Acoustic analysis of surgeons' voices to assess change in the stress response during surgical in situ simulation.

Introduction: Stress may serve as an adjunct (challenge) or hindrance (threat) to the learning process. Determining the effect of an individual's response to situational demands in either a real or simulated situation may enable optimisation of the learning environment. Studies of acoustic analysis suggest that mean fundamental frequency and formant frequencies of voice vary with an individual's response during stressful events. This hypothesis is reviewed within the otolaryngology (ORL) simulation environment to assess whether acoustic analysis could be used as a tool to determine participants' stress response and cognitive load in medical simulation. Such an assessment could lead to optimisation of the learning environment. Methodology: ORL simulation scenarios were performed to teach the participants teamwork and refine clinical skills. Each was performed in an actual operating room (OR) environment (in situ) with a multidisciplinary team consisting of ORL surgeons, OR nurses and anaesthesiologists. Ten of the scenarios were led by an ORL attending and ten were led by an ORL fellow. The vocal communication of each of the 20 individual leaders was analysed using a long-term pitch analysis PRAAT software (autocorrelation method) to obtain mean fundamental frequency (F0) and first four formant frequencies (F1, F2, F3 and F4). In reviewing individual scenarios, each leader's voice was analysed during a non-stressful environment (WHO sign-out procedure) and compared with their voice during a stressful portion of the scenario (responding to deteriorating oxygen saturations in the manikin). Results: The mean unstressed F0 for the male voice was 161.4 Hz and for the female voice was 217.9 Hz. The mean fundamental frequency of speech in the ORL fellow (lead surgeon) group increased by 34.5 Hz between the scenario's baseline and stressful portions. This was significantly different to the mean change of -0.5 Hz noted in the attending group (p=0.01). No changes were seen in F1, F2, F3 or F4. Conclusions: This study demonstrates a method of acoustic analysis of the voices of participants taking part in medical simulations. It suggests acoustic analysis of participants may offer a simple, non-invasive, non-intrusive adjunct in evaluating and titrating the stress response during simulation.

Pediatric laryngoscopy and bronchoscopy during the COVID-19 pandemic: A four-center collaborative protocol to improve safety with perioperative management strategies and creation of a surgical tent with disposable drapes.

Aerosolization procedures during the COVID-19 pandemic place all operating room personnel at risk for exposure. We offer detailed perioperative management strategies and present a specific protocol designed to improve safety during pediatric laryngoscopy and bronchoscopy. Several methods of using disposable drapes for various procedures are described, with the goal of constructing a tent around the patient to decrease widespread contamination of dispersed droplets and generated aerosol. The concepts presented herein are translatable to future situations where aerosol generating procedures increase risk for any pathogenic exposure. This protocol is a collaborative effort based on knowledge gleaned from clinical and simulation experience from Children's Hospital Colorado, Children's Hospital of Philadelphia, The Hospital for Sick Children in Toronto, and Boston Children's Hospital.

Preoperative augmentative and alternative communication enhancement in pediatric tracheostomy.

OBJECTIVES/HYPOTHESIS: Describe augmentative communication tools and strategies used by pediatric patients referred to inpatient speech-language pathologists prior to tracheostomy placement. STUDY DESIGN: Retrospective review. METHODS: A review of patients who underwent initial tracheostomy placement from 2013-2016 was conducted at a tertiary pediatric center. Eligible patients were those who were referred to a specialized speech-language pathologist prior to the date of the tracheostomy placement to support communication abilities. Patients were identified by surgical procedural and billing codes. Data collected included patient demographics, speech and language disorders, and interventions performed. Chart review and cross analysis of billing data for types of assessment and intervention procedures were conducted by two speech-language pathologists for consensus agreement. RESULTS: Forty-six patients (aged 1 month-27 years, mean = 12.9 years) were included in the study. Average time between the bedside communication assessment and tracheostomy procedure date was 17 days. Baseline speech-language disorders were identified in 11 patients (24%). Thirty-eight (83%) patients were nonspeaking at the time of consultation. Thirty-two (70%) patients utilized an electronic communication tool, and 36 (78%) utilized low-technology communication strategies during the preoperative period. A total of 32 (70%) patients were documented as using no-technology or speech-enhancement strategies during the acute hospitalization. CONCLUSIONS: Multidisciplinary tracheostomy teams should consider consultation to speech-language pathologists for patients prior to tracheostomy placement to assess for utility of high-technology, low-technology, and no-technology augmentative and alternative communication strategies. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1817-1822, 2020.

