Factors affecting polysomnography compliance and delays to surgical treatment of obstructive sleep apnea.

OBJECTIVE: To evaluate adherence to polysomnography in pediatric patients and determine if demographics, socioeconomic status, polysomnography indication, or prior otolaryngology intervention are associated with polysomnography adherence and time to definitive surgery. STUDY DESIGN: Retrospective review study. SETTING: Tertiary-care children's hospital. METHODS: Electronic medical record was queried to identify patients ordered for a sleep study between January and May 2019. Demographic information, time to sleep study, and time to surgery were collected and calculated. RESULTS: 304 patients were recommended to obtain polysomnography, with adherence rate of 65.4%. There was no significant difference in adherence or loss to follow-up rates based on patient sex, age, language, socioeconomic status, state of residence, single-parent status, or polysomnography indication. There was no difference between time to surgery for patients who did or did not obtain polysomnography (181 vs. 161 days, P = .51). Patients with prior otolaryngology intervention were more likely to obtain polysomnography and less likely to be lost to follow-up (P < .05). Median household income demonstrated a significant inverse relationship with time to polysomnography (P < .05) as well as time to surgery (P < .05). Medically complex patients tended to experience longer time to surgery compared with non-complex patients. CONCLUSION: Families with lower socioeconomic status or medically complex children may require assistance to obtain polysomnography and pursue surgery for sleep-disordered breathing. Patients without prior otolaryngology intervention may be less likely to follow up and may need assistance with navigating the polysomnography process.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy.

OBJECTIVES: There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision. STUDY DESIGN: Level III, retrospective case-control study. SETTING: A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware). METHODS: A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls. RESULTS: A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy. CONCLUSION: Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy?

IMPORTANCE: Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk. OBJECTIVE: The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk. DESIGN: Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018. SETTING: This study was completed at a tertiary-care pediatric referral center. PARTICIPANTS: 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital. EXPOSURES: Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk. MAIN OUTCOME(S) AND MEASURE(S): Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention. RESULTS: 1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage. CONCLUSIONS AND RELEVANCE: Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.

Comparing telehealth with office-based visits for common pediatric otolaryngology complaints.

OBJECTIVE: The objective of this study was to evaluate the feasibility of telehealth visits and compare office-based visits for pediatric patients undergoing evaluation of recurrent acute otitis media or sleep-disordered breathing. METHODS: A retrospective cohort study compared telehealth patients with matched controls seen in the office. The feasibility of a thorough patient evaluation in a single telehealth visit without a follow-up office visit was assessed. Both groups were also compared for completeness of physical exam, management, follow-up recommendations, and correlation of physical exam findings with intraoperative findings. RESULTS: 100 children [mean age (SD) = 20.7 (15.6) months] with a chief complaint of recurrent acute otitis media and 128 children [5.4 (3.2) years] with a chief complaint of sleep-disordered breathing were evaluated. Recommendations for surgery, additional studies, or routine follow-up were similar between telehealth and office-based groups. Physical exam feasibility was significantly different for the nasal cavity, oropharynx, and middle ear (P < .001). Patients who underwent office-based consultation were much more likely to have findings of middle ear fluid at the time of tympanostomy tube placement (79.3% vs 39.3%, P = .002). There was no significant difference between preoperative and intraoperative tonsil size discrepancies (P = .749). CONCLUSION: Telehealth can be used successfully for the evaluation of pediatric patients with sleep-disordered breathing; however, reliance on history alone may result in unnecessary tympanostomy tube placement in patients with recurrent acute otitis media. Physical examination of the oropharynx, nasal cavity, and middle ear via telehealth presents a unique challenge in pediatric otolaryngology.

Improving Attendance and Patient Experiences During the Expansion of a Telehealth-Based Pediatric Otolaryngology Practice.

OBJECTIVE: To determine the rates and primary causes of missed appointments (MAs) for telehealth visits and present remedies for improvement. METHODS: This cross-sectional survey was conducted at a tertiary care pediatric otolaryngology practice during expansion of telehealth-based visits. A review of questionnaire responses was performed for 103 consecutive patients with MAs over 50 business days from March 20, 2020, to May 29, 2020. Families were asked a brief survey regarding the cause of the MA and assisted with technical support and rescheduling. MA rates and causes were analyzed. RESULTS: The overall MA rate during the initiation of telehealth services was significantly increased at 12.4% as compared with clinic-based visits of a similar duration before COVID of 5.2% (P < .001). Technical issues were the most common causes of MAs (51.3%). Of the caregivers, 23.8% forgot or reported cancellation of the appointment. Five percent of patients were non-English speaking and scheduled without translator support. Minorities and patients with public insurance represented 53.6% and 61.9% of MAs, respectively. DISCUSSION: Technical difficulties were the most commonly reported cause of missed telehealth appointments. Optimization of applications by providing patient reminders, determining need for translator assistance, and reducing required upload/download speeds may significantly reduce rates of MAs and conversions to other communication. IMPLICATIONS FOR PRACTICE: Clear, concise education materials on the technical aspects of telehealth, platform optimization, and robust technical and administrative support may be necessary to reduced missed telehealth appointments and support large-scale telehealth operations. An assessment of institutional capacity is critical when considering telehealth expansion.

Comparing decannulation failures and successes in pediatric tracheostomy: An 18-year experience.

