Gender inequities in ENT: Insights from women speakers at American Head and Neck Society meetings.

BACKGROUND: Gender inequity exists across national speakers at American Head and Neck Society (AHNS) conferences. This qualitative study explores potential causes of this disparity by surveying women invited to speak at AHNS between 2007 and 2019 and examining advice, resources, and meaningful actions from "those who made it." METHODS: An internet search for contact information for the 131 female AHNS was performed. An electronic survey was distributed via email. Deidentified qualitative responses were coded by two independent researchers into themes. Themes characterize barriers that female head and neck (HN) surgeons face and describe ways to mitigate the impact of these for the next generation. RESULTS: Contact information for 73/131 female AHNS speakers was obtained via internet search. Email responses were received from 22/73 (30%). Of those, respondents specialized in otolaryngology (n = 17), medical oncology (n = 2), palliative care (n = 1), vascular surgery (n = 1), and thoracic surgical oncology (n = 1). All speakers worked in academic settings at varying stages of their career with 81.8% (18/22) of respondents fellowship-trained (primarily HN surgery). Concerns about gender disparity in ENT were grouped into the following themes: (1) recruiting women to ENT, (2) removing barriers to career advancement, (3) diversifying ENT's national presence, and (4) improving the broader culture of HN surgery. Respondents emphasized a need for diversifying leadership, early exposure to otolaryngology in medical school, and connecting students with female role models. Outstanding research, involvement at annual meetings, and committee membership were consistently deemed important for establishing a national presence in the field. Implicit bias, "boys clubs" culture, and burdensome childcare responsibilities were described as barriers to career advancement. CONCLUSIONS: While encouraging more women to enter otolaryngology residencies, increasing the number female role models and establishing strong mentoring networks may help to mitigate challenges. Meaningful progress requires the efforts of both male and female allies within the specialty. Simple solutions, such as educating on implicit bias, removing demographics from applications, and eliminating hidden penalties for maternity leave, may help improve diversity and mitigate barriers to career progression for underrepresented groups within ENT.

Establishing a role for the oral microbiome in infectious complications following major oral cavity cancer surgery.

Surgery forms the backbone of treatment for most locoregional or advanced oral cavity squamous cell carcinoma. Unfortunately, infectious complications (including orocutaneous fistulas) are common following such extensive surgery and can afflict over half of patients. These complications can lead to delays in adjuvant treatment, prolonged hospitalization, reconstructive failure, and decreased quality of life. The frequency and morbidity associated with infectious complications has led to the search for pre-disposing risk factors; and, several have been identified, including both patient (e.g. diabetes) and surgical (e.g. operative time) factors. However, these findings are inconsistently reproduced, and risk factor modification has had a limited impact on rates of infectious complications. This is striking given that the likely contaminant-the oral microbiome-is a well-studied microbial reservoir. Because many oral cavity cancer surgeries involve violation of oral mucosa and the spillage of the oral microbiome into normally sterile areas (e.g. the neck), variance in oral microbiome composition and function could underly differences in infectious complications. The goal of this perspective is to highlight 1) this knowledge gap and 2) opportunities for studies in this domain. The implication of this line of thought is that the identification of oral microbial dysbiosis in patients undergoing surgery for oral cavity cancer could lead to targeted pre-operative therapeutic interventions, decreased infectious complications, and improved patient outcomes.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study.

OBJECTIVE: To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS: One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION: Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:97-102, 2024.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Petrous Carotid Artery Thrombosis in an Immunocompromised Patient Presenting With Mastoiditis, A Case Report.

OBJECTIVES: The neurotologic literature commonly describes venous sinus thrombosis as a complication of mastoiditis. However, thrombosis of the internal carotid artery in the setting of mastoiditis is rarely described. We aim to document a case of carotid artery thrombosis in a patient presenting with mastoiditis. METHODS: We describe this case and review relevant literature. RESULTS: A renal transplant patient was transferred to our hospital with a left middle cerebral artery (MCA) infarct due to acute mastoiditis. Examination demonstrated middle ear effusion and radiologic workup confirmed mastoid infection adjacent to the site of arterial thrombosis. During cortical mastoidectomy and facial recess approach to the middle ear, the petrous carotid bone was found to be dehiscent with pneumatization of the petrous apex. Thrombosis was found to resolve following surgery, IV antibiotics and anticoagulation. Clinically, his focal neurological deficits improved. Proximity of the infectious process to an exposed petrous carotid artery supports the hypothesis that this patient's thrombus was a product of infectious spread and extra-luminal compression. CONCLUSION: To our knowledge, this is the first report of MCA infarction due to petrous ICA arterial thrombus in the setting of mastoid infection. The patient's immunocompromised state may have predisposed and contributed to the adverse outcome. We advocate for aggressive management of acute mastoiditis in the immunocompromised to prevent or manage complications (such as venous thrombophlebitis as well as ICA thrombus) as these patients don't show typical signs of infection and inflammation.

