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.

Single Nucleotide Polymorphisms in Chemosensory Pathway Genes GNB3, TAS2R19, and TAS2R38 Are Associated with Chronic Rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a multifaceted disease with a significant genetic component. The importance of taste receptor signaling has recently been highlighted in CRS; single nucleotide polymorphisms (SNPs) of bitter tastant-responsive G-protein-coupled receptors have been linked with CRS and with altered innate immune responses to multiple bacterially derived signals. OBJECTIVE: To determine in CRS the frequency of six SNPs in genes with known bitter tastant signaling function. METHODS: Genomic DNA was isolated from 74 CRS volunteers in West Virginia, and allele frequency was determined and compared with demographically matched data from the 1,000 Genomes database. RESULTS: For two SNPs in a gene recently associated with bitterant signaling regulation, RGS21, there were no associations with CRS (although the frequency of the minor allele of RGS21, rs7528947, was seen to increase with increasing Lund-Mackay CT staging score). Two TAS2R bitter taste receptor gene variants (TAS2R19 rs10772420 and TAS2R38 rs713598), identified in prior CRS genetics studies, were found to have similar associations in this study. CONCLUSION: Unique to our study is the establishment of an association between CRS in this patient population and GNB3 SNP rs5443, a variation in an established G protein component downstream of bitterant receptor signal transduction.

Phenotypical Characterization of Obstructive Sleep Apnea in Premature Infants using Polysomnography.

OBJECTIVE: To use objective quantification of polysomnographic (PSG) parameters in premature infants to define the severity and nature of obstructions (partial hypopnea vs. total obstruction), along with the impact on sleep fragmentation and oxygenation patterns. METHODS: Retrospective comparison of PSG features in 207 infants (<12 months) referred for sleep disordered breathing. Our study groups included term (> = 37 weeks GA, n = 162) and premature (<37 weeks GA, n = 45) infants. Groups were compared for OSA sleep-stage-specific apnea hypopnea (AHI) indexes (REM and NREM), hypopnea indexes (HI), obstructive apnea indexes (OI) and arousal indexes. Oxygenation was assessed as % of time with SpO2 < 90%, nadir with apneic events and frequency of SpO2 desaturations (>3%) calculated as stage-specific O2 desaturation indexes. RESULTS: Overall, premature infants had greater apnea severity (AHI premature 13.9/h vs. Term 7.9/h, p = 0.018). Additional analyses showed that the primary difference between premature and term infants is seen in the group with partial obstructions (HI index) and severe OSA (OAHI> = 10/h). Premature infants also had greater arousal indexes (premature 13.8/h vs. term 10.5/h, p = 0.003). Although the percentage of time <90% at night and the median SpO2 nadir during apneic events was similar in premature vs. term, O2 desaturation indexes were greater in premature infants (10.3/h in term vs. 18.3/h in prematurity, p = 0.03). CONCLUSIONS: Children born premature have an OSA phenotype in infancy characterized by greater severity mostly due to frequent partial obstructions (hypopneas) rather than full obstructions (obstructive apnea). Prematurity is also associated with more intermittent hypoxemia and sleep fragmentation. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1933-1938, 2024.

Can ChatGPT help patients answer their otolaryngology questions?

