A Medicare Physician Fee Schedule Analysis of Reimbursement Trends in Laryngology from 2000 to 2021.

OBJECTIVE: The purpose of this study is to characterize Medicare reimbursement trends for laryngology procedures over the last two decades. METHODS: This analysis used CMS' Physician Fee Schedule (PFS) Look-Up Tool to determine the reimbursement rate of 48 common laryngology procedures, which were divided into four groups based on their practice setting and clinical use: office-based, airway, voice disorders, and dysphagia. The PFS reports the physician service reimbursement for "facilities" and global reimbursement for "non-facilities". The annual reimbursement rate for each procedure was averaged across all localities and adjusted for inflation. The compound annual growth rate (CAGR) of each procedure's reimbursement was determined, and a weighted average of the CAGR for each group of procedures was calculated using each procedure's 2020 Medicare Part B utilization. RESULTS: Reimbursement for laryngology procedure (CPT) codes has declined over the last two decades. In facilities, the weighted average CAGR for office-based procedures was -2.0%, for airway procedures was -2.2%, for voice disorders procedures was -1.4%, and for dysphagia procedures was -1.7%. In non-facilities, the weighted average CAGR for office-based procedures was -0.9%. The procedures in the other procedure groups did not have a corresponding non-facility reimbursement rate. CONCLUSION: Like other otolaryngology subspecialties, inflation-adjusted reimbursements for common laryngology procedures have decreased substantially over the past two decades. Because of the large number of physician participants and patient enrollees in the Medicare programs, increased awareness and further research into the implications of these trends on patient care is necessary to ensure quality in the delivery of laryngology care. LEVEL OF EVIDENCE: NA Laryngoscope, 134:247-256, 2024.

Reimbursement Trends in Pediatric Otolaryngology From 2000 to 2020: A CMS Physician Fee Schedule Analysis.

OBJECTIVE: The aim of this study was to evaluate the financial trends in Medicare reimbursement rates for the most billed procedures at a single institution from 2000 to 2020 within pediatric otolaryngology. STUDY DESIGN: Retrospective data analysis. SETTING: United States. METHODS: The most billed surgical and in-office procedures in pediatric otolaryngology at our institution were identified in the Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services to extract reimbursement data for each CPT code (Current Procedural Terminology). Monetary data were adjusted for inflation to 2020 US dollars per the changes to the consumer price index. Mean annual and total percentage changes in reimbursement were calculated by the adjusted values for all included procedures (N = 25). RESULTS: From 2000 to 2020, without adjusting for inflation, reimbursement for the most billed procedures increased by 10.9%, while the allocated relative value unit per procedure increased by 15.4%. However, when adjusted for inflation, reimbursement for these procedures decreased by 27.5% over the study period. CONCLUSIONS: The study findings identify a downward trend in reimbursement for the most billed procedures in pediatric otolaryngology at our institution. Given the low predominance of pediatric otolaryngology codes within Medicare reimbursement, these codes are rarely reviewed for accurate revaluation. It is imperative that our professional society remain active and engaged within this process to ensure quality delivery of care to our patients.

Practice Consolidation in Otolaryngology: The Decline of the Single-Provider Practice.

OBJECTIVE: To observe trends in practice consolidation within otolaryngology by analyzing changes in size and geographic distribution of practices within the United States from 2014 to 2021. STUDY DESIGN: Retrospective analysis based on the Physician Compare National Database from the US Centers for Medicare and Medicaid Services. SETTING: United States. METHODS: Annual files from the Physician Compare National Database between 2014 and 2021 were filtered for all providers that listed "otolaryngology" as their primary specialty. Organization affiliations were sorted by size of practice and categorized into quantiles (1 or 2 providers, 3-9, 10-24, 25-49, and ≥50). Both the number of practices and the number of surgeons within a practice were collected annually for each quantile. Providers were also stratified geographically within the 9 US Census Bureau divisions. Chi-square analysis was conducted to test significance for the change in surgeon and practice distributions between 2014 and 2021. RESULTS: Over the study period, the number of active otolaryngology providers increased from 7763 to 9150, while the number of practices fell from 3584 to 3152 in that time span. Practices with just 1 or 2 otolaryngology providers accounted for 80.2% of all practices in 2014 and fell to 73.1% in 2021. Similar trends were observed at the individual provider level. Regional analysis revealed that New England had the largest percentage decrease in otolaryngologists employed by practices of 1 or 2 active providers at 45.7% and the Mountain region had the lowest percentage decrease at 17.4%. CONCLUSION: The otolaryngology practice marketplace has demonstrated a global trend toward practice consolidation.

