Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis.

Objective: This study aimed to determine the direct costs of pediatric tracheostomy care within a health care system. Study Design: Prospective analysis. Setting: Academic children's hospital. Methods: Costs associated with caring for pediatric tracheostomy patients under 18 years were analyzed between 2015 and 2021. Direct costs were calculated using the Medicare/Medicaid charges-to-costs ratio for various visit types. Costs were estimated using generalized linear equations, accounting for confounders. Results: A total of 297 children underwent tracheostomy at a median age of 0.94 years. The median follow-up was 2.5 years, resulting in 13,966 visits (mean = 41). The total cost was $321 million. The initial admission accounted for 72% ($231 million) of costs while other inpatient admissions added 24% ($78 million). Emergency department, observation, and outpatient visits comprised 4% of costs. The length of stay (LOS) was the primary cost driver for inpatient visits. Each additional hospital day increased costs by roughly $1195, and each extra admission added about $130,223 after adjusting for confounders. Respiratory failure and infections were the primary reasons for 67% of subsequent admissions. Conclusion: Pediatric tracheostomy care generated over $300 million in direct costs over 5 years. Inpatient stays constituted 96% of these costs, with the LOS being a major factor. To reduce direct health expenditures for these patients, the focus should be on minimizing admissions.

Pediatric tracheostomy audiometric outcomes - A quality improvement initiative.

OBJECTIVE: Pediatric tracheostomy patients disproportionately experience hearing loss and are at risk for delayed identification due to their medical complexity. Nonetheless, protocols to monitor hearing in these children are lacking. This quality improvement (QI) initiative aimed to increase the rates of audiometric testing within 12 months of pediatric tracheostomy placement. METHODS: A retrospective cohort study included children who underwent tracheostomy under 18 months of age between 2012 and 2020. Rates of audiometric assessments before and after QI project implementation (2015) were reported along with hearing loss characteristics. RESULTS: A total of 253 children met inclusion. Before project initiation (2012-2014), 32% of children (28/87) obtained audiometric testing within 12 months after tracheostomy. During the first three years of implementation (2015-2017), 39% (38/97) were tested, while 55% (38/69) were tested during the subsequent three years (2018-2020) (P = .01). A passing newborn hearing screen was obtained for 70% of the 210 children with a recorded result, and 198 survived at least 12 months to receive audiometric testing at a median of 11.3 months (IQR: 6.2-22.8) after tracheostomy. Hearing loss was identified for 44% of children (N = 88), of which 42 children initially passed newborn hearing screen. A second assessment was obtained for 62% of children (123/198) at a median of 11.3 months (IQR: 4.5-17.5) after the initial test. In this group, 23% with a previously normal audiometric exam were found to have hearing loss (15/66). CONCLUSIONS: QI initiatives designed to monitor hearing loss in children with a tracheostomy can result in improved rates of audiometric assessments. This population has disproportionately high rates of hearing loss, including delayed onset hearing loss making audiometric protocols valuable to address speech and language development delays.

The Use of Patient-Specific Orbital Reconstruction Implants During Maxillectomy Reconstruction.

Background: Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity. Study Objective: To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI). Design Type: Case series. Materials and Methods: Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications. Results: The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients. Conclusion: PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.

Characterization of Otolaryngology Referrals among Pacific Islanders in the Commonwealth of the Northern Mariana Islands.

The burden of otolaryngology disease in Pacific Islander populations is relatively uncharacterized. A single-institution retrospective review was undertaken at the Commonwealth Healthcare Corporation in Saipan, the only hospital in the Commonwealth of the Northern Mariana Islands. Demographic, diagnostic, and treatment data were compiled from the clinical charts of all patients seen by an otolaryngologist between January 2015 and April 2020. For all Pacific Islanders in the sample (N=674), the average age was 40.2 (SD 22.4) years and ages ranged from 10 months to 89 years. Patients were 50.7% male and 49.3% female. The most common diagnoses affected the ear (40.8%), followed by the oral cavity/pharynx (23.2%), and nose (14.0%). Middle ear disease comprised 41.7% of reported ear disorders; the most common problem was otitis media (19.4%, n=68) followed by tympanic membrane perforation (14.0%, n=49). Head and neck cancers comprised 8.6% of all diagnoses. Most (77.8%) malignant neoplasms were oral cavity carcinomas. The average age at diagnosis for oral cancer was 46.6 years with a 1.8:1 male-to-female predominance. Patients with cancer of the oral cavity (n=56) chewed betel nut at higher rates (94.6%) compared with other adults in the sample (P<.001). Adult patients reported alcohol use, smoking, and chewing betel quid at rates of 26.5%, 39.9%, and 52.2% respectively. Otolaryngology referrals among Pacific Islanders in this sample were dominated by ear disease and included betel nut-related oral cavity disease.