The Utility of Preoperative Phone Calls for Endoscopic Sinus Surgery Procedures.

OBJECTIVE: Perioperative patient education improves patient satisfaction, surgical outcomes, and can reduce postoperative call volume. Here, we investigate whether the use of standardized preoperative phone calls elicits similar results in patients undergoing endoscopic sinus surgery (ESS). METHODS: Patients undergoing ESS at a tertiary rhinology center were identified prospectively through the electronic medical record (EMR). In the intervention cohort, a standardized preoperative educational phone call was performed. A postoperative survey was utilized to collect self-assessment of satisfaction and understanding in all patients. Postoperative call rates were obtained from the EMR. Wilcoxon rank sum and chi-squared analyses were conducted to compare results. Demographics of the otology and rhinology cohorts were compared with a Mann Whitney U-test. RESULTS: Data from 43 cases and 58 controls were collected. Patients receiving the intervention were similar to controls with regard to patient-reported understanding (case:9.1 ± 1.1 vs control:9.0 ± 1.4, p = 0.801) and satisfaction (case:9.4 ± 1.1 vs 8.9 ± 1.4, p = 0.155). Both cases and controls called the clinic regarding surgical outcomes more often than for postoperative medications or administrative concerns. Independent of receiving the intervention, patients that did not call clinic postoperatively had significantly better understanding of their procedures (call:8.6 ± 1.6 vs no-call:9.5 ± 1.0, p < 0.015) and satisfaction with their experience (call:8.8 ± 1.4 vs no-call:9.5 ± 1.1, p < 0.028). Patient age may contribute to lack of impact in the rhinology cohort, as compared to the otology group, but socioeconomic status does not seem to differentiate the two samples. CONCLUSION: Though shown in other settings, a significant impact of educational phone calls prior to surgery was not observed in this sample. Patient education calls prior to endoscopic sinus surgery were not associated with changes in postoperative call volume to the clinic. Patient understanding and satisfaction may be related to other factors, such as patient selection or demographics. Future studies may target such patients prior to ESS.

It Takes Two to Tango: A Review of Oncogenic Virus and Host Microbiome Associated Inflammation in Head and Neck Cancer.

While the two primary risk factors for head and neck squamous cell carcinoma (HNSCC) are alcohol and tobacco, viruses account for an important and significant upward trend in HNSCC incidence. Human papillomavirus (HPV) is the causative agent for a subset of oropharyngeal squamous cell carcinoma (OPSCC)-a cancer that is impacting a rapidly growing group of typically middle-aged non-smoking white males. While HPV is a ubiquitously present (with about 1% of the population having high-risk oral HPV infection at any one time), less than 1% of those infected with high-risk strains develop OPSCC-suggesting that additional cofactors or coinfections may be required. Epstein-Barr virus (EBV) is a similarly ubiquitous virus that is strongly linked to nasopharyngeal carcinoma (NPC). Both of these viruses cause cellular transformation and chronic inflammation. While dysbiosis of the human microbiome has been associated with similar chronic inflammation and the pathogenesis of mucosal diseases (including OPSCC and NPC), a significant knowledge gap remains in understanding the role of bacterial-viral interactions in the initiation, development, and progression of head and neck cancers. In this review, we utilize the known associations of HPV with OPSCC and EBV with NPC to investigate these interactions. We thoroughly review the literature and highlight how perturbations of the pharyngeal microbiome may impact host-microbiome-tumor-viral interactions-leading to tumor growth.

Adjuvant Radiation after Primary Resection of Atypical Lipomatous Tumors of the Extremity Reduces Local Recurrence but Increases Complications: A Multicenter Evaluation.

