High-Dose Celecoxib for Pain After Pediatric Tonsillectomy: A Randomized Controlled Trial.

OBJECTIVE: Pediatric tonsillectomy causes significant postoperative pain. Newer nonsteroidal anti-inflammatory drugs such as celecoxib control pain without increasing bleeding risk, but in prior studies provided only modest pain reduction at standard doses. We aimed to determine if high-dose celecoxib (double the usual pediatric dose) is effective for pain, without increasing bleeding or other risks. STUDY DESIGN: Randomized double-blind trial. SETTING: Pediatric tertiary center. METHODS: Children aged 3 to 11 years undergoing total tonsillectomy were randomized to receive celecoxib (6 mg/kg/dose) or placebo, twice daily, for up to 10 days. All cases were supplemented with acetaminophen and oxycodone as needed. All participants and personnel were blinded to treatment group. Subjects recorded coanalgesic consumption, pain, diet, and activity. RESULTS: The celecoxib group (n = 68) consumed 0.72 mg/kg of oxycodone, as compared with 1.12 mg/kg in the placebo group (n = 62), a 36% difference that was not significant. However, multivariate analysis by treatment group, separate from pain levels, confirmed that this reduction was due to celecoxib treatment (P = .03). In subjects with more prolonged pain (n = 88), celecoxib reduced consumption by 52% (P = .02). Celecoxib showed greater benefit for subjects in the prolonged pain group than for those in the lesser pain group (P = .006). Incidence of adverse events was similar between groups. Minor hemorrhage occurred in 4.6% (5 placebo, 3 celecoxib). CONCLUSION: High-dose celecoxib is effective in controlling pain after tonsillectomy, with no adverse effects in this relatively small sample. It reduces narcotic consumption, and its impact appears greater in children with higher degrees of pain. Celecoxib can be considered an effective alternative to ibuprofen after tonsillectomy. This trial was registered at ClinicalTrials.gov: NCT02934191.

Principal Factors Associated With Ketorolac-Refractory Pain Behavior After Pediatric Myringotomy and Pressure Equalization Tube Placement: A Retrospective Cohort Study.

BACKGROUND: Prophylactic analgesic administration reduces pain behavior after pediatric bilateral myringotomy and pressure equalization tube placement (BMT). We hypothesized that postoperative pain in children treated with intraoperative ketorolac would, among several exposures of interest, be strongly associated with ear condition. METHODS: We conducted a retrospective cohort study of healthy children (9 months to 7 years) who underwent BMT at the Children's Hospital of Philadelphia or its ambulatory surgery centers from 2013 to 2016. Anesthetic care included preoperative oral midazolam, sevoflurane/nitrous oxide (N2O)/air/oxygen (O2) by mask, and intramuscular ketorolac. Demographic and procedural information included left and right tympanic membrane (normal, retracted, or bulging) and middle ear (normal/no, serous, mucoid, or purulent effusion) conditions. Because tympanic membrane and middle ear conditions were highly concordant and mean maximum Face, Legs, Activity, Cry and Consolability (FLACC) scores (0-10) were not different across the array of abnormal findings, we categorized each ear as normal or abnormal based on middle ear effusion alone. We then defined the ear condition of each child (primary exposure) using bilateral findings: normal/normal, normal/abnormal, and abnormal/abnormal. Secondary exposures included age, BMT history, procedure duration, facility location, and attending surgeon/anesthesiologist pair. The primary outcome was maximum postanesthesia care unit FLACC score: 4-10 (moderate-to-severe pain) versus 0-3 (no-to-low pain). Rescue oxycodone, acetaminophen administration, and emergence agitation were secondary outcomes. Statistical analysis incorporated generalized linear mixed models with random intercepts accounting for the clustering effect of provider pairs. Adjusting for multiple comparisons, significance level was set at P = .004. RESULTS: Excluding recurrent cases, 1922 unique evaluable subjects remained. The probability of moderate-to-severe pain behavior (FLACC, 4-10) was 52.4% (95% confidence interval [CI], 50.2-54.6) overall. In a confounder-adjusted model, ear condition was significantly associated with moderate-to-severe pain: compared to bilateral abnormal (effusions), odds ratio (OR) (95% CI) for bilateral normal was 2.2 (1.6-2.9), P < .0001. Younger age (OR, 1.1 [1.1-1.2] per year; P = .001) and longer procedure duration (OR, 1.1 [1.0-1.2] per minute; P = .0008) were likewise related to higher pain. With surgeon added to the model, variance explained by provider pairs decreased from 9.60% to 1.05%. Two secondary outcome associations also emerged: comparing bilateral normal to abnormal ears, ORs were 1.7 (1.3-2.2), P = .0001, for rescue oxycodone and 2.0 (1.2-3.3), P = .008, for emergence agitation. CONCLUSIONS: Pain behavior after BMT varies by surgeon and is strongly associated with ear condition. Ketorolac as a single prophylactic analgesic appears less effective in younger children with normal middle ear findings.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Association Between Ibuprofen Use and Severity of Surgically Managed Posttonsillectomy Hemorrhage.