Characterizing Posterior Neck Masses: A Single-Institution Retrospective and Systematic Review.

OBJECTIVE: Posterior neck masses are a relatively poorly characterized entity. The authors attempt to further characterize the anatomy and pathology of the posterior neck by way of a combined single-institution retrospective chart review and systematic review of the literature. METHODS: A single-institution retrospective chart review was undertaken for all patients undergoing excision of a posterior neck mass between January 1, 2012, and January 1, 2017. A systematic review of the Medline, Embase, Web of Science, and Cochrane database was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in search of case reports and series describing posterior neck masses. RESULTS: A total of 28 patients who underwent excision of a posterior neck mass were encountered during the retrospective chart review. All pathologies were benign, the most prevalent of which was lipoma (22/28, 79%). A total of 19 articles describing a collective 36 posterior neck masses were encountered during the systematic review. Lipomas were the most common pathology (15/36, 42%). All but one of the masses reported were benign (35/36, 97%). CONCLUSIONS: Patients presenting with posterior neck masses can be reassured of a low risk of malignancy. The majority of posterior neck masses can be appropriately evaluated via physical examination and ultrasound.

Oral Cavity Cancer Outcomes in Remote, Betel Nut-Endemic Pacific Islands.

BACKGROUND: Oral cavity carcinomas individually are the fifth-leading cause of overall cancer mortality in the Northern Mariana Islands, which is likely a representative statistic for many other betel-nut-endemic Pacific islands. Factors associated with survival have been minimally evaluated in this region. The purpose of this study is to further characterize oral cavity carcinoma outcomes and associated prognostic factors in the United States commonwealth of the Northern Mariana Islands (CNMI). METHODS: A single-institution retrospective review was undertaken for 81 patients diagnosed with head and neck cancers at the CNMI's only regional hospital complex from 2005 to 2019. A subset of patients diagnosed with oral cavity carcinoma was further evaluated for survival outcomes. Cox proportional hazard regressions were performed to evaluate for variables associated with survival. RESULTS: A majority of patients had cancer of the oral cavity (64/81, 79%). Fifty-five of these patients had sufficient data for review. The average age at the time of diagnosis was 48 and over half were diagnosed with stage IV disease (29/55, 53%). Five-year overall survival (OS) was 49.5% (95% CI, 33.3-63.7%). Factors associated with worse OS were lymph node metastases at presentation (P = .031), higher overall stage (III or IV vs I or II, P = .016), and higher T-stage (III or IV vs I or II, P = .027). Those who used betel nut were diagnosed at a significantly younger age than those who did not (47.2 vs 55.4, P = .001). CONCLUSIONS: The head and neck cancer burden in the CNMI is dominated by betel nut related oral cavity disease that is characterized by delayed presentations in younger patients and decreased OS. Future studies are indicated to improve health literacy as well as to investigate the potential for screening programs.

A Survey of Areca (Betel) Nut Use and Oral Cancer in the Commonwealth of the Northern Mariana Islands.

Areca nut use is a cause of higher rates of oral cavity cancer in the Commonwealth of the Northern Mariana Islands (CNMI). Little is known about patient insights into the risks of areca nut use worldwide. The purpose of this study is to evaluate perceptions of areca nut use and oral cancer among chewers in the CNMI. This is a survey study undertaken at the CNMI's only regional health center-300 adult participants completed a 21-question survey that assessed demographics, chewing behaviors, perceptions of areca nut use and oral cancer, and the willingness to participate in cessation and screening programs. Data was analyzed using chi-squared tests, at a significance value of P < .05. The participant average age was 38, and 41% were male. Almost all (92%) knew that chewing areca nut causes oral cancer, but only 13% correctly identified the actual areca nut as a carcinogen. About half (59%) believed that oral cancer could be treated. Most people (74%) were willing to participate in screening programs for oral cancer. Those who chewed areca nut daily were more likely to be interested in medicated replacement products relative to those who chewed less frequently (P = .048). In conclusion, there are drastic misperceptions about areca nut and oral cancer in the CNMI. Efforts should be made towards promoting awareness of the carcinogenicity of the actual areca nut, and the treatability of oral cancer. Mandated educational warnings should be required with areca nut sales. Further research evaluating substitution methods and screening programs is indicated.

Asthma and obesity as predictors of severe obstructive sleep apnea in an adolescent pediatric population.