Background: Radiation after resection of an atypical lipomatous tumor (ALT) is controversial. This study evaluates local control and complications after the first resection of ALTs of the extremity with or without adjuvant radiation. Methods: A dual institution, retrospective review of patients treated from 1995 to 2020 with first-time resection of an ALT in the extremity was performed. In total, 102 patients underwent adjuvant radiation (XRT group) and 68 patients were treated with surgery alone (no-XRT group). The median follow-up time was 4.6 years (interquartile range (IQR) 2.0-7.3 years). The median radiation dose was 60 Gy (IQR 55-66 Gy). Univariable and multivariable analyses evaluated the association of patient, tumor, and treatment variables with recurrence and complications. Kaplan-Meier analysis evaluated local recurrence-free survival (LRFS) and time to complication. Results: The overall incidence of local recurrence was 1% (1/102) in the XRT group and 24% (16/68) in the no-XRT group (p < 0.001). The median time-to-recurrence was 8.2 years (IQR 6.5-10.5 years). In the XRT and the no-XRT groups, 5-yr LRFS was 98% and 92% (p=0.21) and 10-yr LRFS was 98% and 41% (p < 0.001), respectively. The absence of radiation (HR = 23.63, 95% CI (3.09-180.48); p < 0.001) and R2 surgical resection margins (HR = 11.04, 95% CI (2.07-59.03); p < 0.001) incurred a 23-fold and 11-fold increased risk of local recurrence, respectively, while tumor size, depth, location, and neurovascular involvement were not found to be independent predictors of recurrence. The complication rate was 37% (38/102) in the XRT group and 10% (7/68) in the no-XRT group (p < 0.001). Eight patients (8/102, 8%) required surgical management for complication in the XRT group compared with two patients (2/68, 3%) in the no-XRT group (p=0.10). Higher radiation dose had a modest correlation with increased severity of complication (ρ=0.24; p=0.02). Conclusions: Adjuvant radiation after first-time resection of an ALT of the extremity was associated with a significantly reduced risk of local recurrence but a three-fold increase in complication rate. These data support a 10-year follow-up for these patients and inform a notable clinical trade-off if considering adjuvant radiation for this tumor with recurrent potential.

Sleep endoscopy-directed management of Arnold-Chiari malformation: a child with persistent obstructive sleep apnea.

None: Arnold-Chiari malformations are structural defects in the base of the skull and cerebellum, when part of the cerebellar tonsils herniates through the foramen magnum into the upper spinal canal, compressing against the brainstem. This anatomical defect can be asymptomatic but often presents with symptoms such as headaches, stridor, dysphagia, and nystagmus. It also presents with a variety of sleep-related breathing disorders such as snoring, obstructive sleep apnea, central sleep apnea, bradypnea, and sleep hypoventilation. Sometimes these conditions can coexist in one patient. Although obstructive sleep apnea can be a manifestation of Arnold-Chiari malformation, identifying causality and the site of obstruction in these children can be a diagnostic challenge. We review the case of a 14-month-old male who presented with noisy breathing and obstructive sleep apnea diagnosed on sleep study that was refractory to initial upper airway surgery. Although a brain computed tomography scan done in the emergency room for altered mental status revealed a type 1 Arnold-Chiari malformation, and a flexible awake laryngoscopy was normal, subsequent drug-induced sleep endoscopy was helpful in justifying surgical decompression of the Arnold-Chiari malformation that resulted in complete resolution of the obstructive sleep apnea.

Patient and caregiver experiences at a Multidisciplinary Tracheostomy Clinic.

