Pediatric airway study: Endoscopic grading system for quantifying tonsillar size in comparison to standard adenotonsillar grading systems.

SIGNIFICANCE: Current grading systems may not allow clinicians to reliably document and communicate adenotonsillar size in the clinical setting. A validated endoscopic grading system may be useful for reporting tonsillar size in future clinical outcome studies. This is especially important as tonsillar enlargement is the cause of a substantial health care burden on children. OBJECTIVE: To propose and validate an easy-to-use flexible fiberoptic endoscopic grading system that provides physicians with a more accurate sense of the three-dimensional relationship of the tonsillar fossa to the upper-airway. METHODS: 50 consecutive pediatric patients were prospectively recruited between February 2015 and February 2016 at a pediatric otolaryngology outpatient clinic. The patients had no major craniofacial abnormalities and were aged 1 to 16years. Each patient had data regarding BMI, Friedman palate position, OSA-18 survey results collected. For each child, digital video clips of fiberoptic nasopharyngeal, oropharyngeal and laryngeal exams were presented to 2 examiners. Examiners were asked to independently use the proposed Endoscopic tonsillar grading system, the Brodsky tonsillar grading scale, the Modified Brodsky tonsillar grading scale with a tongue depressor, and the Parikh adenoid grading system to rate adenotonsillar hypertrophy. Cohen's Kappa and weighted Kappa scores were used to assess interrater reliability for each of the four grading scales. The Spearman correlation was used to test the associations between each scale and OSA-18 scores, as well as Body Mass Index (BMI). RESULTS: 50 pediatric patients were included in this study (mean age 6.1years, range of 1year to 16years). The average BMI was 20. The average OSA-18 score was 61.7. The average Friedman palate position score was 1.34. Twelve percent of the patients had a Friedman palate position score≥3, which made traditional Brodsky grading of their tonsils impossible without a tongue depressor. All four scales showed strong agreement between the two raters. The weighted Kappa was 0.83 for the Modified Brodsky scale, 0.89 for the Brodsky scale, 0.94 for the Parikh scale to 0.98 for the Endoscopic scale (almost perfect agreement). The Endoscopic scale showed the most consistent agreement between the raters during the study. There was a moderate association between the Parikh adenoid grading system with OSA-18 scores (Spearman's ρ=0.58, p<0.001) compared to a low association of the tonsillar grading systems with OSA- 18 scores. None of the scales correlated with patient BMI. CONCLUSIONS: The proposed Endoscopic tonsillar grading system is as reliable of a method of grading tonsillar size as conventional grading systems. It offers the advantage of allowing for critical evaluation of the tonsils without any anatomic distortion which may occur with the use of a tongue blade. This new validated endoscopic grading system provides a tool for communicating the degree of airway obstruction at the level of the oropharynx regardless of Friedman palate position and may be used in future outcomes projects.

Are Otolaryngology Milestones Predictive of Otolaryngology Training Examination Scores?

IMPORTANCE:: Otolaryngology residents take the otolaryngology training examination (OTE) yearly to assess their fund of knowledge. The Accreditation Council for Graduate Medical Education (ACGME) milestone evaluations are also conducted semiannually. Accurate prediction of training examination performance allows identification of residents who are performing well and those who need targeted remediation. Prior studies in other specialties have attempted to use milestone evaluations to help predict in-training examination scores. OBJECTIVE:: In this study, we aim to identify whether ACGME milestone evaluation scores predict OTE performance. DESIGN:: Milestone ratings and OTE scores for residents at 2 US otolaryngology residency programs were collected. Multivariate analysis was achieved using linear mixed modeling. We considered a 2-tailed P value of ≤ .05 as statistically significant. SETTING:: Two US otolaryngology residency programs. PARTICIPANTS:: Forty-eight otolaryngology residents postgraduate years 2 to 5. RESULTS:: Otolaryngology training examination scores and ACGME milestone evaluations were collected from 48 residents from postgraduate year 2 to 5 between the years 2014 and 2017. One hundred eight OTE scores were available. Linear mixed-effect models were constructed, and after adjusting for level of training and OTE year, the total milestone rating made a negligible impact in estimating OTE percentage correct (ß = -.01, P = .9). Similarly, total milestone rating demonstrated a minimal contribution in approximating OTE national stanine score after adjusting for the level of training (ß = -.003, P = .9). CONCLUSIONS AND RELEVANCE:: In our study, ACGME milestone evaluations are not predictive of residents' OTE performance. What these milestone evaluation data mean and how they should be used continues to be an unanswered question. We should aim to identify the most effective applications of the milestone data collected yearly by otolaryngology programs.