The economic burden of vertigo and dizziness in the United States.

BACKGROUND: Vertigo and dizziness are extremely common conditions in the adult population and therefore place a significant social and economic burden on both patients and the healthcare system. However, limited information is available for the economic burden of vertigo and dizziness across various health care settings. OBJECTIVE: Estimate the economic burden of vertigo and dizziness, controlling for demographic, socioeconomic, and clinical comorbidities. METHODS: A retrospective analysis of data from the Medical Expenditures Panel Survey (2007-2015) was performed to analyze individuals with vertigo or dizziness from a nationally representative sample of the United States. Participants were included via self-reported data and International Classification of Diseases, 9th Revision Clinical Modification codes. A cross-validated 2-component generalized linear model was utilized to assess vertigo and dizziness expenditures across demographic, socioeconomic and clinical characteristics while controlling for covariates. Costs and utilization across various health care service sectors, including inpatient, outpatient, emergency department, home health, and prescription medications were evaluated. RESULTS: Of 221,273 patients over 18 years, 5,275 (66% female, 34% male) reported either vertigo or dizziness during 2007-2015. More patients with vertigo or dizziness were female, older, non-Hispanic Caucasian, publicly insured, and had significant clinical comorbidities compared to patients without either condition. Furthermore, each of these demographic, socioeconomic, and clinical characteristics lead to significantly elevated costs due to having these conditions for patients. Significantly higher medical expenditures and utilization across various healthcare sectors were associated with vertigo or dizziness (p < 0.001). The mean incremental annual healthcare expenditure directly associated with vertigo or dizziness was $2,658.73 (95% CI: 1868.79, 3385.66) after controlling for socioeconomic and demographic characteristics. Total annual medical expenditures for patients with dizziness or vertigo was $48.1 billion. CONCLUSION: Vertigo and dizziness lead to substantial expenses for patients across various healthcare settings. Determining how to limit costs and improve the delivery of care for these patients is of the utmost importance given the severe morbidity, disruption to daily living, and major socioeconomic burden associated with these conditions.

A Multimodal Multi-institutional Solution to Remote Medical Student Education for Otolaryngology During COVID-19.

During the coronavirus 2019 pandemic, there has been a surge in production of remote learning materials for continued otolaryngology resident education. Medical students traditionally rely on elective and away subinternship experiences for exposure to the specialty. Delays and cancellation of clinical rotations have forced medical students to pursue opportunities outside of the traditional learning paradigm. In this commentary, we discuss the multi-institutional development of a robust syllabus for medical students using a multimodal collection of resources. Medical students collaborated with faculty and residents from 2 major academic centers to identify essential otolaryngology topics. High-quality, publicly available, and open-access content from multiple sources were incorporated into a curriculum that appeals to a variety of learners. Multimodal remote education strategies can be used as a foundation for further innovation aimed at developing tomorrow's otolaryngologists.

"Hot Zones" for Otolaryngologists: Assessing the geographic distribution of aerosol-generating procedures amidst the COVID-19 pandemic.