INTRODUCTION: Children with tracheostomy are a heterogeneous population requiring care from multiple specialties. Multidisciplinary approaches to treating such patients helps to improve the quality of care they receive. Our institution established a Multidisciplinary Tracheostomy Clinics (MDTC) to address outpatient care coordination for tracheostomy patients by providing care from multiple disciplines at a single visit. We report patient/caregivers' experiences of our MDTC. METHODS: Patients with tracheostomy or their caregivers were prospectively recruited between Dec 2017-Oct 2019 to complete surveys assessing their experience at the MDTC. Demographic and satisfaction questionnaires were sent electronically by a REDCap survey distribution tool. Demographic data were collected, such as patient's residence and education level. Medical care variables assessed included history of MDTC attendance, commute time, medical specialties seen, tracheostomy "Go-Bag" use, home-care nursing, and MDTC satisfaction ratings. RESULTS: Twenty-nine patients/caregivers completed the satisfaction survey and 22 completed both the satisfaction survey and demographics questionnaire. Patient ages ranged from 11 months to 36 years. Twenty-three (79%) participants commuted for up to 2 h to the MDTC, and 6 (21%) commuted for more than 2 h. The median number of medical specialties seen at the MDTC was 3. All participants were satisfied that they saw all requested specialties. Tracheostomy supplies were checked for 25 of 28 patients. Twenty-three of 28 subjects rated staff teamwork as "excellent." Twenty-four of 28 patients were "highly likely" to recommend the MDTC. Twenty-three of 28 participants were "highly likely" to return, and 4 were "somewhat likely" to return. CONCLUSION: This study demonstrates that patients with tracheostomy and caregivers were satisfied with the improved coordination and facilitation of care through a Multidisciplinary Tracheostomy Clinic.

Carbon dioxide laser versus cold-steel supraglottoplasty: A comparison of post-operative outcomes.

OBJECTIVE: Supraglottoplasty is the mainstay of surgical treatment for laryngomalacia, and is commonly performed via two methods: cold steel or carbon dioxide (CO2) laser. The degree of post-operative monitoring following supraglottoplasty varies, both within and between institutions. The aim of this study was to compare the post-operative monitoring and interventions required by patients undergoing cold-steel versus CO2 laser supraglottoplasty. DESIGN: Retrospective cohort of pediatric patients (age < 18 years) undergoing supraglottoplasty at a tertiary care pediatric hospital. The primary exposure was the surgical instrument(s) used during supraglottoplasty. The primary outcome was prolonged intensive care unit (ICU)-stay (defined as >24 h). RESULTS: 155 cases were eligible for inclusion. Fifty-eight (37.4%) patients had a comorbid condition. Common indications for surgery included feeding difficulty (56.1%), severe respiratory distress (33.5%), and obstructive sleep apnea (25.2%). CO2 laser was employed in 49 cases and cold-steel in 106 cases. Prolonged ICU-stay (>24 h) was observed in 14 CO2 laser cases (28.6%) and 11 cold-steel cases (10.4%) (adjusted OR 3.42; 95% CI 1.43, 8.33). CO2 laser cases were more likely to require post-operative intubation, non-invasive positive pressure ventilation, and nebulized racemic epinephrine. Concomitant neurological condition was associated with an increased risk of prolonged ICU-stay, while extent of surgery and age were not. CONCLUSIONS: CO2 laser supraglottoplasty is associated with an increased risk of prolonged ICU-stay and need for ICU-level airway intervention, compared to the cold-steel technique. While this association should not be misconstrued as a causal relationship, the current study demonstrates that specific surgical factors may influence the patient monitoring requirements following supraglottoplasty, particularly the choice of instrument and the extent of surgery.

Shark-based tourism presents opportunities for facultative dietary shift in coral reef fish.

Tourism represents an important opportunity to provide sustainable funding for many ecosystems, including marine systems. Tourism that is reliant on aggregating predator species in a specific area using food provisioning raises questions about the long-term ecological impacts to the ecosystem at large? Here, using opportunistically collected video footage, we document that 61 different species of fish across 16 families are consuming tuna flesh at two separate shark dive tourism operations in the Republic of Fiji. Of these fish, we have resolved 55 to species level. Notably, 35 (63%) of the identified species we observed consuming tuna flesh were from ostensibly non-piscivorous fishes, including four Acanthuridae species, a group primarily recognized as browsers or grazers of algae and epibenthic detritus. Our results indicate that shark diving is having a direct impact on species other than sharks and that many species are facultatively expanding their trophic niches to accommodate the hyperabundance of resources provided by ecotourism.

Intraoperative Ultrasound for Localization and Removal of an Oropharyngeal Wire Grill-Brush Bristle.

OBJECTIVES: This paper reports the utilization of intraoperative ultrasound in the removal of an accidentally ingested wire grill-brush bristle from the pharyngeal space of a child. METHODS: Standard procedures for obtaining imaging of an accidentally ingested foreign body were performed, including radiograph, computed tomography (CT) imaging, and preoperative ultrasonography. Despite preoperative imaging, the object could neither be located nor removed. Ultrasonography was performed intraoperatively for real-time localization. RESULTS: Intraoperative ultrasonography was required to successfully locate and remove the wire grill-brush bristle from the patient's oropharyngeal space. CONCLUSIONS: Intraoperative ultrasound serves as a useful tool to guide surgical removal of aerodigestive foreign bodies and may offer an opportunity to reduce the need for CT imaging.