Current Status of Radiology Training in Otolaryngology Residency Programs.

IMPORTANCE: Otolaryngologists use head and neck imaging on a daily basis. However, little is known about the training residents receive on the subject. Understanding the current training environment is important to identify areas of improvement for resident education. OBJECTIVE: To assess the current state of radiology training in otolaryngology residency programs. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional survey of 106 otolaryngology residency program directors involving multiple academic institutions. MAIN OUTCOMES AND MEASURES: The main outcome of this study is the number of US otolaryngology residency programs that have a radiology curriculum. Measured outcomes were obtained from an anonymous online survey and reported as a percent of total respondents. RESULTS: Program directors from 39 of 106 (37%) US otolaryngology residency training programs responded to the survey. Twenty-eight of 39 (71%) have a focused radiology curriculum; 18 of 28 (64%) conduct sessions on a monthly basis, 8 of 28 (29%) on a quarterly basis, and 2 of 28 (7%) on a weekly basis. The predominant format (20 of 27 programs [74%]) is a mix of case-based review of inpatient studies and standard lectures. The largest proportion of sessions were run by radiologists (13 of 28 [46%]), with a mix of radiology and otolaryngologists close behind (11 of 28 [39%]). Twenty-two of 39 residency programs (56%) have a dedicated radiology rotation within their educational curriculum, of which 17 of 22 (77%) occur in postgraduate year 1 (PGY-1) of training, 3 of 22 (14%) in PGY-3, and 2 of 22 (9%) in PGY-4. Rotation lengths range from 1 week to 3 months, with most running 1 to 4 weeks. Thirty-two of 38 of US program directors (84%) believe that a formal radiology curriculum would benefit their residents. Thirty-five of 39 believe that this should be a case-based review of images. Twenty-four of 38 believe this should be done on a monthly basis. Fifteen of 39 responding program directors (39%) believe the optimal time is during the PGY-3 of training, 36% (14 of 38) favor the PGY-2, and 23% (9 of 38) in PGY-1. CONCLUSIONS AND RELEVANCE: Despite no standardized requirements from the Accreditation Council for Graduate Medical Education (ACGME), 71% of US otolaryngology residency program directors who responded to our survey have a radiology curriculum. Most run didactics sessions at the desired frequency, setting, and format preferred by responding program directors. More than half of programs provide a dedicated radiology rotation, mostly during PGY-1, while identifying PGY-2 and PGY-3 as the optimal time for such an experience. These results highlight the need for a more thorough review of radiology education requirements from the ACGME to improve the training of otolaryngology residents across the country.

Choanal Atresia and Craniosynostosis: Development and Disease.

A number of textbooks, review articles, and case reports highlight the potential comorbidity of choanal atresia in craniosynostosis patients. However, the lack of a precise definition of choanal atresia within the current craniosynostosis literature and widely varying methods of detection and diagnosis have produced uncertainty regarding the true coincidence of these conditions. The authors review the anatomy and embryologic basis of the human choanae, provide an overview of choanal atresia, and analyze the available literature that links choanal atresia and craniosynostosis. Review of over 50 case reports that describe patients diagnosed with both conditions reveals inconsistent descriptions of choanal atresia and limited use of definitive diagnostic methodologies. The authors further present preliminary analysis of three-dimensional medical head computed tomographic scans of children diagnosed with craniosynostosis syndromes (e.g., Apert, Pfeiffer, Muenke, and Crouzon) and typically developing children and, although finding no evidence of choanal atresia, report the potentially reduced nasal airway volumes in children diagnosed with Apert and Pfeiffer syndromes. A recent study of the Fgfr2c Crouzon/Pfeiffer syndrome mouse model similarly found a significant reduction in nasal airway volumes in littermates carrying this FGFR2 mutation relative to unaffected littermates, without detection of choanal atresia. The significant correlation between specific craniosynostosis syndromes and reduced nasal airway volume in mouse models for craniosynostosis and human pediatric patients indicates comorbidity of choanal and nasopharyngeal dysmorphologies and craniosynostosis conditions. Genetic, developmental, and epidemiologic sources of these interactions are areas particularly worthy of further research.

Pediatric meningoencephaloceles and nasal obstruction: a case for endoscopic repair.