OBJECTIVE: To study a cohort of children referred for full-night polysomnography (PSG) due to suspicion of obstructive sleep apnea (OSA). We examined the relationship between asthma, obesity, and severe OSA (sOSA). METHODS: We performed a retrospective case control analysis of children, ages 9 to 17 years, who underwent full-night PSG. The primary goal was to determine the association between asthma, obesity, and sOSA (apnea-hypopnea index ≥10). We used multiple logistic regression analysis to estimate these associations after controlling for covariates. A P value of ≤.05 was considered significant. RESULTS: The study included 367 children (mean [standard deviation] age 14 years (1.7), 56% male, 43% Hispanic). The prevalence of asthma was 188 of 367 (52%); obesity was 197 of 367 (54%); and sOSA was 109 of 367 (30%). sOSA was less likely in asthmatics (coefficient = -0.59; standard error [SE] = 0.23; P = .01; odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.34 to 0.88) and more likely with obesity (coefficient = 0.89; SE = 0.24; P < .001; OR = 2.4; 95% CI = 1.5 to 3.9). The presence of asthma reduced the likelihood of sOSA by an average of 14% among obese patients and 9% among nonobese patients. These associations held even after controlling for age, sex, race, income, and tonsillar hypertrophy. CONCLUSION: The presence of asthma reduced, whereas obesity increased the likelihood of sOSA among a large cohort of older children referred for PSG. These relationships were additive. Further research is indicated regarding these relationships. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:812-817, 2020.

Meta-analysis does not support routine traditional nuclear medicine studies for malignant otitis.

OBJECTIVES: The role of traditional nuclear medicine studies in the management of malignant otitis externa (MOE) is unclear and there are ongoing debates regarding their diagnostic value. The authors perform a systematic review and meta-analysis to assess the sensitivity and specificity of traditional nuclear medicine studies in the diagnosis of MOE. METHODS: In accordance with PRISMA guidelines, a query of the Medline, Embase, Web of Science, and Cochrane databases was undertaken. The primary outcomes of interest were the sensitivity and specificity of traditional nuclear medicine studies to detect MOE. RESULTS: Of the initial 1317 hits from the four databases, 20 articles with a combined 608 patients were ultimately included in the review. The pooled sensitivities for Technetium-99 and Gallium-67 were 85.1% (95% CI, 72.0-98.1%) and 71.2% (95% CI, 55.1-87.3%) respectively. The available evidence suggested poor specificity of these modalities, but was insufficient for meta-analysis. Neither modality was shown to be effective in the assessment of disease resolution. CONCLUSION: The sensitivities of Technetium-99 and Gallium-67 to detect MOE are less favorable than was initially thought. Given this finding and their poor specificity, lack of anatomic resolution, unproven ability to detect disease resolution and variable availability, this review does not support the routine use of these studies in the management of MOE. LEVEL OF EVIDENCE: N/A Laryngoscope, 130:1812-1816, 2020.

Weight gain velocity as a predictor of severe obstructive sleep apnea among obese adolescents.

OBJECTIVES/HYPOTHESIS: To evaluate a cohort of obese adolescents with obstructive sleep apnea (OSA) to determine if increased yearly weight gain was a predictor of severe OSA. STUDY DESIGN: Retrospective cohort study. METHODS: Obese adolescents (body mass index percentile >95% for that age and sex based upon the Centers for Disease Control and Prevention weight classifications), ages 12 to 17 years, referred for full night polysomnography (PSG) were analyzed. We examined demographics, weight classifications, yearly weight gain from age 9 years onward, PSG data (apnea-hypopnea index), and tonsil size. We performed a mixed-effect linear regression model to test whether the velocity of weight gain was increased in obese patients with severe OSA when compared to those without severe OSA. RESULTS: This study included 166 obese adolescents, 105 with and 61 without severe OSA. The average age was 14 years and was predominately male (57%) and Hispanic (44%). The regression analysis found that the yearly change in weight among obese adolescents with severe OSA was significantly higher than those without (B = 1.4, standard error = 0.50, P = .005, 95% confidence interval: 0.42-2.4). For the group with severe OSA, weight increased 6.5 kg every year before their PSG, whereas for those without, weight increased 5.1 kg per year. CONCLUSIONS: The rate of weight gain over time is an important predictor of severe OSA in obese adolescents. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:1339-1342, 2020.

The profound oral cavity cancer burden in the United States Commonwealth of the Northern Mariana Islands: A global health opportunity.