Readmissions following ambulatory pediatric endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Endoscopic sinus surgery (ESS) is indicated in select pediatric patients with medically refractory sinus disease. Our objectives were to examine indications and rates of readmission following ambulatory pediatric ESS and identify specific subgroups that may benefit from inpatient admission. STUDY DESIGN: Retrospective database review. METHODS: The Pediatric Health Information Systems (PHIS) 2004-2016 database was retrospectively reviewed for patients age <18 years who underwent ambulatory ESS between January 2011 and December 2016 and were readmitted within 30 days postoperatively. Data regarding demographics, extent of surgery, comorbidities, adjunctive procedures, and cost were collected. A multivariable mixed-effects logistic regression model was employed for analysis. RESULTS: We identified 3,669 unique pediatric ESS cases with 128 readmissions within 30 days (3.5%; 95% confidence interval [CI]: 2.9%-4.1%). Median cost of readmission was $980 (mean, $5,890; standard deviation, $13,421). The most common indication for readmission was epistaxis (17.2%), followed by nausea/abdominal pain (14.1%). Respiratory infection (13.3%) and sinusitis (10.2%) presented a combined readmission rate exceeding that of epistaxis alone. Multivariable analysis indicated age <3 years (odds ratio [OR]: 3.41, 95% CI: 1.96-5.93) and a prior diagnosis of asthma (OR: 2.88, 95% CI: 1.99-4.18) or cystic fibrosis (OR: 1.57, 95% CI: 1.00-2.44) significantly increased the risk of readmission. Extent of ESS and simultaneous adenoidectomy, septoplasty, or turbinate reduction had no significant impact on readmission rates. CONCLUSIONS: ESS is a relatively safe outpatient surgical procedure in pediatric patients, with an overall readmission rate of 3.5%. Clinicians should consider careful preoperative evaluation of very young patients and those with cystic fibrosis or asthma to optimize perioperative management and determine if postoperative admission is warranted, given their significantly higher readmission rates. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2681-2686, 2019.

Risk Factors for Multiple Hemorrhages Following Tonsil Surgery in Children.

OBJECTIVES/HYPOTHESIS: Although much is known about the incidence and risk factors for hemorrhage after tonsil surgery, the incidence and factors related to multiple episodes of hemorrhage are not well examined. Our objective was to identify risk factors that may contribute to multiple hemorrhages following tonsil surgery in children. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review was conducted of pediatric patients who experienced one or more hemorrhages following tonsillectomy/tonsillotomy, with or without adenoidectomy, between 2010 and 2016 at a single, tertiary-care hospital. Risk factors for multiple hemorrhages were examined using a multivariable logistic regression model. RESULTS: Among the 11,140 patients who underwent tonsil surgery, 452 patients experienced one or more hemorrhages; 32 of these had multiple episodes of hemorrhage (7.1% of all patients with bleeds/0.3% of all patients). Older age (≥12 years: adjusted odds ratio [OR]: 3.13; 95% confidence interval [CI]: 1.47-6.68) and high body mass index for age (≥85th percentile: adjusted OR: 2.26; 95% CI: 1.06-4.85) were significantly associated with an increased risk of multiple hemorrhages in the multivariable model. Medical comorbidities, indications for surgery, surgical technique, intraoperative blood loss, and perioperative medications were not associated with multiple episodes of bleeding. CONCLUSIONS: Multiple hemorrhages after tonsillectomy/tonsillotomy are uncommon. The risk of a second PTH after an initial episode is 7.1%, almost double the risk of a bleed after the initial tonsil surgery. Age > 12 years and high BMI for age may be associated with increased risk of rebleeding. After an initial bleed, increased surveillance may be warranted, particularly for patients with risk factors. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2765-2770, 2019.

Standardization of pediatric tracheostomy care with "Go-bags".

