Americans with disabilities act cases initiated by individuals with cochlear implants in the United States.

OBJECTIVE: The Americans with Disabilities Act (ADA) is a federal law that forbids discrimination against individuals with certain disabilities, including hearing impairment. This study aimed to determine the nature of ADA discrimination complaints in individuals with cochlear implants. METHODS: A search for court decisions containing the terms "cochlear implant" and ("Americans with Disabilities Act" or "ADA") from 1985 to 2021 was performed with the Westlaw Campus Research legal database. Cases were included and analyzed if at least one of the plaintiffs had a cochlear implant and was claiming discrimination related to their hearing impairment based on the ADA. RESULTS: 24 cases initiated between 2003 and 2021 in 19 US states were identified based on inclusion criteria. The highest number of cases occurred in California (N = 4, 16.7 %). The alleged discrimination most frequently took place at a K-12 school (N = 9, 37.5 %), workplace (N = 7, 29.2 %), or during an encounter with police/correctional officers (N = 4, 16.7 %). Fourteen (58.3 %) cases involved complaints under Title II (Public Services) of the ADA. Seven (29.2 %) involved Title I (Employment) and 4 (16.7 %) involved Title III (Public Accommodations). Summary judgment was given in favor of the defendant or the case was dismissed entirely in 16 (66.7 %) of the cases. CONCLUSION: Patients with cochlear implants are still at risk of discrimination because of their disability. Cochlear implantees, school employees, workplace supervisors, and law enforcement personnel can benefit from ADA education.

Second opinions: Do otolaryngologist demographics matter?

OBJECTIVE: Pediatric patients and their caregivers may receive information from their primary care physician (PCP) that does not match current American Academy of Otolaryngology (AAO) guidelines. The purpose of this study is to evaluate the frequency of parents deciding to seek a second opinion based on the demographics of pediatric otolaryngologists who deliver guideline supported advice, contrary to advice from their child's PCP. METHODS: A survey was distributed to parents in a pediatric otolaryngology clinic between June 2021 and July 2023. Demographics included parent age category, gender, race, and age of youngest child. The survey included a scenario depicting recurrent otitis media with clear ears and a suggestion to defer tympanostomy tube insertion per AAO guidelines after their child's PCP recommended tubes. Thirteen variations of otolaryngologist photos were used in the case, including a control case with no picture. RESULTS: Of the 658 participants, 460 (69.9 %) were female. 551 (83.7 %) were aged 30-49 years, 70 (10.7 %) were younger, and 37 (5.6 %) were older. 545 (82.8 %) were White, 30 (4.6 %) were Black, 20 (3.0 %) were Asian, and 31 (4.7 %) were Hispanic. 39.9 % of parents would seek a second opinion if an otolaryngologist recommended watchful waiting following evaluation of their child's otitis media. Participants given the control case were 2.23 times more likely to listen to the otolaryngologist's advice (p = .025). If a picture was provided, respondents were more likely to follow advice given if the pictured otolaryngologist was female (p = .025, OR = 1.47) or Asian (p = .042, OR = 1.53). CONCLUSION: In this group, there is evidence that physician race and gender may influence decision making when considering action versus monitoring in the context of recurrent otitis media.

Does resident involvement in tonsillectomy affect outcomes?