OBJECTIVE: Given high COVID-19 viral load and aerosolization in the head and neck, otolaryngologists are subject to uniquely elevated viral exposure in most of their inpatient and outpatient procedures and interventions. While elective activity has halted across the board nationally, the slow plateau of COVID-19 case rates prompts the question of timing of resumption of clinical activity. We sought to prospectively predict geographical "hot zones" for otolaryngological exposure to COVID-19 based on procedural volumes data from 2013 to 2017. METHODS: Otolaryngologic CPT codes were stratified based on risk-level, according to recently published specialty-specific guidelines. Using the Medicare POSPUF database, aerosol-generating procedures (AGPs) were mapped based on hospital referral regions, against up-to-date COVID-19 case distribution data, as of April 24, 2020. RESULTS: The most common AGPs were diagnostic flexible laryngoscopy, diagnostic nasal endoscopy, and flexible laryngoscopy with stroboscopy. The regions with the most AGPs per otolaryngologist were Iowa City, IA, Detroit, MI, and Burlington, VT, while the states with the most COVID-19 cases as of April 24th are New York, New Jersey, and Massachusetts. CONCLUSIONS: Our study provides a model for predicting possible "hot zones" for otolaryngologic exposure based on both COVID-19 case density and AGP-density. As the focus shifts to resuming elective procedures, these potential "hot zones" need to be evaluated for appropriate risk-based decision-making, such as "reopening strategies" and allocation of resources.

Geospatial analysis of COVID-19 and otolaryngologists above age 60.

OBJECTIVE: The 2019 novel coronavirus (COVID-19) is disproportionately impacting older individuals and healthcare workers. Otolaryngologists are especially susceptible with the elevated risk of aerosolization and corresponding high viral loads. This study utilizes a geospatial analysis to illustrate the comparative risks of older otolaryngologists across the United States during the COVID-19 pandemic. METHODS AND MATERIALS: Demographic and state population data were extracted from the State Physician Workforce Reports published by the AAMC for the year 2018. A geospatial heat map of the United States was then constructed to illustrate the location of COVID-19 confirmed case counts and the distributions of ENTs over 60 years for each state. RESULTS: In 2018, out of a total of 9578 practicing U.S. ENT surgeons, 3081 were older than 60 years (32.2%). The states with the highest proportion of ENTs over 60 were Maine, Delaware, Hawaii, and Louisiana. The states with the highest ratios of confirmed COVID-19 cases to the number of total ENTs over 60 were New York, New Jersey, Massachusetts, and Michigan. CONCLUSIONS: Based on our models, New York, New Jersey, Massachusetts, and Michigan represent states where older ENTs may be the most susceptible to developing severe complications from nosocomial transmission of COVID-19 due to a combination of high COVID-19 case volumes and a high proportion of ENTs over 60 years.

Health Disparities in the Access and Cost of Health Care for Otolaryngologic Conditions.

OBJECTIVE: To demonstrate whether race, education, income, or insurance status influences where patients seek medical care and the cost of care for a broad range of otolaryngologic diseases in the United States. STUDY DESIGN: Retrospective cohort study using data from the Medical Expenditure Panel Survey, from 2007 to 2015. SETTING: Nationally representative database. SUBJECTS AND METHODS: Patients with 14 common otolaryngologic conditions were identified using self-reported data and International Classification of Diseases, 9th Revision Clinical Modification diagnosis codes. To analyze disparities in the utilization and cost of otolaryngologic care, a multivariate logistic regression model was used to compare outpatient and emergency department visit rates and costs for African American, Hispanic, and Caucasian patients, controlling for sociodemographic characteristics. RESULTS: Of 78,864 respondents with self-reported otolaryngologic conditions, African American and Hispanic patients were significantly less likely to visit outpatient otolaryngologists than Caucasians (African American: adjusted odds ratio [aOR], 0.57; 95% CI, 0.5-0.65; Hispanic: aOR, 0.64; 95% CI, 0.56-0.73) and reported lower average costs per emergency department visit than Caucasians (African American: $4013.67; Hispanic: $3906.21; Caucasian: $7606.46; P < .001). In addition, uninsured, low-income patients without higher education were significantly less likely to receive outpatient otolaryngologic care than privately insured, higher-income, and more educated individuals (uninsured: aOR, 0.38; 95% CI, 0.29-0.51; poor: aOR, 0.75; 95% CI, 0.64-0.87; no degree: aOR, 0.67; 95% CI, 0.54-0.82). CONCLUSION: In this study, significant racial and socioeconomic discrepancies exist in the utilization and cost of health care for otolaryngologic conditions in the United States.