OBJECTIVES: To describe how pediatric tracheostomy emergency supplies and education are standardized with the use of "Go-bags" and to demonstrate how this has impacted tracheostomy-related adverse events. METHODS: A prospective study was completed at an urban pediatric tertiary care center. Standardized "Go-bags" of tracheostomy supplies were provided to pediatric patients with tracheostomy. All caregivers received standardized tracheostomy education. Check lists were used to monitor contents at return visits or admissions. Tracheostomy related adverse events were tracked on all patients with tracheostomy from July 2016 to May 2018, and rates were compared for patients who had received a "Go-bag" to those who had not. RESULTS: 292 "Go-bags" were distributed during the two-year study period. 35% were distributed by inpatient respiratory therapists, 23% by the home ventilation team, and 22% by a tracheostomy clinic nurse. Supply checks have led to more than 185 cases of emergency tracheostomy equipment replacement. 35% of tracheostomy-related adverse event (TRAE) occurred in patients who did not have a "Go-bag", while 22% of TRAEs occurred in patients who had "Go-bags". CONCLUSION: Standardized pediatric tracheostomy care is critical to patient safety, both in and out of the hospital. Standardized tracheostomy "Go-bags" are a simple and efficient method to educate caregivers, improve the quality of care for children with tracheostomy, and ultimately reduce tracheostomy related adverse events.

Association of a Multidisciplinary Care Approach With the Quality of Care After Pediatric Tracheostomy.

IMPORTANCE: Incidence of tracheostomy placement in children is increasing, and these children continue to have high incidences of morbidity and mortality. A multidisciplinary tracheostomy program may help improve the quality of care received by these patients. OBJECTIVE: To determine whether implementation of a multidisciplinary tracheostomy program can improve the care of children who received a tracheostomy through reduction in tracheostomy-related adverse events (TRAEs), improved tracheostomy education, and caregiver preparedness. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted from January 2015 to June 2018 at a pediatric tertiary referral center in Boston, Massachusetts. The participants included 700 children who had received a tracheostomy, most of whom were aged birth to 18 years, but some patients with congenital disorders were much older. EXPOSURES: Institution of a multidisciplinary tracheostomy team (MDT) whose activities included conducting staff meetings, organizing outpatient clinics, conducting inpatient tracheostomy ward rounds, and conducting inpatient tracheostomy rounds at a local rehabilitation hospital. Quality improvement initiatives included monitoring standardized TRAEs and distributing standardized tracheostomy "go-bags." MAIN OUTCOMES AND MEASURES: Reduction of TRAEs and improved caregiver preparedness through distribution of tracheostomy go-bags were assessed following the establishment of a multidisciplinary tracheostomy program. RESULTS: In total, 700 children who had received a tracheostomy during the study period were actively followed up by the MDT. Of these children, 378 (54.0%) were males and 322 (46.0%) were females; mean (SD) age was 4.1 (6.1) years. More than 60 new pediatric tracheostomies were performed annually at the referral center. Reported TRAEs were reduced by 43.0% from the first to the third year after the implementation of a standardized, closed-loop monitoring system (from a mean [SD] of 6.1 [5.2] TRAEs per 1000 inpatient tracheostomy-days in 2015 to a mean [SD] of 4.0 [2.5] in 2018). The most common TRAE was unplanned decannulation, which occurred 64 times during the study period. On average, 10 patients were seen in each monthly multidisciplinary tracheostomy clinic. Clinic interventions included continuing care (146 [52.5%]), communication enhancement (67 [23.6%]), plans for decannulation (52 [18.6%]), and referrals for comorbidities (13 [4.6%]). Approximately 19 inpatients were seen during biweekly rounds and 8 during monthly rounds at a local rehabilitation hospital. A total of 297 patients received standardized tracheostomy go-bags, and more than 70 positive bag checks were performed in the monthly MDT clinics. A positive bag check refers to the incidence when a family is given a go-bag and also uses it. In contrast, a negative bag check refers to when a family is given a go-bag but neither brings it to the clinic nor acknowledges that they use it. CONCLUSIONS AND RELEVANCE: This study's findings suggest that a multidisciplinary tracheostomy program may be a powerful tool for enhancing patient safety and quality improvement. Ongoing studies will develop measurable pediatric tracheostomy outcome metrics and assess long-term outcomes.

A standardized, closed-loop system for monitoring pediatric tracheostomy-related adverse events.