Importance: Ibuprofen used in postoperative management of pain after tonsillectomy has not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The severity of bleeding is difficult to quantify but may be a more important outcome to measure. Objective: To evaluate the association between ibuprofen use and severity of PTH using transfusion events as a marker of severity. Design, Setting, and Participants: This retrospective cohort study identified 8868 patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the tertiary academic Children's Hospital of Philadelphia. Of these patients, 6710 met the inclusion criteria. Data were collected using electronic database acquisition and query. Main Outcomes and Measures: Multivariate analysis was performed to identify independent prognostic factors for PTH and receipt of transfusion. Results: Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256 female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%) presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of 222 patients undergoing sPTH (6.8%) received transfusions. No significant independent increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90; 95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of the 95% CI suggests the difference could be nearly 10 times greater. Conclusions and Relevance: The risk for sPTH is not increased with use of postoperative ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with ibuprofen use when using transfusion rate as a surrogate marker for severity.

Beare-Stevenson syndrome: two new patients, including a novel finding of tracheal cartilaginous sleeve.

Beare-Stevenson syndrome (BSS) is a rare FGFR2-associated craniosynostosis syndrome with a higher rate of sudden unexplained death than related conditions such as Apert, Pfeiffer, and Crouzon syndromes. BSS presents with craniosynostosis, cutis gyrata, and significant developmental delay in most patients who survive infancy. There have only been 21 reported patients with BSS, which limits prognostication for clinicians and likely does not capture the full extent of the phenotype. Here we report on two additional patients with molecularly confirmed BSS, one each with p.Ser372Tyr and p.Tyr375Cys mutations in FGFR2. Cloverleaf skull was identified prenatally in one patient, with initial concern for Crouzon syndrome. Prenatal 3D ultrasound was performed, but cutis gyrata was only visible on retrospective examination following the clinical diagnosis of BSS after birth. Due to phenotypic overlap with Crouzon syndrome, but worse prognosis, we recommend consideration of prenatal 3D ultrasound and mutation testing for patients with suspected Crouzon to allow for prenatal diagnosis of BSS and to enable appropriate genetic counseling and postnatal care. One of our patients was noted to have a tracheal cartilaginous sleeve, which if present could explain sudden death. Of note, tracheal cartilaginous sleeves have been reported in other FGFR2-related craniosynostosis syndromes, and are associated with 90% risk of death by two years of age without tracheostomy. Tracheal cartilaginous sleeves are often only found incidentally at autopsy as they are difficult to diagnose without direct visualization of the trachea. This association and our experience suggests that BSS patients be evaluated for tracheal cartilaginous sleeve to prevent airway compromise.

Risk of otitis externa following manual cerumen removal.