Sex-specific enlarged vestibular aqueduct morphology and audiometry.

OBJECTIVE: Enlargement of the vestibular aqueduct (EVA) is one of the most common congenital malformations in pediatric patients presenting with sensorineural or mixed hearing loss. The relationship between vestibular aqueduct (VA) morphology and hearing loss across sex is not well characterized. This study assesses VA morphology and frequency-specific hearing thresholds with sex as the primary predictor of interest. MATERIALS AND METHODS: A retrospective, longitudinal, and repeated-measures study was used. 47 patients at an academic tertiary care center with hearing loss and a record of CT scan of the internal auditory canal were candidates, and included upon meeting EVA criteria after confirmatory measurements of vestibular aqueduct midpoint and operculum widths. Audiometric measures included pure-tone average and frequency-specific thresholds. RESULTS: Of the 47 patients (23 female and 24 male), 79 total ears were affected by EVA; the median age at diagnosis was 6.60 years. After comparing morphological measurements between sexes, ears from female patients were observed to have a greater average operculum width (3.25 vs. 2.70 mm for males, p = 0.006) and a greater average VA midpoint width (2.80 vs. 1.90 mm for males, p = 0.004). After adjusting for morphology, male patients' ears had pure-tone average thresholds 17.6 dB greater than female patients' ears (95% CI, 3.8 to 31.3 dB). CONCLUSIONS: Though females seem to have greater enlargement of the vestibular aqueduct, this difference does not extend to hearing loss. Therefore, our results indicate that criteria for EVA diagnoses may benefit from re-evaluation. Further exploration into morphological and audiometric discrepancies across sex may help inform both clinician and patient expectations.

Morphology and cochlear implantation in enlarged vestibular aqueduct.

PURPOSE: The purpose of this work is to explore audiometry following cochlear implantation (CI) in patients with enlarged vestibular aqueduct (EVA) and to investigate the effects of inner ear morphological variation on post CI audiometry. METHODS: This was a retrospective review of both natural and cochlear-implant-aided audiometry results, using all available measurements in a mixed-effects model accounting for longitudinal change and the grouping structure of ears. Patients who visited our tertiary academic medical center between 2000 and 2016 were identified as having EVA according to Cincinnati criteria on radiological examination; patients eligible for CI were then selected for analysis. RESULTS: Multivariable modeling showed a statistically significant hearing improvement in ears with EVA undergoing CI with regards to pure tone average (-64.0 dB, p < 0.0001), speech reception threshold (-57.90 dB, p < 0.0001), and word score (34.8%, p > 0.0001). Vestibular aqueduct midpoint size and the presence of incomplete partition type II (IP II) did not have significant independent associations with audiometric findings. However, multivariable modeling revealed a statistically significant interaction between IP II and CI such that IP II ears demonstrated a decrease in WS improvement of 30.2% (p = 0.0059) compared to non-IP II ears receiving CI. CONCLUSION: There is a statistically significant audiometric benefit to ears with EVA receiving CI. Morphology, specifically the presence of IP II, may hinder CI benefit in terms of word score however this finding needs clinical validation. This data improves personalization of surgical counseling and planning for patients with EVA considering CI.

Vestibular Aqueduct Midpoint Width and Hearing Loss in Patients With an Enlarged Vestibular Aqueduct.

