Utilization of Training Dolls to Enhance Caregiver Education for Pediatric Tracheostomy Care.

BACKGROUND: Caregivers of tracheostomized children must learn and demonstrate multiple tracheostomy care skills. At our hospital, caregiver education is provided through a combination of written instructions, classroom sessions, hands-on practice with a manikin, and bedside demonstration. As part of a quality improvement initiative, caregivers were provided a training doll to practice skills. METHODS: A training doll was provided to caregivers of children within the first week of tracheostomy placement to practice skills. Two questionnaires were utilized during the education process to evaluate utility of the training dolls, skills practiced, and confidence in performing skills. The first questionnaire was completed at the time of the classroom session and the second questionnaire after training was completed. A chart review was conducted to compare outcomes for children whose caregivers did and did not receive a training doll. RESULTS: Caregivers of 33 children with a tracheostomy received training dolls, and 28 were not provided dolls. The majority of caregivers felt the training doll was helpful for practicing skills (initial 93%, second questionnaire 85%). Some caregivers reported a lack of confidence in changing the tracheostomy tube (47%) and using a self-inflating bag (21%) in the initial questionnaire. Confidence increased for all skills in the second questionnaire. Few caregivers reported not using the training doll (initial 21%, second 11%). There were no significant differences in hospital length of stay (LOS) (P = .21) or time to complete training (P = .21) for children whose caregivers were and were not provided a doll. CONCLUSIONS: The majority of caregivers utilized the training doll to practice tracheostomy skills and found it helpful for training. The training doll did not significantly impact hospital LOS or time to complete training. Use of a training doll to practice tracheostomy skills is an additional tool to assist caregivers with learning required skills prior to discharge home.

A novel algorithm to reduce bias and improve the quality and diversity of residency interviewees.

Objective: Improve the quality and diversity of candidates invited for the Otolaryngology-Head and Neck Surgery residency match by reducing geographical and inter-rater bias with a novel geographic distribution algorithm. Methods: Interview applicants were divided into geographic regions and assigned to reviewers. Each reviewer selected by force-ranking a pre-determined number of applicants to invite for interviews based on the percentage of applications received for each region. Our novel geographic distribution algorithm was then applied to maintain the geographic representation and underrepresented minority status of invited applicants to match the applicant pool. Results: Analysis of previous interview selection methods demonstrated a statistically significant overrepresentation of local applicants invited for interviews. In 2022, 324 domestic applications were received for the otolaryngology match, which were divided into six geographic regions. There was no significant difference in USMLE scores between regions. The implementation of our distribution algorithm during applicant selection eliminated local overrepresentation in the invited pool of applicants and maintained the representation of underrepresented minority applicants. Following the match, reviewers indicated that implementation of the geographic distribution algorithm was simple and improved the quality and diversity of the group of interviewed applicants. Conclusion: Traditional methods of scoring and inviting otolaryngology residency applicants can be confounded by regional and inter-rater biases. Employing a geographic distribution algorithm improves the quality and diversity of invited applicants, eliminates bias, and maintains the representation of underrepresented minority applicants.

Process improvement strategy to implement an outpatient surgery center efficiency model in an academic inpatient setting.

OBJECTIVES: By utilizing process improvement methodology, we aim to: 1) create an ambulatory surgical efficiency model (SEM) confined to an inpatient setting, and 2) reduce patient wait time and improve patient flow within the operating room. METHODS: A prospective cohort of all otolaryngology cases performed from May 2016 to October 2017 at a tertiary, academic, pediatric hospital. Intraoperative timestamps were collected to determine turnover times. Time to procedure was collected from clinic visit to the day of operation. RESULTS: A total of 5955 patients were enrolled. 3393 cases were performed prior to the implementation of SEM and 2562 after. Of the 2562 cases, 819 were deemed appropriate for the SEM. Prior to the SEM, the average number of working days between the clinic visit and operating room (WD) was 31.1 days (95% CI 30.7-31.4). After the SEM, the WD for non-SEM cases was 30.0 days (95% CI 29.7-30.2), and the WD for SEM cases was 14.4 days (95% CI 14.2-14.6). The average turnover time was significantly less for SEM cases at 11.4 min (95% CI 10.7-12.2) vs. non-SEM cases at 24.4 min (95% CI 23.9-25.0) (p < 0.0001). CONCLUSION: Process improvement methodology is effective in improving perioperative patient flow. This quality improvement project decreased the average time from diagnosis to surgical procedure, as well as decreased the average turnover time between cases. Patient flow can improve with a high-volume SEM within an inpatient hospital operating room setting. This strategy can be instrumental in improving patient care by providing increased access to the operating room.