Background: Over the past year, the world has been captivated by the potential of artificial intelligence (AI). The appetite for AI in science, specifically healthcare is huge. It is imperative to understand the credibility of large language models in assisting the public in medical queries. Objective: To evaluate the ability of ChatGPT to provide reasonably accurate answers to public queries within the domain of Otolaryngology. Methods: Two board-certified otolaryngologists (HZ, RS) inputted 30 text-based patient queries into the ChatGPT-3.5 model. ChatGPT responses were rated by physicians on a scale (accurate, partially accurate, incorrect), while a similar 3-point scale involving confidence was given to layperson reviewers. Demographic data involving gender and education level was recorded for the public reviewers. Inter-rater agreement percentage was based on binomial distribution for calculating the 95% confidence intervals and performing significance tests. Statistical significance was defined as p < .05 for two-sided tests. Results: In testing patient queries, both Otolaryngology physicians found that ChatGPT answered 98.3% of questions correctly, but only 79.8% (range 51.7%-100%) of patients were confident that the AI model was accurate in its responses (corrected agreement = 0.682; p < .001). Among the layperson responses, the corrected coefficient was of moderate agreement (0.571; p < .001). No correlation was noted among age, gender, or education level for the layperson responses. Conclusion: ChatGPT is highly accurate in responding to questions posed by the public with regards to Otolaryngology from a physician standpoint. Public reviewers were not fully confident in believing the AI model, with subjective concerns related to less trust in AI answers compared to physician explanation. Larger evaluations with a representative public sample and broader medical questions should immediately be conducted by appropriate organizations, governing bodies, and/or governmental agencies to instill public confidence in AI and ChatGPT as a medical resource. Level of Evidence: 4.

Down Syndrome for the Otolaryngologist: A Review.

Importance: There are many features of Down syndrome that prompt referral to an otolaryngologist. As the lifetime prevalence and life expectancy of individuals with Down syndrome increase, it is increasingly likely that otolaryngologists will have the opportunity to care for patients with Down syndrome. Observations: A confluence of characteristics common to Down syndrome may be associated with issues in the head and neck, from infancy through adulthood. Hearing concerns range from narrow ear canals and cerumen impactions to eustachian tube dysfunction, middle ear effusion, cochlear malformations, and conductive, sensorineural, and/or mixed hearing loss. Immune deficiency, hypertrophy of Waldeyer ring, and hypoplastic sinuses may complicate and develop into chronic rhinosinusitis. Speech delay, obstructive sleep apnea, dysphagia, and airway anomalies are also common among this patient population. Because these concerns may necessitate otolaryngologic surgery, it is vital for otolaryngologists to familiarize themselves with anesthetic concerns, including cervical spine instability, in patients with Down syndrome. Comorbid cardiac disease, hypothyroidism, and obesity may also affect these patients and otolaryngologic care. Conclusions and Relevance: Individuals with Down syndrome may visit otolaryngology practices at all ages. Otolaryngologists that familiarize themselves with the head and neck manifestations that are common among patients with Down syndrome and know when to order screening tests will be able to provide comprehensive care.

Ensuring tympanostomy tube follow-up during the COVID-19 pandemic.

OBJECTIVES: The impact of the COVID-19 pandemic on surgical practice was widespread. Local health restrictions in many communities limited the number and types of patients seen and treated. Our goal is to understand the discrepancies in follow-up for bilateral myringotomy with tubes (BMT) and understand whether the pandemic made it more difficult for certain patient populations to continue routine follow up. METHODS: This cross-sectional study abstracted demographic and clinical data from the medical charts of randomized pediatric patients who underwent a BMT procedure between 2017 and 2022 at a tertiary pediatric academic care center site. Suboptimal follow-up was defined as no clinic visits within the first 6 months of surgery, and less than 3 follow-ups within a 24-month period after surgery. Data regarding secondary surgeries, clinical variables, race, zip code, and dates and number follow-ups were recorded from randomly chosen eligible charts. Complications were defined as need for revision surgery or development of post-tympanostomy sequalae such as perforation, cholesteatoma, or granuloma. RESULTS: Pre-pandemic (N = 150) patients from 2017 to 2019 and post-pandemic (N = 150) patients from 2020 to 2022 cohorts were analyzed. No significant differences were identified between the groups regarding age, presence of combined surgery, anesthesia class, diagnosis, or race. There was no significant difference in rate of complications or need for revision surgery between either cohort nor when stratified for demographics. CONCLUSION: Limitations imposed upon medical care including outpatient clinics due COVID restrictions did not have an impact on tympanostomy tube follow-up regarding frequency of visits and risk of complication or revision surgery. LEVEL OF EVIDENCE: IV.