OBJECTIVES: Based on an interpretation of a recent Joint Commission protocol to sterilize instruments coming into contact with mucous membranes, there has been institutional interest in sterile packaging of cerumen curettes used for manual cerumen removal. To date, there are no studies that have assessed the risk of otitis externa (OE) following cerumen removal and the utility of sterile packaging is questionable. The objective of this study is to assess the incidence of OE following cerumen disimpaction prior to the implementation of sterile packaging at our institution. METHODS: This was a retrospective chart review. Over a I-year period, 1457 episodes of manual cerumen removal took place in the otolaryngology clinic. Charts were assessed for signs or symptoms of OE within 2 weeks of the procedure through follow-up phone calls and clinic visits in the otolaryngology division. RESULTS: There were no patients who followed up with symptoms or signs suggestive of OE in the 2-week postprocedure period. CONCLUSION: There is no evidence that OE is a complication of manual cerumen removal when performed by otolaryngologists using clean technique. Unnecessary sterilization of tools leads to increased cost and time for this common outpatient procedure performed by the otolaryngologist.

Postoperative recovery after microdebrider intracapsular or monopolar electrocautery tonsillectomy: a prospective, randomized, single-blinded study.

OBJECTIVE: To prospectively assess the postoperative recovery in patients randomly selected to receive either microdebrider intracapsular tonsillectomy (MT) or monopolar electrocautery tonsillectomy (ET). DESIGN: A prospective, randomized, single-blinded study. SETTING: Tertiary care children's hospital. PATIENTS: A total of 74 patients between the ages of 3 and 7 years undergoing adenotonsillectomy for obstruction were randomly assigned to the MT and ET groups. MAIN OUTCOME MEASURES: Families were blinded to the technique used and given a checklist to fill out daily quantifying pain, activity, diet, and the number of doses of pain medication given over a 10-day period. Other variables assessed included the time of surgery and intraoperative blood loss. RESULTS: The average time of surgery was 16.9 minutes for ET compared with 20.9 minutes for MT (P<.001). The average blood loss was 30 mL for ET compared with 45 mL for MT (P = .01). Resumption of near-normal dietary intake was achieved 1.7 days earlier in patients receiving MT compared with ET (P = .04). There was no significant difference in the number of days taken for the resolution of pain or resumption of normal activity between the 2 groups. CONCLUSIONS: Microdebrider tonsillectomy takes over 4 minutes longer to perform compared with ET and has slightly higher intraoperative blood loss. There appears to be a slight advantage in the resumption of normal dietary intake with MT but no significant difference in the number of days taken for the resolution of pain or resumption of normal activity.

Pediatric submandibular triangle masses: a fifteen-year experience.

BACKGROUND: The purpose of this study was to evaluate the surgical results of pediatric submandibular triangle masses, with specific attention to neoplastic processes. METHODS: We retrospectively reviewed the medical records of 105 patients aged 6 months to 21 years who underwent surgery in the submandibular triangle at a major pediatric tertiary care hospital from 1987 to 2001. RESULTS: One hundred five patients who underwent surgery in the submandibular triangle were included in the study. Twenty patients had neoplastic processes, six of which were of primary salivary origin (two mucoepidermoid carcinomas and four pleomorphic adenomas). Twenty-four patients underwent excision of inflamed or infected lymph nodes, and 23 patients underwent excision of inflamed or infected submandibular glands. Thirty-eight patients were included who underwent surgery for sialorrhea or to gain access for another surgical procedure. Complications included tumor recurrence, transient and permanent marginal mandibular nerve weakness, ranula, postoperative fluid collection, and cellulitis. Duration of follow-up ranged from no follow-up to 11 years. CONCLUSION: Surgical excision of submandibular triangle masses is uncommon. We present our experience with these lesions, with a discussion of diagnosis, surgical indications, and surgical complications.

Pistachio nutshell foreign body of the oral cavity in two children.

