. METHODS: A meta-analysis of English language literature pertaining to SSCD was performed, with extraction and evaluation of available human audiometric data. Our own institution's case series of SSCD patients was also similarly analysed. Hearing loss in SSCD ears was compared to same patient control ears and to age-matched normative audiometric data. RESULTS: Ears with SSCD had statistically significant worse hearing as compared to both normative data and to own normal ear controls at 2000 Hz and below. The effect appears to diminish with increasing frequency. DISCUSSION: The presence of statistically significant conductive hearing loss in the low frequencies was confirmed for SSCD ears. SSCD may also predispose ears to high frequency sensorineural hearing loss.