Managing the Destructive Foreign Body: Water Beads in the Ear (A Case Series) and Literature Review.

OBJECTIVE: To characterize our experience with super-absorbent polymer beads placed in the external auditory canal to better understand the damage caused and subsequent management required. METHODS: Retrospective chart review of pediatric patients at 2 separate tertiary referral centers. RESULTS: Seven patients were identified as having placed super-absorbent polymer beads in the external auditory canal, 6 of whom required removal under general anesthesia. Three patients did not suffer otologic trauma or hearing loss (average foreign body duration <72 hours). Four patients experienced severe otologic complications (average foreign body duration >1 week), all of whom were treated with otologic drops prior to bead identification. Of this severe complication group, 3 patients had restored hearing after surgical intervention, while 1 patient suffered profound hearing loss secondary to labyrinthitis ossificans. CONCLUSION: Early recognition of otologic foreign bodies is important, particularly if expansile water-bead is suspected. Depending on timeframe, water beads are highly destructive to the middle ear structures, and most patients will require surgical intervention.

Evaluating the Current Ability of ChatGPT to Assist in Professional Otolaryngology Education.

Objective: To quantify ChatGPT's concordance with expert Otolaryngologists when posed with high-level questions that require blending rote memorization and critical thinking. Study Design: Cross-sectional survey. Setting: OpenAI's ChatGPT-3.5 Platform. Methods: Two board-certified otolaryngologists (HZ, RS) input 2 sets of 30 text-based questions (open-ended and single-answer multiple-choice) into the ChatGPT-3.5 model. Responses were rated on a scale (correct, partially correct, incorrect) by each Otolaryngologist working simultaneously with the AI model. Interrater agreement percentage was based on binomial distribution for calculating the 95% confidence intervals and performing significance tests. Statistical significance was defined as P < .05 for 2-sided tests. Results: In testing open-ended questions, the ChatGPT model had 56.7% of initially answering questions with complete accuracy, and 86.7% chance of answer with some accuracy (corrected agreement = 80.1%; P < .001). For repeat questions, ChatGPT improved to 73.3% with complete accuracy and 96.7% with some accuracy (corrected agreement = 88.8%; P < .001). For multiple-choice questions, the ChatGPT model performed substantially worse (43.3% correct). Conclusion: ChatGPT currently does not provide reliably accurate responses to sophisticated questions in Otolaryngology. Professional societies must be aware of the potential of this tool and prevent unscrupulous use during test-taking situations and consider guidelines for clinical scenarios. Expert clinical oversight is still necessary for myriad use cases (eg, hallucination).

Systematic Review of Slide Tracheoplasty Outcomes.

OBJECTIVE: To identify factors predicting success in slide tracheoplasty surgery at a regional children's hospital and compare with available published literature. MEASURES: Retrospective chart review comparing demographics (age, weight) and clinical (operative and hospital course, need for additional airway intervention) factors experienced with slide tracheoplasty. Findings were compared with a systematic review of published literature. RESULTS: Of the 16 tracheal stenosis patients in our cohort, 13 (81.3%) presented with an additional congenital or cardiovascular anomaly. When adjusted for cardiovascular anomalies, congenital tracheal stenosis patients had a mean age of 5.2 months (range 6 days-17 months), mean weight of 5.04 kg, and average ICU and hospital length of stay of 31.5 and 36.0 days, respectively. Tracheostomy was required for 4 patients and no early deaths were recorded. Of the 391 children in the grouped cohort, mean age and weight was older at 7.67 months and larger at 5.70 kg. Length of stay in both ICU and overall hospital course was 31.6 and 43.5 days, respectively. Mortality etiology for 44 patients was reported: 17 (38.6%) cardiac-related and 28 (63.6%) late mortalities. Our overall calculated mortality risk of 1.26 (P < .05) was lower than reported ratios of 2.0+. CONCLUSION: Despite the numerous institutional studies involving tracheal stenosis, mortality and surgical challenges remain high. Future studies with the inclusion of specific perioperative data can prove to further evaluate correlations between presentation characteristics and mortality.