Importance: Elucidating the relationship between vestibular aqueduct size and hearing loss progression may inform the prognosis and counseling of patients who have an enlarged vestibular aqueduct (EVA). Objectives: To examine the association between vestibular aqueduct size and repeated measures of hearing loss. Design, Setting, and Participants: For this retrospective medical record review, 52 patients with a diagnosis of hearing loss and radiologic diagnosis of EVA according to the Valvassori criterion were included. All available speech reception threshold and word recognition score data was retrieved; mixed-effects models were constructed where vestibular aqueduct size, age at diagnosis of hearing loss, and time since diagnosis of hearing loss were used to predict repeated measures of hearing ability. This study was performed at an academic tertiary care center. Exposures: Variable vestibular aqueduct size, age at first audiogram, length of time after first audiogram. Main Outcomes and Measures: Speech reception threshold (dB) and word recognition score (%) during routine audiogram. Results: Overall, 52 patients were identified (29 females [56%] and 23 males [44%]; median age at all recorded audiograms, 7.8 years) with a total of 74 ears affected by EVA. Median (range) vestibular aqueduct size was 2.15 (1.5-5.9) mm, and a median (range) of 5 (1-18) tests were available for each patient. Each millimeter increase in vestibular aqueduct size above 1.5 mm was associated with an increase of 17.5 dB in speech reception threshold (95% CI, 7.2 to 27.9 dB) and a decrease of 21% in word recognition score (95% CI, -33.3 to -8.0 dB). For each extra year after a patient's first audiogram, there was an increase of 1.5 dB in speech recognition threshold (95% CI, 0.22 to 3.0 dB) and a decrease of 1.7% in word recognition score (95% CI, -3.08 to -0.22 dB). Conclusions and Relevance: Hearing loss in patients with an EVA is likely influenced by vestibular aqueduct midpoint width. When considering hearing loss prognosis, vestibular aqueduct midpoint width may be useful for the clinician who counsels patients affected by EVA.

Analysis of outcomes in treatment of obstructive sleep apnea in infants.

OBJECTIVES/HYPOTHESIS: To investigate interventions used for treatment of obstructive sleep apnea (OSA) in infants. STUDY DESIGN: Retrospective medical record review. METHODS: Patients 3 to 24 months old at the time of diagnosis of OSA by polysomnography (PSG) were studied at a tertiary care children's hospital. The main outcome measures were demographic data, PSG data, intervention data, subjective results of interventions, and medical comorbidities. RESULTS: Of the 295 patients included, 196 (66%) were males and 99 (34%) were females. The most common interventions with average age at the time of intervention were: adenotonsillectomy, 115 patients (31.8%, 22.3 months); adenoidectomy, 82 patients (22.5%, 17.7 months); observation, 76 patients (20.9%, 12.8 months); supplemental oxygen, 27 patients (7.4%, 11.7 months); continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP), 18 patients (4.9%, 15.6 months); tonsillectomy, 16 patients (4.4%, 25.7 months); and tracheostomy, six patients (1.7%, 15.3 months). In the youngest patients (3-5 months of age), 89.3% of interventions were nonsurgical and 10.7% were surgical. In the oldest patients (older than 24 months), 17.5% of interventions were nonsurgical and 82.5% were surgical. Subjective improvement following intervention was highest after adenotonsillectomy. The intervention with the greatest percentage decrease in apnea-hypopnea index (objective efficacy) was tracheostomy, followed by CPAP/BiPAP. Average time from diagnosis to intervention was 35.5 days for nonsurgical interventions and 92.4 days for surgical interventions. CONCLUSIONS: Observation was the most common nonsurgical intervention and the most common intervention in patients younger than 12 months. Adenotonsillectomy was the most common surgical and overall intervention. Adenotonsillectomy had the greatest subjective efficacy, and tracheostomy had the greatest objective efficacy.

Evaluating the management of obstructive sleep apnea in neonates and infants.