Detection of Respiratory Pathogens Does Not Predict Risks After Outpatient Adenotonsillectomy.

OBJECTIVES/HYPOTHESIS: To determine whether the presence of detectable upper respiratory infections (URIs) at the time of adenoidectomy/adenotonsillectomy is associated with increased morbidity, complications, and unexpected admissions. STUDY DESIGN: Prospective double-blinded cohort. METHODS: In this prospective cohort study, nasopharyngeal swabs were obtained intraoperatively from 164 pediatric patients undergoing outpatient adenoidectomy/tonsillectomy with or without pressure equalization tubes (PETs) and were analyzed with PCR for the presence of 22 known URIs, including SARS-CoV-2. Surgeons and families were blinded to the results. At the conclusion of the study, rates of detectable infection were determined and intraoperative and postoperative events (unexpected admissions, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, and postoperative presentation to an emergency department) were compared between infected and uninfected patients. RESULTS: Of the 164 patients (50% male, 50% female, ages 8 mo-18 y), 136 patients (82.9%) tested positive for one or more URI at the time of surgery. Forty one patients (25.0%) tested positive for three or more URIs concurrently, and 11 (6.7%) tested positive for five or more URIs concurrently. There were no significant differences in admission rates, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, or postoperative presentation to an emergency department between positive and negative patients. No patients tested positive for SARS-CoV-2. CONCLUSIONS: A recent positive URI test does not confer any additional intraoperative or postoperative risk in the setting of outpatient adenoidectomy/tonsillectomy in healthy patients. There is no utility in preoperative URI testing, and delaying surgery due to a recent positive URI test is not warranted in this population. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2074-E2079, 2021.

Routine pathologic examination of tonsillectomy specimens: A 10-year experience at a tertiary care children's hospital.

OBJECTIVE: To review histopathologic diagnoses from tonsillectomy specimens and determine whether routine pathologic exam is necessary. METHODS: Pathology reports of patients undergoing tonsillectomy from 2005 to 2014 at our pediatric tertiary care hospital were reviewed. Histopathologic diagnoses were recorded with special attention to identification of malignancy. RESULTS: A total of 8807 paired tonsil specimens were sent to pathology over a 10-year course. Gross analysis was performed on all. Microscopic histopathologic analysis was performed on 612 (6.95%) specimens with all but one demonstrating strictly reactive lymphoid hyperplasia. The single specimen (0.16%) demonstrated follicular hyperplasia with focal necrotizing granulomatous lymphadenitis without organisms identified on special staining. The surgeon requested pathologic diagnosis to rule out lymphoma in 4 of 8087 (0.05%) of the specimens. No malignancies were identified. The approximate charges for gross examination of a paired tonsillectomy specimen and microscopic examination were $136.10 and $294.54, respectively. Over the 10 year period of the study, total charges were estimated at $1,115,340 (gross) and $180,258 (microscopic). DISCUSSION: Microscopic analysis of tonsil specimens is unlikely to identify abnormal pathology that changes patient management. This study suggests that neither gross nor microscopic pathologic examination of tonsillectomy specimens is necessary on a routine basis. Histologic analysis of tonsils should be requested only on a case by case basis when clinical suspicion for malignancy is high. Avoiding routine pathologic exam of tonsils may be cost effective and medically safe.

The impact of tobacco exposure on development of otorrhea after myringotomy tube placement.

INTRODUCTION: Otorrhea is a common sequela after myringotomy with tube placement (MTP). The purpose of this study was to identify any significant relationship between passive tobacco exposure and the development of post-tympanostomy tube otorrhea. METHODS: Retrospective chart review was performed on 774 cases of patients who underwent MTP by a single surgeon at a tertiary pediatric hospital from 2012 to 2014. Patients with multiple medical comorbidities, craniofacial anomalies, syndromes and those over 12 years of age were excluded. Multivariate logistic regression analysis was performed to determine if there was a relationship between risk factors (including tobacco exposure, age, pre-operative diagnosis, operative findings and duration of follow-up) and the development of post-tympanostomy tube otorrhea. RESULTS: One hundred and ninety-one patients (average age of 1.92 years) were included. Overall, 16.8% of patients (32/191) had exposure to tobacco smoke. Of patients with passive smoke exposure, 65.6% (21/32) developed otorrhea, as compared to 45.3% (72/159) of those without tobacco exposure. Passive exposure to tobacco smoke by (OR = 2.307; p = 0.009; 95% CI, 1.734-6.028) and younger age (p = 0.012; 95% CI, 0.602-0.938) were associated with increased risk for otorrhea. DISCUSSION: This study suggests that in a cohort of patients undergoing MTP, passive exposure to tobacco smoke significantly increases the risk of developing post-operative otorrhea. This information is valuable to include in parental preoperative counseling regarding tympanostomy tube placement.