OBJECTIVES: There is a paucity of published literature identifying patients at higher risk of decannulation failure. The purpose of this study is to evaluate patient factors that may predict successful decannulation of pediatric tracheostomy patients and analyze factors contributing to tracheostomy decannulation failures. METHODS: A retrospective chart review of tracheostomy outcomes was conducted at a pediatric referral hospital. Successful and failed decannulations were compared using the following patient variables: age at tracheostomy, sex, ethnicity, gestational age and weight, the primary indication for tracheostomy, comorbidities, age at decannulation attempt, polysomnography data, and status of airway before decannulation as assessed endoscopically by airway team. RESULTS: Four hundred thirty-nine tracheostomies were performed over the 18-year period with 173 decannulation attempts. The overall rate of successful decannulation on the first attempt was 91.9% (159 of 173), with an eventual decannulation success rate of 97.1% (168 of 173). Compared with failed decannulations, the patients with successful decannulations had a shorter duration of tracheostomy and no medical comorbidities. Gestational age and weight approached, but did not achieve, statistical significance. After 25 months with a tracheostomy, approximately 50% of patients are decannulated with very few decannulations occurring after 75 months. The overall mortality rate in this cohort was 18.6% (78 of 420) with a tracheostomy-related mortality rate of 0.95% (4 of 420). CONCLUSIONS: The decannulation protocol at this institution is successful nearly 92% of the time. Fewer medical comorbidities, shorter duration of tracheostomy placement, and older gestational age may improve the likelihood of successful decannulation. Future studies are needed to determine the optimal timing and workup to evaluate patients for decannulation.

Interstate variation within a five-state health system: Polysomnography prior to tonsillectomy in trisomy 21 patients.

OBJECTIVES: Since 2011, the American Academy of Otolaryngology - Head and Neck Surgery Clinical Practice Guidelines have recommended polysomnography (PSG) prior to tonsillectomy in children with Down syndrome (DS). The purpose of this study was to determine adherence to guidelines recommending polysomnography before tonsillectomy for children with DS and sleep-disordered breathing among pediatric otolaryngologists. METHODS: A one-year quality assurance retrospective review was conducted at four hospitals within one pediatric health system to identify children with a diagnosis of DS who underwent a tonsillectomy with or without adenoidectomy from January 1, 2018, to December 31, 2018. De-identified data related to age, sex, BMI, procedure type, and preoperative PSG were collected and examined. RESULTS: The rate of PSG prior to tonsillectomy was 90.4% (66 of 73) among patients with DS. 51.6% of PSG studies were performed within 90 days before surgery, and 92.2% (59 of 64) of PSG studies were performed within one year before surgery. 33% of patients who did not undergo PSG also were obese or under age two years. The most common reason for not obtaining a PSG prior to tonsillectomy was that either the provider or parent felt the patient would not tolerate it. There was no variance from guidelines by age, sex, and procedure type. CONCLUSIONS: Polysomnography for children with DS prior to tonsillectomy is achieved greater than 90% of the time in a multistate pediatric health system. Broader assessment across the nation and future studies regarding the timing of PSG before tonsillectomy are warranted.

General anesthesia risk across pediatric surgical specialties: Low in otolaryngology.

PURPOSE: To determine the relevance of the Food and Drug Administration (FDA) warning regarding general anesthesia (GA) in children under 3 years of age for procedures lasting longer than 3 h, by surgical specialty and for otolaryngology specifically. METHODS: A one-year retrospective review was conducted at a tertiary-care medical center for all children younger than 3 years undergoing surgical procedures with durations greater than 3 h. De-identified data related to age, surgical service, procedure types, American Society of Anesthesiologists (ASA) physical status classification, and general anesthesia time were collected and examined. RESULTS: During 2017, 430 of 11,757 patients (3.7%) met the age and duration of anesthesia criteria. Procedures performed by the cardiothoracic surgery service were mostly likely to result in duration of surgery greater than 3 h (46.6%), followed by neurosurgery (12.9%), cardiology (9.3%), plastic surgery (7.1%), general surgery (6.6%), and urology (5.1%). Less than 2% of patients undergoing ophthalmology (1.9%), orthopedic surgery (1.7%), and otolaryngology (0.5%) procedures required anesthesia greater than 3 h. CONCLUSION: Less than 4% of patients younger than 3 years undergoing surgery required general anesthesia for longer than 3 h. The theoretical risks of general anesthesia per the FDA warning are discussed and must be balanced against the known functional and neurodevelopmental consequences of not performing critical and time-sensitive surgery on children in this age group. A strategy for addressing parental and provider concerns is discussed.

Biocompatibility comparison of novel soft tissue implants vs commonly used biomaterials in a pig model.

OBJECTIVE: To develop a model to evaluate biocompatibility, integration, and substrate independence of novel porous bioscaffolds for maxillofacial and plastic reconstruction using sphere-templated angiogenic regeneration technology compared with currently available synthetic and biologic soft tissue implants. STUDY DESIGN: A prospective pilot study using animals. SETTING: Military medical center. SUBJECTS AND METHODS: Five pigs underwent dorsal subcutaneous implantation of a polypropylene-based material coated with precision pore silicone granules (sphere-templated scaffold), expanded polytetrafluoroethylene, human dermis, and porcine dermis. Sham and undissected sites were also used as controls. Specimens were harvested 7, 21, 90, and 180 days after surgery and evaluated histologically for inflammation, neovascularization, and collagen deposition. RESULTS: All materials and sham sites induced a mild to moderate inflammation that decreased over time, except for human dermis, which elicited a moderate to severe inflammatory response. The responses were varied and measurable using subjective scoring methods. The sphere-templated scaffold demonstrated numerous foreign body giant cells adjacent to the silicone granules, which were not seen in any of the other specimens. CONCLUSION: Subjective scoring of pathology slides and measurement of capsule thickness appeared to show differences between the materials, but these differences require a larger number of subjects and proper statistical analysis to assess. The robust foreign body reaction elicited by the polypropylene/silicone-based scaffold argues against the use of this material in future studies. The authors advocate using inert biodegradable substances for future bioscaffold constructs.