OBJECTIVE: Tonsillectomy is essentially a solo surgery with a well-described complication profile. It may serve as a good benchmark to evaluate the resident-as-surgeon. This study examined complications such as post-tonsillectomy bleeding in children undergoing tonsillectomy by attending surgeons (AS) or pediatric otolaryngologist-supervised residents. METHODS: Charts were reviewed of all children aged 12 and under who had tonsillectomy +/- adenoidectomy at a children's hospital between Jan 2019 and Dec 2020. Patient age, gender, BMI, indication for surgery, surgical technique, presence of a resident surgeon, primary bleeding, secondary bleeding, treatment of bleeding, other Emergency Room (ER) visits, and clinic phone calls were recorded. Binary logistic regression was performed. RESULTS: 2051 total children (1092 (53.2 %) males and 956 (46.6 %) females) with a mean age of 6.1 years (95 % CI 6.0-6.2) were included. 1910 (93.0 %) underwent surgery for tonsillar obstruction. 1557 (75.9 %) underwent monopolar cautery tonsillectomy. 661 (32.2 %) had a resident surgeon. 274 (13.4 %) had a related ER visit within 15 days. 18 (0.9 %) had a primary bleed and 155 (7.6 %) had a secondary bleed. Binary logistic regression showed that significant predictors of postoperative ER visits were patient age (OR = 1.101, 95 % CI = 1.050-1.154, p < .001) and resident involvement (OR = 0.585, 95 % CI = 0.429-,797, p < .001). Only age was associated with overall postoperative bleeding incidence (OR = 1.131, 95 % CI = 1.068-1.197, p < .001), as well as secondary bleeding (OR = 1.128, 95 % CI = 1.063-1.197, p < .001). There were no significant predictors of primary bleeding. CONCLUSION: Resident involvement in pediatric tonsillectomy is associated with decreased postoperative ER utilization and does not appear to increase common postoperative complications including bleeding and dehydration.

An Analysis of Postoperative Complications in Medialization Thyroplasty: NSQIP Data.

INTRODUCTION: Medialization thyroplasty is a procedure indicated for treatment of impaired vocal fold movement. The purpose of this study was to identify variables associated with length of hospital stay (LOS), reoperation, and readmission in patients who underwent a medialization thyroplasty procedure for unilateral vocal cord paralysis. METHODS: Adults who underwent unilateral medialization thyroplasty were identified using the 2017 to 2019 NSQIP databases via Current Procedural Terminology code 31591. Data collected included patient demographics, comorbidities, preoperative labs, American Society of Anesthesiologists classification, inpatient status, operative length, and complications. Univariate and multivariate logistic regression were used to analyze effects on total LOS, reoperation, and readmission. RESULTS: 320 patients were identified, with a mean age of 61 years (95% Cl 59.4-62.7) and a female-to-male ratio of 1.1:1. Forty-two (13.1%) patients reported dyspnea as a preoperative symptom. Seven patients (2.2%) reported postoperative complications, 2 with multiple complications: 2 surgical site infections, 2 pneumonias, 2 unplanned intubations, 2 myocardial infarctions, 1 septic shock, 1 cardiac arrest, 1 ventilator use (>48 h), and 1 acute renal failure. Fifty-one (15.9%) were inpatient procedures, with a mean LOS of 1.43 days (95% CI 0.92-1.94). Preoperative functional status and bilirubin were significantly associated with longer LOS (p < 0.001). There were 6 (1.9%) readmissions and 2 (0.6%) reoperations. In univariate analysis, dyspnea varied with reoperation which is important to note in this patient population with glottic insufficiency. CONCLUSION: Medialization thyroplasty is a procedure with a low risk of mortality. However, preexisting patient comorbidities are associated with an increased risk of postoperative complications and an increased length of stay.

Laryngeal surgery for congenital laryngomalacia: NSQIP-P analysis of complications.

OBJECTIVE: To evaluate predictors of complications in children with congenital laryngomalacia who underwent laryngeal surgery. METHODS: Multi-institutional retrospective analysis using the American College of Surgeons-NSQIP-P database (2014-2019). CPT code 31541 and ICD-10 code Q35.1 (congenital laryngomalacia) were used to select patients <18 years. Variable predictors included demographics and medical co-morbidities. Main outcomes assessed included total length of hospital stay (LOS), reintubation, reoperation and readmission. RESULTS: 1092 children were identified, 450 (41.1%) females and 642 (58.6%) males, with a mean age of 1.1 years (95% CI 1.0-1.2). Mean LOS was 3.9 days (95% CI 3.3-4.6). Sixteen (1.5%) were reintubated, 30 (2.7%) were readmitted, and 18 (1.6%) were reoperated within 30 days. Thirty-one (2.8%) were still in hospital at 30 days. Regression analysis revealed an increase in LOS for several groups; the largest effect was seen for patients with preoperative ventilator dependence, admission within the first 28 days of life, and those who were discharged to other healthcare facilities (p < .001). Preoperative co-morbidities significantly associated with a higher frequency of reintubation included ventilator dependence (p = .003), history of prematurity (p = .016) and chronic lung disease (p = .041). Children undergoing surgery in the first 28 days of life were 10.16 times as likely to return to the OR for a related reason within 30 days than older children (p = .038). CONCLUSION: Complications were rare after laryngeal surgery with a postop diagnosis of laryngomalacia. Recognizing pertinent clinical factors can help with risk assessment and management.