PURPOSE: Betel nut consumption contributes to higher rates of oral cavity cancer throughout Micronesia. The purpose of this study is to review local surveys and cancer data to further characterize these issues in the Northern Mariana Islands (CNMI). METHODS: Two commonwealth-wide health inquiries were reviewed: The Non-Communicable Diseases Survey (NCDS), 2016 and The Youth Risk Behavior Survey (YRBS), 2013. Data pertaining to betel nut, tobacco and alcohol use was extracted. Relevant cancer data from the Commonwealth Healthcare Corporation (CHC) of Saipan and the Surveillance, Epidemiology, and End Results (SEER) databases was assessed. RESULTS: Betel nut chewing was reported by 43% of Asian Pacific Islander (API) adults, with 88% adding tobacco to the chew. Adults aged 20-30 had significantly higher rates of chewing relative to older groups (p < .0001). Tobacco smoking and alcohol use were reported by 25% and 23% of adults, respectively. Betel nut chewing was reported by 33% of high school students. From 2007 to 2016, oral cavity cancers contributed to 9% of all cancer diagnoses and 13% of cancer-related mortalities. SEER data supported oral cavity cancer diagnoses at younger ages in APIs. CONCLUSION: These results demonstrate concerning trends regarding alcohol, tobacco and betel nut use in the CNMI. Betel nut use is prevalent among APIs of nearly all ages, with the majority adding tobacco to their chew. The available data suggests a drastic oral cavity cancer burden in the CNMI. Efforts should be made to evaluate for effective means of primary and secondary prevention in API regions.

Defining Genetic Fitness Determinants and Creating Genomic Resources for an Oral Pathogen.

Periodontitis is a microbial infection that destroys the structures that support the teeth. Although it is typically a chronic condition, rapidly progressing, aggressive forms are associated with the oral pathogen Aggregatibacter actinomycetemcomitans One of this bacterium's key virulence traits is its ability to attach to surfaces and form robust biofilms that resist killing by the host and antibiotics. Though much has been learned about A. actinomycetemcomitans since its initial discovery, we lack insight into a fundamental aspect of its basic biology, as we do not know the full set of genes that it requires for viability (the essential genome). Furthermore, research on A. actinomycetemcomitans is hampered by the field's lack of a mutant collection. To address these gaps, we used rapid transposon mutant sequencing (Tn-seq) to define the essential genomes of two strains of A. actinomycetemcomitans, revealing a core set of 319 genes. We then generated an arrayed mutant library comprising >1,500 unique insertions and used a sequencing-based approach to define each mutant's position (well and plate) in the library. To demonstrate its utility, we screened the library for mutants with weakened resistance to subinhibitory erythromycin, revealing the multidrug efflux pump AcrAB as a critical resistance factor. During the screen, we discovered that erythromycin induces A. actinomycetemcomitans to form biofilms. We therefore devised a novel Tn-seq-based screen to identify specific factors that mediate this phenotype and in follow-up experiments confirmed 4 mutants. Together, these studies present new insights and resources for investigating the basic biology and disease mechanisms of a human pathogen.IMPORTANCE Millions suffer from gum disease, which often is caused by Aggregatibacter actinomycetemcomitans, a bacterium that forms antibiotic-resistant biofilms. To fully understand any organism, we should be able to answer: what genes does it require for life? Here, we address this question for A. actinomycetemcomitans by determining the genes in its genome that cannot be mutated. As for the genes that can be mutated, we archived these mutants into a library, which we used to find genes that contribute to antibiotic resistance, leading us to discover that antibiotics cause A. actinomycetemcomitans to form biofilms. We then devised an approach to find genes that mediate this process and confirmed 4 genes. These results illuminate new fundamental traits of a human pathogen.

Placental Toll-like receptor 3 and Toll-like receptor 7/8 activation contributes to preeclampsia in humans and mice.

Preeclampsia (PE) is a pregnancy-specific hypertensive syndrome characterized by excessive maternal immune system activation, inflammation, and endothelial dysfunction. Toll-like receptor (TLR) 3 activation by double-stranded RNA (dsRNA) and TLR7/8 activation by single-stranded RNA (ssRNA) expressed by viruses and/or released from necrotic cells initiates a pro-inflammatory immune response; however it is unknown whether viral/endogenous RNA is a key initiating signal that contributes to the development of PE. We hypothesized that TLR3/7/8 activation will be evident in placentas of women with PE, and sufficient to induce PE-like symptoms in mice. Placental immunoreactivity and mRNA levels of TLR3, TLR7, and TLR8 were increased significantly in women with PE compared to normotensive women. Treatment of human trophoblasts with the TLR3 agonist polyinosine-polycytidylic acid (poly I:C), the TLR7-specific agonist imiquimod (R-837), or the TLR7/8 agonist CLO97 significantly increased TLR3/7/8 levels. Treatment of mice with poly I:C, R-837, or CLO97 caused pregnancy-dependent hypertension, endothelial dysfunction, splenomegaly, and placental inflammation. These data demonstrate that RNA-mediated activation of TLR3 and TLR7/8 plays a key role in the development of PE.