OBJECTIVES: Congenital anterior skull base defects with meningoencephaloceles causing nasal obstruction are rare clinical entities. Nasal obstruction in children may also be a symptom of multiple benign nasal and allergic disorders, making the initial diagnosis of meningoencephalocele difficult. Traditionally, skull base defects have been repaired via a bifrontal craniotomy approach. With the advent of pediatric endoscopic instrumentation, more of these lesions are accessible via an intranasal endoscopic approach, even in the infant population. However, owing to the rarity of these lesions, there is a paucity of data demonstrating successful adaptation of endoscopic skull base techniques to the pediatric population. METHODS: Retrospective review of two cases of endoscopic repair of anterior skull base defects with meningoencephaloceles at a tertiary care medical center. RESULTS: Two children, ages 15 months and 6 years, underwent successful endoscopic closure of their anterior skull base defects and resection of their intranasal meningoencephalocele with resolution of their nasal obstruction and cerebrospinal fluid rhinorrhea. CONCLUSIONS: Pediatric nasal meningoencephaloceles with anterior skull base defects can be successfully repaired via a transnasal endoscopic technique, thus minimizing the complications associated with craniotomy and frontal lobe retraction. Triplanar computed tomographic and magnetic resonance imaging is paramount to evaluate the caliber of the skull base defect, consistency of the herniated intracranial contents, as well as the presence of cerebral vasculature.

Predicting decannulation outcomes after distraction osteogenesis for syndromic micrognathia.

OBJECTIVES: To characterize the airway anatomy by upper endoscopy in children with syndromal mandibular hypoplasia and to determine whether predistraction endoscopy is predictive of the likelihood of successful outcomes after mandibular distraction. STUDY DESIGN: Retrospective chart review. METHODS: Assessment of the upper airway by subsites was qualitatively extrapolated into a devised 4-point scale. Upper airways were characterized and evaluated in patients on the basis of decannulation outcomes after distraction. RESULTS: Of the 20 patients, 12 were decannulated, and 6 remain tracheostomy dependent. The average compiled preoperative airway obstruction scores in decannulated patients (2.25) compared with those who failed decannulation (2.36) was not statistically significant (P =.291). A significant change after distraction was noted only at the levels of the oropharynx and supraglottis (P <.001). The average airway scores at these subsites in decannulated patients improved from a mean of 3.46 to 2.17 (P =.002). In patients who failed decannulation, the pre- and postdistraction scores also improved from 3.92 to 2.50 (P =.026). Analysis of the average postdistraction airway scores in decannulated patients (2.17) compared with failures (2.5) failed to reveal a significant difference (P =.375), suggesting that some patients remain tracheostomy dependent despite adequate mandibular expansion. Preoperative airway scores in the two groups were statistically equivocal and, therefore, not predictive of the likelihood of decannulation. CONCLUSIONS: Preoperative airway endoscopy alone is not predictive of the likelihood of successful decannulation after distraction osteogenesis. Comparison of the airway patency after distraction revealed statistically equivocal airway caliber, suggesting that some children fail to advance to decannulation despite adequate mandibular distraction.

Randomized, controlled, multisite study of intracapsular tonsillectomy using low-temperature plasma excision.

OBJECTIVE: To determine the efficacy of intracapsular tonsillectomy using low-temperature plasma excision for improving the quality of the postoperative experience and for treating obstructive symptoms through 12 months postoperatively. DESIGN: Prospective, randomized, controlled, single-blind study. SETTING: Multiple private or institutional otolaryngology clinics. PATIENTS: Fifty-five children (aged 3-12 years) with obstructive tonsillar hypertrophy. INTERVENTION: Patients were randomly assigned and blinded to undergo either intracapsular tonsillectomy using low-temperature plasma excision (n = 27) or total tonsillectomy using conventional electrosurgery (n = 28). MAIN OUTCOME MEASURES: Operative data, 14-day recovery variables, and obstructive symptoms were prospectively collected through 12 months. RESULTS: During the first 14 days, significantly fewer children in the intracapsular group reported nausea (P = .01) or lost weight (P = .003). The intracapsular group had a significantly faster resolution of pain (P = .01), had an earlier return to a normal diet (P = .004), ceased taking pain medication sooner (P = .002), and returned to normal activity sooner (P = .04). Postoperatively, the intracapsular group had more residual tonsil tissue than the total tonsillectomy group (P = .002 for the 3- and 12-month visits). However, the incidence of recurring obstructive symptoms, pharyngitis, and antibiotic use was similar in both treatment groups during the 12 months. CONCLUSIONS: Postoperative morbidity normally associated with traditional (total) tonsillectomy was significantly reduced after intracapsular tonsillectomy using low-temperature plasma excision. The residual tonsillar tissue associated with this technique was of no clinical consequence.