Improving Team Performance Through Simulation-Based Learning.

American health care is facing an epidemic of medical errors. A major cause of these errors is poor teamwork. Crisis resource management (CRM) is a set of teamwork principles derived from the airline industry. Medical simulation is an educational tool that affords health care providers a means of improving teamwork by learning and practicing CRM. This article (1) discusses the case for teaching team training, (2) reviews the principles of medical simulation as they pertain to team training, (3) provides practical guidelines for using medical simulation in otolaryngology education, (4) discusses current evidence for the efficacy of medical simulation.

Emergency use of a customized tracheostomy tube for pediatric patients.

This article describes how to make a customized tracheostomy tube in an emergency setting for a pediatric patient. This is particularly critical when a commercial customized tracheostomy tube cannot be readily obtained.

Using medical simulation to teach crisis resource management and decision-making skills to otolaryngology housestaff.

OBJECTIVES: Develop a course to use in situ high-fidelity medical simulation (HFS) in an actual operating room (OR) to (1) teach teamwork and crisis resource management (CRM) skills simultaneously to otolaryngology and anesthesia trainees and OR nurses and (2) provide decision-making experience to ear, nose, and throat residents and OR teams in simulated high-risk, low-frequency airway emergencies. STUDY DESIGN: A simulation-based, in situ CRM course was developed to teach airway management and CRM in the OR. Upon completion of each course, the participants were surveyed using questions with (1-5) scale answers. SETTING: The simulated clinical scenarios took place in the intensive care unit and OR at Children's Hospital Boston. SUBJECTS AND METHODS: The participants consisted of pediatric otolaryngology fellows, otolaryngology residents, anesthesiology residents, fellows, and certified registered nurse anesthetists as well as OR nurses. Fifty-nine individuals participated in 9 simulation-based courses given between October 2008 and May 2010. The team members participated together in 3 simulated medical crises that centered on airway and anesthesia issues. Each simulated crisis was followed by a structured debriefing session conducted by trained debriefers. Embedded within the course were didactics on CRM principles. RESULTS: The participants' responses on the survey included General Course Organization, Realism, Debriefing, and Relevance to Future Practice. Ninety percent of the responses were favorable or very favorable. CONCLUSION: Using a newly developed, in situ HFS-based course, clinical decision-making skills and teamwork can be effectively taught concurrently to members of an OR team.

Minimally invasive endoscopic management of subglottic stenosis in children: success and failure.

OBJECTIVE: To assess the efficacy and safety of endoscopic management of subglottic stenosis both as a primary and as an adjunctive treatment in the pediatric population. METHODS: Retrospective review of pediatric patients with subglottic stenosis undergoing endoscopic airway procedures at a tertiary care pediatric medical center. Outcomes were assessed by systematic review to determine the success and failure of the endoscopic approach. RESULTS: Forty patients (22 male, 18 female) underwent endoscopic interventions for a diagnosis of subglottic airway stenosis between 2003 and 2006. Age ranged from 22 days old to 20 years old. Recorded degree of subglottic stenosis ranged from 10% to 99%. Fifty-three percent (21/40) had a history of prematurity, and 40% (16/40) had secondary airway diagnoses. Twenty-four patients underwent an endoscopic intervention initially (including laser or dilation, with or without topical mitomycin treatment), including four patients who underwent tracheostomy prior to the first endoscopic intervention. Sixteen underwent laryngotracheoplasty initially, including ten patients who underwent tracheostomy prior to the laryngotracheoplasty. Endoscopic treatment resulted in resolution of symptoms, and/or decannulation, and no further need for an open procedure in 58% of patients. Of the 24 patients undergoing endoscopic interventions initially, 14 patients underwent two or more endoscopic interventions, and 10 patients subsequently required tracheostomy or laryngotracheoplasty. When endoscopic procedures were used as an adjunct to laryngotracheoplasty, 60% (12/20) had resolution of symptoms, underwent decannulation, and did not require tracheostomy or revision laryngotracheoplasty. CONCLUSIONS: The endoscopic approach can be successful in the management of properly selected patients with subglottic stenosis, either as the initial treatment modality or as an adjunctive treatment in cases of re-stenosis after open airway surgery. The likelihood of success with a minimally invasive procedure as the primary treatment decreases with worsening initial grade of subglottic stenosis.