Characterization of litigation after tonsillectomy in the United States.

BACKGROUND: Tonsillectomy is a common procedure performed for both adults and children. When unfavorable outcomes occur during perioperative events, patients may seek compensation through medical malpractice or medical negligence litigation. An understanding of these cases can help physicians and involved health care providers avoid risk and improve patient satisfaction. The aims of this study were to identify reasons for litigation after tonsillectomy and to examine outcomes of tonsillectomy-related litigation in the United States. METHODS: All available court decisions associated with medical malpractice and negligence after tonsillectomy in the Westlaw Campus Research legal database were reviewed. The plaintiff' relationship to the patient, patient characteristics, state where the tonsillectomy took place, specialty of the defendant(s), allegations, and adjudicated case outcomes were obtained from case documents and analyzed. RESULTS: Forty-two relevant judicial opinions written between 1986 and 2020 in 24 states were included. Twenty-two (52.4 %) of the cases involved female patients, and 24 (57.1 %) involved pediatric patients. Otolaryngology, anesthesiology, primary care, emergency medicine, orthodontics, and pharmacy were the disciplines involved in the negligence claims. Claims involved postoperative management in 18 (42.9 %) of the cases and intraoperative misadventure in 17 (40.5 %) of the cases. Six (14.3 %) of the 42 patients experienced an anesthesia complication, and 11 (26.2 %) experienced a surgical complication. Eleven (26.2 %) patients experienced postoperative bleeding. All cases involved postoperative concerns, and death occurred in 14 (33.3 %) of the patients. Overall, 21 (45.7 %) of the rulings were for the defendant. CONCLUSIONS: Postoperative management and intraoperative misadventure are commonly cited reasons for legal action after tonsillectomy procedures in the United States. All litigation surrounding tonsillectomy arose if concerns were present postoperatively. Thorough communication and attentive postoperative management are critical in order to avoid complications and patient injury, including death, associated with tonsillectomy.

Maxillofacial trauma in children: Association between age and mandibular fracture site.

PURPOSE: To describe the association between age and location of facial fractures in the pediatric population. MATERIALS AND METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project (HCUP) from the 2016 Kids' Inpatient Database (KID) in children aged ≤18 years was conducted. International Statistical Classification of Diseases, 10th Revision (ICD-10) codes were used to extract facial fracture diagnoses. Logistic regression was used to evaluate and compare the contribution of various demographic factors among patients who had different types of facial fractures. RESULTS: A total of 5568 admitted patients were identified who sustained any type of facial bone fracture. Patients who had facial fractures were significantly more likely to be male (68.2% versus 31.8%; p<0.001) and were older with a mean age of 12.86 years (95% confidence interval [CI]: 12.72-12.99). Approximately one-third of patients with a facial fracture had a concomitant skull base or vault fracture. Maxillary fractures were seen in 30.9% of the cohort while mandibular fractures occurred in 36.9% of patients. The most common mandibular fracture site was the symphysis (N=574, 27.9% of all mandibular fractures). Condylar fractures were more common in younger children while angle fractures were more common in teenagers. Regression analysis found that age was the only significant contributor to the presence of a mandibular fracture (ß=0.027, p<0.001) and race was the only significant contributor to maxillary fractures (ß=-0.090, p<0.001). CONCLUSIONS: Facial fractures increase in frequency with increasing age in children. The mandible was the most commonly fractured facial bone, with an age-related pattern in fracture location.

Characterization of Medical Malpractice Litigation After Rhinoplasty in the United States.