OBJECTIVES: To investigate interventions used in treating obstructive sleep apnea in neonates and infants and to report their efficacies. DESIGN: Retrospective medical record review. SETTING: Tertiary care children's hospital. PATIENTS: Neonates and infants aged 0 to 12 months at the time of obstructive sleep apnea diagnosis by polysomnography. MAIN OUTCOME MEASURES: Demographic data, comorbidities, polysomnography data, and intervention data. RESULTS: In total, 126 patients (86 [68.3%] male and 40 [31.7%] female) were included in the study. The most common interventions (and the mean age at the time of intervention) were anti-gastroesophageal reflux disease treatment (88 patients [69.8%] at age 7 months), observation (33 patients [26.2%] at age 6 months), supplemental oxygen (31 patients [24.6%] at age 4 months), adenoidectomy (30 patients [23.8%] at age 15 months), other surgical (25 patients [19.8%] at age 7 months), continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP) (18 patients [14.3%] at age 16 months), supraglottoplasty (11 patients [8.7%] at age 6 months), tonsillectomy and adenoidectomy (9 patients [7.1%] at age 24 months), tracheostomy (7 patients [5.6%] at age 10 months), and other nonsurgical (7 patients [5.6%] at age 15 months). Among neonates and infants, nonsurgical interventions were performed in most cases, although those aged 0 to 3 months underwent more surgical interventions (19.7%) than those aged older than 3 to 9 months (11.7%). The mean objective improvement, measured as a percentage decrease in preintervention to postintervention apnea-hypopnea index, was greatest in neonates and infants receiving CPAP/BiPAP, followed by those undergoing tracheostomy. CONCLUSIONS: Anti-gastroesophageal reflux disease treatment is the most common intervention in each age group. Although adenoidectomy is the most common surgical intervention overall, the prevalence increases with age. Supraglottoplasty is the most common surgical intervention in neonates and infants aged 0 to 3 months and offers the greatest objective improvement in this age group. Overall, the use of CPAP/BiPAP is associated with the greatest objective improvement.

Increased eustachian tube dysfunction in infants with obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To investigate the prevalence of eustachian tube dysfunction (ETD) in infants with obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective medical record review of infants (3-24 months old) diagnosed with OSA and ETD. METHODS: There were 94 infants diagnosed with OSA by polysomnography and ETD as determined by performance of myringotomy and ventilation tube placement (MT). The main outcome measures were demographic data, apnea-hypopnea index, dates and number of MTs, interventions for treatment of OSA, and medical comorbidities. RESULTS: Of 295 infants diagnosed with OSA, 94 (31.9%) had concomitant ETD. A total of 135 MT procedures were performed, with 30 (31.9%) patients undergoing two or more procedures. The average age of first MT was 16.3 months for those undergoing MT only once, and 11.1 months for those undergoing at least two MT procedures. There was no difference in average age of first MT when analyzed by OSA severity (15.6 months, 14.2 months, and 14.6 months for mild, moderate, and severe OSA, respectively). The first MT procedure was performed before or concurrent with the first treatment for OSA in 75 (80%) patients. Of the 137 interventions for treatment of OSA, 10 (45.5%) nonsurgical and 75 (65.2%) surgical interventions did not require further MT procedures afterward. CONCLUSIONS: The ETD prevalence of 32% in infants with OSA is increased compared to the general pediatric prevalence of 4% to 7%. Patients presenting for evaluation of OSA should also be evaluated for ETD. Surgical interventions for treatment of OSA led to decreased need for further MT procedures.

The otolaryngologic manifestations in children with eosinophilic esophagitis.

OBJECTIVES: (1) To describe the incidence of eosinophilic esophagitis (EoE) in the population of patients undergoing esophagoscopy with biopsy by a pediatric otolaryngology service. (2) To elucidate the demographics, presenting symptoms, and endoscopic findings in children with EoE. DESIGN: Case series. PATIENTS/METHODS: The reports of esophageal biopsy specimens taken over 5 years in 2429 patients were reviewed. Ninety-two patients who received their initial diagnosis of EoE by the pediatric otolaryngology service with specimens showing 15 or greater eosinophils per high power field (HPF) were included. INTERVENTIONS: The demographic data, history, presenting symptoms, and endoscopic findings were reviewed retrospectively for the patients. MAIN OUTCOME MEASURE: The percentage of children diagnosed with EoE of all children undergoing esophageal biopsy. RESULTS: A total of 92 children were diagnosed with EoE (3.8% of total children biopsied). The mean age at biopsy was 4.4 years, much lower than previously reported in the literature (approximately 8 years); 73% were boys and 27% girls. The main presenting symptom was cough (46%) followed by hoarseness, throat clearing, burping/vomiting, and abdominal pain. Forty three percent had a history of asthma and 17% a history of GERD. Half of patients had esophageal edema, a third were normal, and only a quarter had mucosal furrowing on endoscopic examination. CONCLUSIONS: EoE is increasingly diagnosed as a clinical entity with a distinct symptom profile and etiology. Increased understanding of EoE and its predisposing factors requires a multidisciplinary approach to diagnosis and management involving the pediatric otolaryngologist.