Validation of the Pediatric Voice-Related Quality-of-Life survey.

OBJECTIVE: To validate the Pediatric Voice-Related Quality-of-Life (PVRQOL) survey, which was designed to assess voice changes over time in the pediatric population. DESIGN: Prospective longitudinal study. SETTING: Outpatient pediatric otolaryngology office practice. PARTICIPANTS: One hundred twenty parents of children aged 2 through 18 years having a variety of otolaryngological diagnoses including disorders that affect the voice. INTERVENTIONS: The previously validated Pediatric Voice Outcomes Survey and the PVRQOL were jointly administered to the parents of the study participants. Test-retest reliability was accomplished by having 70 caregivers repeat the instrument 2 weeks after the initial visit. The Cronbach alpha value was calculated to determine reliability. Instrument validity was determined by examining convergent and discriminant validity. MAIN OUTCOME MEASURE: Correlation of PVRQOL scores with Pediatric Voice Outcomes Survey scores. RESULTS: Reliability of the PVRQOL was established by evaluating the Cronbach alpha value (.96; P<.001) and by test-retest reliability (weighted kappa value, 0.8). Validity of the PVQROL was tested by evaluating its ability to show significant change in voice-related quality-of-life after adenoidectomy (discriminant validity) (P<.001). The PVQROL also proved valid when the overall score was correlated with the previously validated Pediatric Voice Outcomes Survey (r = 0.7; P<.001). CONCLUSION: The PVRQOL is a more comprehensive survey than the previously validated Pediatric Voice Outcomes Survey and is another valid instrument to examine the health-related quality-of-life issues in pediatric voice disorders.

Recurrent fetal rhabdomyoma of the head and neck.

We present a case of a congenital fetal rhabdomyoma which recurred after surgical excision. A review of the patient's chart, imaging studies, operative reports and histologic findings were conducted. A congenital fetal rhabdomyoma involving the head and neck region diagnosed prenatally by ultrasound and MRI was surgically excised without complications. The patient presented with recurrence of the tumor fourteen months after the initial surgery. This case report is supplemented with a review of the relevant literature on congenital fetal rhabdomyoma. This is the fifth documented case of recurrence of a fetal rhabdomyoma. Extracardiac rhabdomyomas are extremely rare benign tumors. Complete excision of these lesions is curative with only a handful of recurrences documented in the literature. Close follow up and a complete workup to rule out rhabdomyosarcoma is warranted in all cases of recurrence.

Robin sequence: a retrospective review of 115 patients.

OBJECTIVES: Review a large series of patients with Robin sequence to document the incidence of (1) associated syndromic diagnoses; (2) co-morbid conditions; (3) frequency and type of operative management for airway compromise and feeding difficulties; and (4) possible differences in treatment between syndromic and nonsyndromic infants. METHODS: Retrospective case-review of 115 patients with Robin sequence managed between 1962 and 2002 at two tertiary-care teaching hospitals for evaluation of demographic information, clinical findings, and treatment interventions. RESULTS: Fifty-four percent (N=63) of patients were nonsyndromic. Syndromic patients included: Stickler syndrome (18%), velocardiofacial syndrome (7%), Treacher-Collins (5%), facial and hemifacial microsomia (3%), and other defined (3.5%) and undefined (9%) disorders. There was no statistical difference between the syndromic and nonsyndromic patients with regard to need for operative airway management (Fisher's exact test, p=0.264). Forty-two percent of patients required a feeding gastrostomy tube to correct feeding difficulties. Patients with a syndromic diagnosis were more likely to be developmentally delayed. Fifty-one (44%) patients underwent operative airway management: 61% underwent tongue-lip adhesion and 39% underwent tracheotomy. Fifteen percent of patients initially had tongue-lip adhesion subsequently required tracheotomy. While the preferred treatment for respiratory compromise differed between the two institutions, the percentage of patients requiring operative intervention was similar. CONCLUSIONS: The pathogenesis of Robin sequence is multifactorial and syndromic in nearly half of the patients. Operative treatment of respiratory failure was required in 44% of infants; the rate was similar in both hospitals. The operative approach differed significantly between the institutions, however, based on the philosophy and training of the managing surgical specialty. Co-morbid factors such as baseline cardiopulmonary and neurologic status did not play a significant role in surgical decision making.