BACKGROUND: When complications following rhinoplasty occur or when the desired outcome is not achieved, patients may seek litigation on the premise that there was a violation in the standard of care. Knowledge of malpractice claims can inform rhinoplasty surgeons on how to minimize risk of future litigation as well as improve patient satisfaction. OBJECTIVES: The aims of this study were to identify motives for seeking medical malpractice litigation after rhinoplasty, and to examine outcomes of malpractice litigation after rhinoplasty in the United States. METHODS: The Westlaw legal database was reviewed for all available court decisions related to malpractice after rhinoplasty. Data collected and analyzed included plaintiff gender, location, specialty of defendant(s), plaintiff allegation, and adjudicated case outcomes. RESULTS: Twenty-three cases were identified between 1960 and 2018, located in 12 US states; 70% of the plaintiffs were female. Otolaryngologists were cited in 11 cases, whereas 12 cases involved a plastic surgeon. All cases alleged negligence. Cases involved "technical" errors (69.6%), "unsatisfactory" outcomes (39.1%), inadequate follow-up or aftercare (30.4%), issues with the informed consent process (21.7%), unexpectedly extensive surgery (8.7%), improper medication administration (4.3%), and failure to recognize symptoms (4.3%). Twenty of the 23 adjudicated cases (86.9%) were ruled in favor of the surgeon. The main contributing factor in cases alleging malpractice was poor aesthetic outcome/disfigurement (60.7%). CONCLUSIONS: Malpractice litigation after rhinoplasty favored the surgeon in the majority of the adjudicated cases reviewed. The principal reason for litigating was dissatisfaction with aesthetic outcomes. Rhinoplasty surgeons may mitigate possible litigation by developing a positive doctor-patient relationship, clearly understanding the patient's surgical expectations, and obtaining detailed informed consent while maintaining frequent and caring communication with the patient.

Epiglottopexy with or without aryepiglottic fold division: Comparing outcomes in the treatment of pediatric obstructive sleep apnea.

OBJECTIVE: To determine the success of epiglottopexy with or without aryepiglottic fold division for treatment of patients with obstructive sleep apnea (OSA) with epiglottic obstruction. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic hospital. METHODS: Children with sleep study proven OSA who underwent epiglottopexy with or without aryepiglottic fold division from January 2013 to June 2017 were included. The epiglottis contributed to airway obstruction in all patients. Pre- and post-operative apnea-hypopnea index (AHI) were compared. Age, sex, body mass index (BMI) z-score and post-operative complications were also evaluated. Success was defined by post-operative AHI < 5.0 with resolution of OSA symptoms or AHI ≤ 1.0 events per hour. RESULTS: Twenty-eight children (age 2-17 years) underwent either epiglottopexy with division of aryepiglottic folds (N = 18) or epiglottopexy alone (N = 10). There was no difference in preoperative age, AHI, or BMI between the groups. Post-operative AHI was lower in the group undergoing epiglottopexy alone (AHI 1.50) versus with aryepiglottic fold division (AHI 3.17) (P < 0.05). No difference was found in mean AHI improvement between the two groups. For the entire cohort, success criteria were met by 53.6% of patients for AHI < 5.0 without symptoms and 25.0% of patients for AHI ≤ 1.0, with no difference in surgical success between procedures (P > 0.05). CONCLUSIONS: Children undergoing epiglottopexy with division of aryepiglottic folds for laryngeal collapse were as likely to have improved OSA symptoms as children undergoing epiglottopexy alone.

Morbidity after tonsillectomy in children with autism spectrum disorders.

OBJECTIVES: As the incidence of autism spectrum disorder (ASD) increases, otolaryngologists are more likely to encounter patients from this population during tonsillectomy. The purpose of this study was to examine whether outcomes differ between pediatric patients with and without ASD in a national cohort of children undergoing tonsillectomy. Understanding these differences may be used to inform future approaches to improve clinical outcomes and healthcare costs. METHODS: Data for this study were obtained from the Kids Inpatient Database (KID) of the Healthcare Cost Utilization Project. We studied pediatric patients who underwent tonsillectomy during 2003, 2006, 2009, and 2012. Tonsillectomy was identified using ICD-9-CM diagnosis codes 28.2 (tonsillectomy without adenoidectomy) and 28.3 (tonsillectomy with adenoidectomy). ASD was identified using ICD-9-CM diagnosis code 299 (autism). Outcomes including complications, length of hospital stay, and total hospitalization costs. Analyses were performed using multivariable models. Propensity score matching was used to control for covariate imbalance between patients with and without ASD. RESULTS: In our sample of 27,040 patients, 322 (1.2%) had a diagnosis of ASD. After controlling for potential confounders, multivariable modeling suggested patients with ASD had a shorter LOS of 0.50 days (p < 0.0001), were less likely to experience complications (odds ratio 0.57, p = 0.001), and had lower associated costs of $1308 less (p < 0.0001). Propensity score matching confirmed the findings of the multivariable modeling. CONCLUSION: Although ASD alone does not appear to confer additional costs or morbidity, differences between children with and without ASD suggest the need for providers to address patients with ASD uniquely.