OBJECTIVES/HYPOTHESIS: Advancement in neonatal and pediatric intensive care has increased the need for chronic-care interventions, including tracheostomy. It is well established that children with a tracheostomy are at a high risk for adverse events, many of which are preventable. Despite this, there is no standardized method of monitoring tracheostomy-related adverse events (TRAEs). Our objective was to describe and assess a standardized, closed-loop system for monitoring TRAEs. STUDY DESIGN: Prospective Study. METHODS: A specific tracheostomy-related category was established within the adverse event reporting system in January 2015. Monthly TRAE reports were supplied to the multidisciplinary tracheostomy team (MDT) with descriptions of event type, severity, and preventability. The MDT reviewed events and discussed necessary follow-up. The frequency of events was standardized by inpatient tracheostomy days (ITDs) using an automated monthly list. Adverse events were tracked using a control chart. Aggregated data were divided into biannual reports for analysis. RESULTS: Eighty-five TRAEs were reported between January 2015 and June 2017, averaging 5.75 per 1,000 ITDs. Most common events include unplanned decannulation (50%) and improper use of tracheostomy supplies (21%). The frequency of all preventable events has decreased by 76% since the second half of 2015. During this timeframe, minor events have decreased, moderate events have maintained a frequency of less than one per 1,000 ITDs, and only one severe event occurred. CONCLUSIONS: This standardized, closed-loop reporting method, modeled after other successful intensive care unit reporting systems, accurately tracks TRAEs. We have observed a decrease in preventable TRAEs without a negative impact on rates of severe events. Results suggest improved quality of care for patients with tracheostomy. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2419-2424, 2018.

Does Clarithromycin Cause Hearing Loss? A 12-Year Review of Clarithromycin Therapy for Nontuberculous Mycobacterial Lymphadenitis in Children.

OBJECTIVE(S): The objective was to describe the characteristics of hearing losses documented in patients treated with clarithromycin alone for nontuberculous mycobacterial NTM lymphadenitis in a pediatric tertiary care center over a 12-year period. METHODS: An institutional review board (IRB) approval was obtained. A database search was performed using the ICD-10 diagnosis codes 31.0, 31.1, and 31.8 between January 2004 and January 2017. A REDCap database was created to record variables. Patients were included if they received clarithromycin alone and had, at the minimum, a baseline audiology assessment, and 1 further evaluation during treatment. Fisher's exact test was used to analyze categorical variables, and Wilcoxon rank sum test was used to analyze continuous variables. RESULTS: A total of 167 patients with cervicofacial NTM were identified. Of them, 42 patients fulfilled inclusion criteria. Three children (7%) developed a hearing loss (HL) between 25 and 63 days after starting treatment. HL was unilateral in 2 children. HL persisted in 1 child following cessation of treatment. However, this patient had Rubinstein Taybi syndrome, limiting our ability to attribute the HL solely to clarithromycin. CONCLUSION: We noted a 7% hearing loss rate in our series. Confounding issues, such as 1 patient with a syndrome potentially contributing to HL, and limitations to this study, including retrospective design and loss to follow-up, temper our ability to conclude that clarithromycin was the sole cause of these HL. However, enough supporting data for a role in clarithromycin causing HL exist that testing should be considered for patients undergoing long-term clarithromycin treatment.

Collateral damage to marine and terrestrial ecosystems from Yankee whaling in the 19th century.

Yankee whalers of the 19th century had major impacts on populations of large whales, but these leviathans were not the only taxa targeted. Here, we describe the "collateral damage," the opportunistic or targeted taking of nongreat whale species by the American whaling industry. Using data from 5,064 records from 79 whaling logs occurring between 1840 and 1901, we show that Yankee whalers captured 5,255 animals across three large ocean basins from 32 different taxonomic categories, including a wide range of marine and terrestrial species. The taxa with the greatest number of individuals captured were walruses (Odobenus rosmarus), ducks (family Anatidae), and cod (Gadus sp.). By biomass, the most captured species were walruses, grampus (a poorly defined group within Odontoceti), and seals (family Otariidae). The whalers captured over 2.4 million kg of nongreat whale meat equaling approximately 34 kg of meat per ship per day at sea. The species and areas targeted shifted over time in response to overexploitation of whale populations, with likely intensive local impacts on terrestrial species associated with multiyear whaling camps. Our results show that the ecosystem impacts of whaling reverberated on both marine and coastal environments.