Pistachio nutshell foreign bodies have been documented in the literature, occurring most commonly in the bronchi. The objective of this study is to report on two cases of oral cavity lesions, which were subsequently found to be pistachio nutshell foreign bodies. The first patient is a 9-month-old male who presented with a hard palate mass measuring 1.5 cm. The patient was evaluated in the operating room, and found to have a submucosal pistachio nutshell foreign body. The second patient is a 17-month-old female who presented with a firm, fixed midline hard palate mass. The lesion was subsequently noted to dislodge from the palate, and was identified as a pistachio nutshell.

Actinomycosis of the temporal bone: a report of a case.

Actinomycosis is a chronic suppurative infection of the cervicofacial region caused by Actinomyces species, which are anaerobic, gram-positive filamentous bacteria. Although actinomycosis has a propensity for involving the oral cavity, rare cases of actinomycosis involving the temporal bone have been published. We report the case of a 14-year-old girl who presented with clinical, audiometric, and radiologic findings consistent with right chronic suppurative otitis media that persisted despite tympanomastoidectomy. Findings on histologic evaluation of a specimen obtained during revision surgery were consistent with a diagnosis of actinomycosis. Although actinomycosis of the temporal bone is rare, it should be considered in the differential diagnosis of chronic suppurative temporal bone infections that are resistant to standard therapy.

Heterotopic gastric mucosa of the oral cavity: a rare entity.

OBJECTIVE: Heterotopic gastric mucosa found within the oral cavity has been reported as a rare occurrence with less than 30 cases in the English literature. We propose that this entity may not be as rare as originally described. METHOD: Five cases of heterotopic gastric mucosa in the oral cavity were collected from three institutions. RESULTS: Five new cases of heterotopic gastric mucosa in the oral cavity were confirmed. CONCLUSIONS: Heterotopic gastric mucosa of the oral cavity may not be as rare as originally thought.

A staging system for congenital cholesteatoma.

OBJECTIVE: To develop a staging system for congenital cholesteatoma in predicting the likelihood of residual disease. DESIGN: Retrospective analysis of data from a case series, to identify predictors of residual disease. SETTING: Tertiary care pediatric hospital. PARTICIPANTS: Children undergoing surgical removal of congenital cholesteatoma. There were 156 patients, with 160 cholesteatomas; 4 children had bilateral disease. INTERVENTIONS: Each case was scored as to quadrants of the middle ear involved, ossicular involvement, and mastoid extension. MAIN OUTCOME MEASURE: Surgically confirmed residual disease at any time after the initial procedure. RESULTS: Four stages were defined as follows: stage I, disease confined to a single quadrant; stage II, cholesteatoma in multiple quadrants, but without ossicular involvement or mastoid extension; stage III, ossicular involvement without mastoid extension; and stage IV, mastoid disease. There was a strong association between stage and residual disease, ranging from a 13% risk in stage I to 67% in stage IV. CONCLUSIONS: This simple staging system may be particularly useful in standardizing the reporting of congenital cholesteatoma and in adjusting for severity in evaluating outcomes. It also provides information that is useful in counseling parents.

Congenital cholesteatoma: 20 years' experience at The Children's Hospital of Philadelphia.

OBJECTIVE: We report our experience with congenital cholesteatoma over a span of 20 years with an emphasis on presenting characteristics and predictors of outcome. METHODS: We conducted a retrospective review from 1981 through 2000. RESULTS: One hundred seventy-two congenital cases were identified in 167 patients. Five patients had bilateral disease. The majority (72%) were found in boys, with an average age of 5.0 years. Hearing loss was slight to moderate. When confined to 1 quadrant, cholesteatoma was anterosuperior in 82% of cases; 47% had cholesteatoma in 2 or more quadrants. Ossicular chain involvement was found in 43% of all cases, and mastoid extension was evident in 23%. The rate of recurrent disease was directly related to the extent and number of quadrants involved. CONCLUSION: To our knowledge, this is the largest series of congenital cholesteatomas to be reported. This review confirms the male predominance and predilection for the anterosuperior quadrant. The extent of cholesteatoma and its relation to residual disease should be used as a guide for planning a second-look procedure.