Association of ibuprofen use with post-tonsillectomy bleeding in older children.

OBJECTIVE: Evaluate post-tonsillectomy outcomes in children discharged with ibuprofen versus those without. METHODS: This was a retrospective review of children who underwent tonsillectomy ±â€¯adenoidectomy from 2012 to 2016 at a tertiary care children's hospital. Main outcome measures included bleed rates, ER visits, and nurse phone calls. RESULTS: Seven hundred and seventy-three patients were included; 504 had ibuprofen at discharge (ID) and 269 did not (NID). There were significant differences in mean age, 6.7 years in the ID group years versus 8.6 for the NID group (P < 0.001). Indication for surgery was sleep apnea in 70.5% of ID patients and 44.0% of NID patients (P < 0.001). Post-tonsillectomy bleeds occurred in 8.7% in the ID group and 5.9% of the NID group (P = 0.168). Other outcome measures revealed no significant differences between the two groups. There was no significant difference in the outcome measures between patients with sleep apnea or recurrent tonsillitis. Age was important; 12.1% of children 9-18 years versus 4.8% in children 3.1-6 years (P = 0.006) had post-tonsillectomy bleeding. For children 9-18 years old, 16.7% in the ID group bled versus 7.5% in the NID group (P = 0.039). Logistical regression revealed that age contributed to post-op bleeding, and ibuprofen contributed to number of ER visits. CONCLUSION: Ibuprofen is associated with significantly elevated post-tonsillectomy bleeding in older children, further research is needed and other analgesics should be considered.

Sleep study indices and early post-tonsillectomy outcomes.

OBJECTIVES: To investigate the relationships between preoperative sleep study findings of children undergoing adenotonsillectomy anesthesia emergence time, recovery room time, and length of stay. STUDY DESIGN: Retrospective case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: All children aged 1-17 years who had undergone adenotonsillectomy between 2013 and 2016 were included. Apnea-hypopnea index (AHI), central apnea index (CAI), oxygen saturation nadir, and end-tidal carbon dioxide were compared with the in-operating room times, recovery room time, and length of stay. RESULTS: Three hundred and fourteen patients with a mean age of 6.67 (95% CI 6.25-7.09) years were included. Mean AHI was 9.14 (95% CI 7.33-10.95), mean CI was 0.88 (95% CI 0.50-1.26), mean oxygen saturation nadir was 82.9% (95% CI 81.41-84.32), mean end-tidal carbon dioxide was 50.3 (95% CI 49.39-51.15). Mean emergence time was 16 min (95% CI 15:11-17:13 min), recovery room time was 66 min (95% CI 1:00-1:11 h), and length of stay was 25.7 h (95% CI 21:43-30:00 h). When controlled for age, gender and BMI, linear regression showed that children with a higher AHI had a significantly longer operating room and operative times (p < 0.001), emergence time (p < 0.001) and length of stay (p = 0.01). CAI was related to shorter total operating room times (p = 0.03). AHI, oxygen saturation nadir, CAI and end-tidal carbon dioxide were not associated with recovery room time. CONCLUSION: Preoperative sleep study indices are associated with longer in-operating room times and length of stay, and can be useful in planning operating room and hospital flow.

Common causes of congenital stridor in infants.

Stridor is a high-pitched respiratory sound that signals upper airway obstruction. It can be encountered by clinicians in a variety of clinical settings and requires a team-based, interdisciplinary approach. Early recognition is crucial, as the differential diagnosis can be broad, and causes range from benign to life-threatening. This article reviews the most commonly encountered causes of chronic congenital stridor in infants, focusing on the diagnostic approach, pathophysiology, clinical presentation, and management strategies.