Base of Tongue Surgery and Pediatric Obstructive Sleep Apnea.

OBJECTIVE: Drug-induced sleep endoscopy-directed lingual tonsillectomy and midline posterior glossectomy have been employed for the treatment of obstructive sleep apnea in children. The purpose of this study is to evaluate outcomes in children undergoing lingual tonsillectomy, midline posterior glossectomy, or combined base of tongue reduction procedures for obstructive sleep apnea. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care academic medical center. METHODS: A case series was performed with chart review of pediatric patients with obstructive sleep apnea who underwent base of tongue surgery as directed by drug-induced sleep endoscopy. Pre- and postoperative obstructive apnea-hypopnea index (oAHI) was compared. Age, sex, body mass index z score, and medical history were also evaluated. RESULTS: A total of 168 children were included, with a mean ± SD age of 8.3 ± 3.6 years. Of these patients, 101 underwent lingual tonsillectomy alone; 25, midline posterior glossectomy alone; and 42, both. Their mean oAHI improvement was 3.52 ± 8.39, 2.55 ± 5.59, and 3.70 ± 6.07, respectively. Each surgical group experienced significant improvement in sleep apnea when pre- and postoperative oAHI was compared (P < .01). Overall surgical success, as defined by oAHI <1 (or <5 without clinical symptoms), was 75% (126 patients). CONCLUSION: When guided by drug-induced sleep endoscopy, pediatric tongue base surgery can significantly improve oAHI and thus demonstrates promising success in treating pediatric obstructive sleep apnea.

Expert Consensus Statement: Management of Pediatric Persistent Obstructive Sleep Apnea After Adenotonsillectomy.

OBJECTIVE: To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged. METHODS: An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey. RESULTS: After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care. CONCLUSION: The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research.

Stridor in the Infant Patient.

Stridor is a high-pitched extrathoracic noise associated with turbulent airflow, commonly associated with respiratory distress in infants. Workup for stridor requires evaluation of the upper-respiratory airway, with severe distress requiring evaluation under anesthesia. The differential diagnosis of stridor depends on location of the obstruction, age of the patient, and acuity of the symptoms. The most common reason is laryngomalacia; most patients can be managed conservatively with resolution of symptoms by 2 years of age. In children who do not improve or have severe disease, supraglottoplasty is the treatment of choice, and the majority will have resolution of stridor postoperatively.

Reliability of a pediatric sleep endoscopy scoring system.

INTRODUCTION: The surgical management of Obstructive Sleep Apnea (OSA) may be guided by Drug Induced Sleep Endoscopy (DISE), but there is no universally accepted scoring system for DISE in children. The purpose of this study is to compare a novel system to the more commonly used VOTE (Velum, Oropharynx, Tongue base, Epiglottis) system. METHODS: A total of thirty pediatric DISE videos were reviewed and scored twice by 5 raters with a range of experience levels. The videos were scored using both the VOTE and the new scoring systems. The raters were also asked to recommend surgical intervention based on the DISE exam alone. Intra-rater test-retest analysis of the responses was conducted using weighted kappa (WK) statistic and percentage agreement (PA), respectively. Inter-rater reliability analysis of responses was evaluated using Krippendorff's alpha reliability coefficient (KA). Using a proportional odds model, a comparison of the weighted kappa statistic for the VOTE and the novel scoring systems was conducted. RESULTS: For the novel scoring system, the intra-rater test-retest WK coefficient was 0.62 and 0.87 and the PA was 64% and 82% at the 25th and 75th percentiles, respectively. For the VOTE system, the intra-rater test-retest WK coefficient was 0.50 and 1.00 and PA was 75% and 100% at the 25th and 75th percentiles, respectively. KA was 0.36 and 0.77 at the 25th and 75th percentiles. In addition, responses to the surgical intervention survey analysis yielded a test-retest WK coefficient of 0.40 and 1.00 and a PA 71%-100% at the 25th and 75th percentiles, respectively. KA was 0.40 and 0.61 at the 25th and 75th percentiles, respectively. There was no significant difference between the 2 scoring systems on the WK statistic (p = .15), but significant difference on PA (p = .01). CONCLUSION: Our novel scoring system demonstrated intra-rater test-retest and inter-rater reliability similar to the VOTE system, includes more sites of potential airway obstruction, and has potential for widespread use.