Increased prevalence of obstructive sleep apnea in patients with cleft palate.

OBJECTIVE: To evaluate the prevalence of sleep-disordered breathing (SDB) and/or obstructive sleep apnea (OSA) in the population with nonsyndromic cleft palate. DESIGN: Retrospective medical record review of symptoms of SDB and/or OSA and results of polysomnography (PSG) studies. SETTING: The craniofacial clinic of a tertiary pediatric hospital. PATIENTS: A total of 459 patients, with an additional 48 patients with Pierre Robin syndrome, met inclusion criteria. MAIN OUTCOME MEASURES: Medical records from January 1, 2005, through July 31, 2009, were reviewed for demographic data, SDB symptoms, surgical procedures, and PSG results. RESULTS: Of the 459 patients, 172 (37.5%) had symptoms of SDB and 39 (8.5%) had PSG-diagnosed OSA. Forty-six patients underwent 1 or more PSGs, with results of 49 of the 59 studies (83.1%) being positive for OSA. Surgical procedures to address SDB and/or OSA were undertaken in 89 patients (51.7%), with combined tonsillectomy and adenoidectomy the most common procedure (44.9%). An additional 48 patients who met the inclusion criteria with a diagnosis of Pierre Robin syndrome were also identified. In this population, 35 patients (72.9%) had symptoms of SDB and/or OSA. CONCLUSIONS: An increased prevalence of SDB and/or OSA exists in the population with cleft palate, with an even greater prevalence in patients with Pierre Robin syndrome. Definitive diagnosis of OSA by PSG is underused. We suggest that surgical management of SDB and/or OSA be followed by PSG to demonstrate resolution or persistence of symptoms to ensure appropriate further management.

Prevalence of hoarseness in the cleft palate population.

OBJECTIVE: To determine the prevalence of hoarseness in the cleft palate population. DESIGN: Retrospective chart review from a tertiary pediatric hospital's craniofacial clinic. PATIENTS: Nonsyndromic patients with cleft palate who had undergone cleft palate repair were eligible for inclusion. Patients were excluded if they had previously undergone a tracheostomy or if they had significant hearing loss. A total of 487 patients met the inclusion criteria. MAIN OUTCOME MEASURES: Medical records were reviewed for demographic data, presence of hoarseness, velopharyngeal insufficiency, symptoms of gastroesophageal reflux disease, and laryngoscopic findings. RESULTS: Of the 487 patients, 27 (5.5%) had complaints of hoarseness: 13 boys and 14 girls. The average age at initial complaint was 4.6 years, with slight differences according to sex: 4.2 years for boys and 5.0 years for girls. Of those with hoarseness, 19 (70%) had velopharyngeal insufficiency, and 8 (30%) had concomitant symptoms of possible gastroesophageal reflux disease. Eleven patients underwent either direct or flexible laryngoscopy: 9 (33%) had vocal fold nodules, and 2 (7%) had edema and/or mucosal thickening of the vocal folds. CONCLUSIONS: The 5.5% prevalence of hoarseness in this study is similar to the reported prevalence of 6% to 34% in the normal pediatric population. These results suggest that there is no difference in the cleft palate population and that hoarseness is either underrecognized and/or underreported. More studies are needed to fully elucidate the true prevalence of hoarseness in the cleft palate population and any correlation of hoarseness with velopharyngeal insufficiency and/or gastroesophageal reflux disease.