Current trends in perioperative antibiotic use: a survey of otolaryngologists.

This study describes the patterns of perioperative antimicrobial use by otolaryngologists during common otolaryngologic surgical procedures. Through the American Academy of Otolaryngology--Head and Neck Surgery Infectious Diseases Committee, a survey was developed to assess the current practice patterns regarding the use of perioperative antibiotics in otolaryngology. A total of 6903 surveys were sent out; 458 were fully or partially completed, and a total of 442 responses were included in the final analysis. Most physicians reported routinely prescribing antibiotics either preoperatively or postoperatively for 12 of the 17 procedures included in the questionnaire despite providers agreeing that there is not enough evidence to support their use. The most common procedure for which antibiotics were prescribed was laryngectomy (91.1%). Antibiotic use is a common practice during the perioperative period for otolaryngologic procedures; however, there is a discrepancy between utilization and evidence of benefit.

Pediatric cervical lymphadenopathy.

This article provides an overview for evaluation and management of the pediatric patient with cervical lymphadenopathy. A thorough history and physical examination are crucial in developing a differential diagnosis for these patients. Although infectious causes of lymphadenopathy are more prevalent in the pediatric population compared with adults, neoplasms should also be considered. Judicious use of imaging studies, namely ultrasound, can provide valuable information for accurate diagnosis. Common and uncommon infectious causes of cervical lymphadenopathy are reviewed. Surgical intervention is occasionally necessary for diagnosis and treatment of infections, and rarely indicated for the possibility of malignancy. Indications for surgery are discussed.

Paediatric cervical lymphadenopathy: when to biopsy?

PURPOSE OF REVIEW: Cervical lymphadenopathy is common in the paediatric population and persistent lymphadenopathy of unknown cause is a frequent reason for otolaryngology referral. Diagnostic work-up is variable among physicians and deciding when excisional biopsy is necessary remains a challenge. This update reviews the recent literature on the work-up and diagnosis of paediatric cervical lymphadenopathy, with a focus on factors that may influence the need for excisional biopsy. RECENT FINDINGS: The majority of paediatric cervical lymphadenopathy cases are benign, with infection and reactive lymphoid hyperplasia being far more common than malignancy. Ultrasound is the initial imaging modality of choice for paediatric cervical lymphadenopathy and can provide critical information to aid in diagnosis. Clinical factors that may predict malignancy include lymph node size greater than 2 cm, multiple levels of adenopathy and supraclavicular location. Biopsy should be strongly considered in patients with a combination of these factors or other suspicious findings such as severe systemic symptoms. SUMMARY: Paediatric cervical lymphadenopathy is commonly encountered in general and paediatric otolaryngology practice; however, absolute guidelines for biopsy do not exist. Careful consideration of history, physical examination, laboratory work-up and diagnostic imaging must be used to guide the clinician in decision-making for biopsy.

Osseointegrated hearing device placement in congenital lamellar ichthyosis.

OBJECTIVE: To present a case of osseointegrated hearing device placement in a child with conductive hearing loss related to manifestations of congenital lamellar ichthyosis. PATIENT: A 5-year-old female patient with congenital lamellar ichthyosis resulting in conductive hearing loss because of bilateral external auditory canal stenosis and tympanic membrane blunting. INTERVENTION: Unilateral osseointegrated hearing device placement using a traditional skin flap technique. MAIN OUTCOME MEASURES: Frequency and severity of adverse skin reactions, device usage, and audiometric testing. RESULTS: After 51 months of follow-up postoperatively, the patient has only required 2 treatments for minor skin reactions (Holgers Grade I). Aided speech reception threshold was 15 dB hearing level (HL) compared to 35 dB HL unaided. The subject has used the device continuously with parental report of improvement in school performance. CONCLUSION: Osseointegrated hearing device placement may be a viable option in patients with congenital lamellar ichthyosis despite the skin-related comorbidities known to be associated with this disease condition.

Ectopic thymus presenting as a retropharyngeal mass: surgical approach.

Cervical ectopic thymus is a rare cause of solid neck masses in children. Most children are asymptomatic, but some may present with a palpable neck mass, with or without compressive symptoms. Cervical ectopic thymus is often discovered incidentally and mistaken for an infection or neoplasm. We present the case of an infant with retropharyngeal ectopic thymus and describe our intraoral surgical approach.