Age-related outcomes after pediatric branchial cleft cyst excision via NSQIP-P.

OBJECTIVE: Branchial cleft cysts present at varying ages; sometimes excision is delayed because of concern about operating in small children. Our goal was to determine if outcomes and complications differed among pediatric age groups. STUDY DESIGN: Retrospective, cross-sectional. SETTING: American College of Surgeons' National Surgical Quality Improvement Pediatric database. METHODS: Patients who underwent a branchial cleft cyst excision between 2016 and 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database. Patients with CPT code 42,815: 'excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx' as their primary procedure were included. Variables of interest included patient demographics, comorbidities, pre-operative risk factors and complications. RESULTS: 2267 patients with median age of 3.9 (IQR: 7.4, range: 0.04-17.9) years were included. The most common pre-operative risk factors were 149 (7 %) patients with prematurity, 136 (6 %) with developmental delay, 135 (6 %) with congenital malformation, and 128 (6 %) with open wound or wound infection. 68 (3 %) patients experienced at least one post-operative complication, with 73 post-operative complications documented in total. Surgical site infections were the most common complications with 49 (67.1 %) superficial infections, 11 (15.1 %) deep infections, and 4 (5.5 %) organ/space infections. Surgical site infections were the most common reason for related readmission. Duration of anesthesia and operative time increased significantly as patient age increased (p < .001 for both). There was no significant correlation between age and complication incidence. CONCLUSION: Branchial cleft cyst excision is a relatively safe operation with a low complication rate, even in young pediatric populations.

Do Children with Previous COVID Infection Have Hyposmia?

OBJECTIVE: Our goal was to see if children with a history of COVID infection had subclinical hyposmia. METHODS: Consecutive patients at a pediatric otolaryngology clinic aged 5-17 years were recruited. Demographics including gender, race, use of nasal topical medications (NTM), previous nasal surgery including adenoidectomy (NSA), and previous COVID-19 infection were collected. Each child performed a test of their sense of smell using the Pediatric Smell Wheel (PSW, Sensonics Intl, USA) under the direct supervision and scores were compared. RESULTS: 260 children were included; mean age 10.1 years (95% CI 9.7-10.5), 128 (49.2%) female and 132 (50.8%) male. 65 (25%) used steroid nasal sprays, 100 (38.5%) had undergone adenoidectomy, and 36 (13.8%) had other nasal surgery. 120 (46.2%) had a previous COVID-19 infection. The COVID+ and COVID- groups were the same for age, gender, race, use of NTMs, and previous NSA (p > 0.05). Mean PSW score was 7.8 (95% CI 7.6-8.0), median of 8, ranging from 2 to 11. The mean PSW score was 8.0 for the COVID- group and 7.6 for the COVID+ group (p = 0.005). There was no significant difference in total PSW scores based on gender, race, use of NTMs, previous NSA. Linear regression showed previous COVID infection was significantly negatively associated with total PSW score (Beta -0.636, p = 0.006) with age significantly positively associated (Beta 0.122, p < 0.001). CONCLUSION: Children with a history of COVID infection performed slightly worse when identifying odors than children without a COVID history. More study into the rates of pediatric anosmia related to COVID infection is needed. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:901-906, 2024.

Post-Tonsillectomy Bleeding and Analgesic Use Before and After the FDA Boxed Warning Against Codeine.

OBJECTIVE: The aim of this study was to investigate the trends in post-tonsillectomy analgesic utility and incidence of post-tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy. METHODS: A retrospective study was conducted using TriNetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD-10 codes were used to identify children who experienced post-tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013. RESULTS: Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post-tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone. CONCLUSION: Analgesics used post-tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post-tonsillectomy bleeding. LEVEL OF EVIDENCE: IV Laryngoscope, 2024.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea.

STUDY OBJECTIVES: Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery. METHODS: A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes. RESULTS: A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005). CONCLUSIONS: This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%). CITATION: Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Tracheotomy in children older than two years: Analysis of discharge trends from 2015 to 2020.