Subglottic stenosis examined as a fibrotic response to airway injury characterized by altered mucosal fibroblast activity.

OBJECTIVE: To investigate the association between mucosal fibroblast activity and subglottic stenosis (SGS) development. DESIGN: Prospective study of an animal model of SGS. SETTING: Academic research laboratory. SUBJECTS: New Zealand white rabbits were assigned to either the cricothyroidotomy and carbon dioxide laser injury group or the cricothyroidotomy and silver nitrate injury group. Airways were excised for histologic analysis and the establishment of primary fibroblast cultures. Lesions from surgical excision of established SGS and subglottic tissue were used to analyze SGS recurrence. INTERVENTIONS: The subglottis was approached via cricothyroidotomy and was subjected to either carbon dioxide laser or silver nitrate injury before closure. The SGS lesions were excised at 8 to 10 weeks and were used to establish explants for fibroblast culture. The animals underwent recovery for an additional 14 days to follow recurrence of SGS. After 14 days, all the animals were killed humanely, and subglottic tissue was harvested for histologic evaluation. Rates of migration and contraction of SGS and normal airway fibroblasts were assayed using established in vitro methods under basal conditions and with prostaglandin E(2) treatment. MAIN OUTCOME MEASURES: For in vivo studies, injury, healing, and scarring of the mucosa and cartilage were the primary measures. For cultured fibroblast experiments, cellular responses of fibroblasts from normal and stenosed mucosa were compared and contrasted. RESULTS: Mucosal injury resulted in acute fibroplasia and chronic SGS, surgical excision of mature SGS at 8 weeks resulted in rapid recurrence of stenosis, and SGS-derived fibroblasts were relatively refractory to the effects of prostaglandin E(2) on migration and contraction. CONCLUSIONS: Subglottic stenosis represents a fibrotic airway repair process that involves fibroblasts that produce recurrent, excessive scar formation. We suggest that SGS development and recurrence may be partially dictated by altered fibroblast responsiveness to antifibroplastic signals during mucosal repair.

Prostaglandin E2 is activated by airway injury and regulates fibroblast cytoskeletal dynamics.

OBJECTIVES/HYPOTHESIS: To characterize the activation of cyclooxygenase (COX)-2/prostaglandin (PG) E2 signaling during airway mucosal repair and its subsequent role during the wound healing process. STUDY DESIGN: Prospective animal study. METHODS: The subglottis was approached via cricothyroidotomy. Sham airways were closed, and wounded airways were subjected to laser injury and closed. Subglottic tissue was harvested at 12 hours, 24 hours, 48 hours, and 72 hours postinjury. Secretions were collected preoperatively and at time of sacrifice. Inflammatory gene expression was analyzed using quantitative reverse transcriptase polymerase chain reaction. Subglottic/tracheal explants were exposed to exogenous IL-1beta in the presence or absence of COX inhibitors. Explant-produced PGE2 levels were assayed using enzyme linked immunoassays. Human airway fibroblast migration and collagen contraction were assayed in the presence or absence of prostaglandin E2. RESULTS: Laser injury triggers a rapid, dose-dependent increase in mucosal IL-1beta and COX-2 gene expression, with an anatomical distribution proportional to the distance from the site of injury. Gene upregulation correlates with dose-dependent increases in PGE2 mucosal secretion levels. Ex vivo analysis indicates IL-1beta is responsible for the activation of the COX-2 / PGE2 pathway. Prostaglandin E2 differentially inhibits airway fibroblast migration and contraction in a specific, dose-dependent manner. CONCLUSIONS: PGE2 is activated during mucosal inflammation and acts to decrease fibroplastic activity in the mucosal wound bed. During subglottic stenosis (SGS) development, the levels of PGE2 generated in response to injury may be insufficient to blunt the intrinsically fibroplastic phenotype of SGS fibroblasts, resulting in excessive scarring.