Incidence of complications for subtotal ionized field ablation of the tonsils.

OBJECTIVE: Ionized field ablation, or coblation-assisted subtotal tonsillectomy, has been described as a new alternative technique for the management of tonsillar disease. This study was designed to review the incidence of complications in patients undergoing this procedure. STUDY DESIGN: A 10-surgeon retrospective chart review of the intraoperative and postoperative complications of patients undergoing ionized field ablation subtotal removal of tonsils was performed. Postoperative pain, dietary restrictions, and activity level were not reviewed. RESULTS: Of the 528 patients who underwent ionized field ablation of their tonsils, the incidence of intraoperative and postoperative complications compared favorably with those reported in retrospective studies in the literature for traditional subcapsular tonsillectomy. Significant postoperative bleeding occurred in less than 1%, and only 1 patient required surgical control of bleeding in the operating room. No patients required transfusions of any blood products. CONCLUSIONS: Ionized field ablation subtotal tonsillectomy may offer an alternative to traditional subcapsular tonsillar surgery with a decreased incidence of postoperative complications. Further study is necessary to establish the complication rate of this technique.

Clinical characteristics of New York City children who received tympanostomy tubes in 2002.

OBJECTIVE: Tympanostomy tube insertion is the most common procedure that requires general anesthesia for children in the United States. We report on the clinical characteristics of a cohort of New York City children who received tympanostomy tubes in 2002. METHODS: This retrospective cohort study included all 1046 children who received tubes in 2002 in any of 5 New York City area hospitals. We analyzed clinical data for all 682 (65%) children for whom we were able to abstract data for the preceding year from all of 3 sources: hospital, pediatrician, and otolaryngologist medical charts. RESULTS: Mean age was 3.8 years, 57% were male, and 74% had private insurance. More than 25% of children had received tubes previously. The stated reason for surgery was otitis media with effusion for 60.4% of children, recurrent acute otitis media for 20.7%, and eustachian tube dysfunction for 10.6%. Children with recurrent acute otitis media averaged 3.1 +/- 0.2 episodes (median: 3.0) in the previous year; those with otitis media with effusion averaged effusions that were 29 +/- 1.7 days long (median: 16 days) at surgery. Twenty-five percent of children had bilateral effusions of >42 days' duration at surgery. Despite a clinical practice guideline for otitis media with effusion that recommends withholding tympanostomy tubes for otherwise healthy children until a bilateral effusion is at least 3 to 4 months old, 50% of children had surgery without having had 3 months of effusion cumulatively during the year before surgery. CONCLUSIONS: The clinical characteristics of children who received tympanostomy tubes varied widely. Many children with otitis media with effusion had shorter durations of effusions than are generally recommended before surgery. The extent of variation in treating this familiar condition with limited treatment options suggests both the importance and the difficulty of managing common practice in accordance with clinical practice guidelines.

Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort.

OBJECTIVES: To compare tympanostomy tube insertion for children with otitis media in 2002 with the recommendations of two sets of expert guidelines. DESIGN: Retrospective cohort study. SETTING: New York metropolitan area practices associated with five diverse hospitals. PARTICIPANTS: 682 of 1046 children who received tympanostomy tubes in the five hospitals for whom charts from the hospital, primary care physician, and otolaryngologist could be accessed. RESULTS: The mean age was 3.8 years. On average, children with acute otitis media had fewer than four infections in the year before surgery. Children with otitis media with effusion had less than 30 consecutive days of effusion at the time of surgery. Concordance with recommendations was very low: 30.3% (n=207) of all tympanostomies were concordant with the explicit criteria developed for this study and 7.5% (n=13) with the 1994 guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology-Head and Neck Surgery. Children who had previously had tympanostomy tube surgery, who were having a concomitant procedure, or who had "at risk conditions" were more likely to be discordant. CONCLUSIONS: A significant majority of tympanostomy tube insertions in the largest and most populous metropolitan area in the United States were inappropriate according to the explicit criteria and not recommended according to both guidelines. Regardless of whether current practice represents a substantial overuse of surgery or the guidelines are overly restrictive, the persistent discrepancy between guidelines and practice cannot be good for children or for people interested in improving their health care.