OBJECTIVE: In light of increasingly complex patients being discharged with tracheostomies, we aimed to evaluate discharge trends over time in pediatric tracheotomy patients. We hypothesized that there would be delays in discharge from increased focus on preparing families for at-home care of critically ill pediatric patients. MATERIALS AND METHODS: We conducted a cross-sectional analysis of pediatric patients who underwent tracheotomy (Current Procedural Terminology code 31600) between 2015 and 2020 using the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIP-P). Univariate and multivariate regression analyses were performed to assess patient demographics, comorbidities, perioperative factors, postoperative complications, and discharge information. Data were analyzed using Stata 15. RESULTS: A total of 1552 patients were identified. There were 868 (56 %) males and 684 (44 %) females with a mean age of 7.3 ± 5.7 years. At least one comorbidity was seen in 1282 (83 %) patients, with 907 (58 %) having impaired cognitive status or developmental delay. Thirty-six (2.3 %) patients experienced mortality within 30 days, while 710 (46 %) were still in the hospital at 30 days. The odds of remaining in the hospital after 30 days were positively correlated with the year (p=.001). Other factors associated with an increased likelihood of remaining in the hospital after 30 days included younger patient age (p <.001), any complication (p <.001), and a higher American Society of Anesthesiologists classification (p <.001). CONCLUSION: As years have progressed, fewer children were discharged from the hospital after 30 days following tracheotomy. Further research may identify socioeconomic factors contributing to the increasing length of hospital stays associated with a need for tracheotomy.

Are children with unilateral sensorineural hearing loss receiving cochlear implants?

INTRODUCTION: The US Food and Drug Administration (FDA) granted its first approval for cochlear implants (CI) in children with bilateral sensorineural hearing loss (SNHL) in 1990. In 2019, the FDA expanded CI indications to include children with unilateral SNHL. OBJECTIVE: The aim of this study was to assess the prevalence of children with unilateral SNHL in the population of new pediatric CI recipients between 2012 and 2021. METHODS: A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Pediatric database examined patients under 18 years of age with bilateral or unilateral SNHL who underwent CI between 2012 and 2021. Current Procedural Terminology code 69930 identified patients with 'cochlear device implantation, with or without mastoidectomy.' The percentage of children undergoing CI for unilateral versus bilateral SNHL during the study period was calculated and subjected to statistical analysis. RESULTS: 9863 pediatric CI patients were included with a mean age of 5.1 (95 % CI 5.1-5.2) years at the time of implantation. 7.5 % (N = 739) of patients had unilateral SNHL and 92.5 % (N = 9124) had bilateral SNHL. Children with bilateral SNHL undergoing CI were significantly younger (5.0 years versus 6.9 years for those with unilateral SNHL, p < .001). There was a statistically significant difference in the percentage of children receiving CI for unilateral versus bilateral SNHL (3.3 % in 2012 to 14.3 % in 2021, p < .001) before and after the FDA changes. CONCLUSIONS: The proportion of CIs placed for unilateral SNHL has increased annually even before 2019 when the FDA expanded its CI indications to include children with unilateral SNHL for the first time.

Acute Intratonsillar Abscess in an Adult: A Case Report and Literature Review.

Intratonsillar abscess (ITA) is rarely reported. Here, we present an uncommon case of acute ITA in an adult, discuss the evaluation and treatment plan, and review the ITA literature.  The abscess reported in the present study was diagnosed through a combination of clinical findings and computed tomography imaging, and treatment included drainage, intravenous (IV) clindamycin, and IV dexamethasone. The literature reports 72 ITA cases with specified treatments: 21 (29.2%) in adults, 19 (26.4%) in children, and 32 (44.4%) in patients of unspecified ages. Among them, 25 (34.7%) responded to antibiotics alone, 11 (15.3%) to needle aspiration and antibiotics, and 36 (50.0%) needed further intervention. Based on the presented case and literature review, we suggest the use of IV antibiotics with needle aspiration as the primary treatment for acute ITA. Incision and drainage (I&D) with antibiotics should be reserved for cases unresponsive to initial measures, and tonsillectomy is recommended for recurrent post-I&D cases.