Transoral versus Transcervical Drainage of Pharyngeal Abscesses in Children: Post-Operative Complications.

INTRODUCTION: The objective of this study was to compare complications and other perioperative outcomes between intraoral and transcervical drainage of both retropharyngeal and parapharyngeal abscesses. MATERIALS AND METHODS: This was a retrospective study that analyzed data from the 2012 to 2016 National Surgical Quality Improvement Program (NSQIP)-Pediatric public use files. Baseline characteristics and perioperative outcomes including postoperative complications and length of hospital stay (LOS) were compared between intraoral and transcervical drainage groups. Multivariable logistic regression was performed to inspect predictors of having an extended LOS, defined as LOS greater than 3 days. RESULTS: A total of 1174 patients were included. Mean age was 5.1 ± 3.8 years in the intraoral group (N = 1063) and 4.2 ± 4.3 years in the transcervical group (N = 111, P < .001). There was no significant difference in the rate of post-operative complications between groups (5.7% intraoral vs 8.1% transcervical, P = .316). LOS was significantly longer in the transcervical group (>3 days in 36.2% of intraoral vs 49.5% of transcervical, P = .006). Patients in the transcervical group had 1.59 times the odds of extended LOS, after adjusting for age, pre-operative ventilator support, asthma, structural pulmonary disease, hematologic disorders, and all post-operative complications (P = .024). CONCLUSION: There does not appear to be a significant difference in the rate of post-operative complications after intraoral versus transcervical drainage for pharyngeal abscesses in children. However, transcervical drainage was associated with an extended hospital stay. Further prospective studies will be needed to determine the reasons for this.

Round window anatomy predicts ease of cochlear implantation in children.

OBJECTIVES: We aim to evaluate the utility of the Round Window Angle (RWA) as a predictor of difficulty and operative time in cochlear implantation. METHODS: A retrospective study of pediatric patients that underwent cochlear implantation and CT temporal bone imaging from January 2008 to November 2019. Correlation, univariate, and multivariate analysis were conducted. RESULTS: 347 implantations met inclusion criteria. We found a difference in RWA for difficult (median: 101°, n = 5) and non-difficult (median: 74, n = 317) implantations (p < 0.0001). There was also a difference in RWA in patients with round windows visualized intra-operatively (p < 0.0197). When controlling for age and intraoperative round window visualization, logistic regression showed RWA was significantly associated with difficult insertion (OR: 1.687; p = 0.0246). Further, there was positive correlation between RWA and operative time (r = 0.1779, p = 0.0013) with patients with acute RWAs having shorter operative times (mean 115.7 ± 32.1 min) than those with obtuse RWA (mean 183.5 ± 97.0 min) (p = 0.0035). When accounting for surgeon and patient age, multivariate linear regression showed round window visualization (ß = 3.456, p = 0.0006) and obtuse RWA (ß = 6.172, p < 0.0001) was associated with an increase in operative time. CONCLUSION: Further research is needed to identify difficult cochlear implantations to increase the success and reduce risks associated with the surgery. Our study reports the possibility that an obtuse RWA both significantly increases difficulty and time of operation due to decreased round window visualization.

Standardization and Reduction of Narcotics After Pediatric Tonsillectomy.

OBJECTIVES: (1) To measure caregiver satisfaction with a nonstandardized postoperative pain regimen after pediatric tonsillectomy. (2) To implement a quality improvement project (QIP) to reduce the number and volume of narcotics prescribed and to describe the effect on caregiver satisfaction. METHODS: A prospective cohort study at a tertiary children's hospital examined postoperative narcotics prescribed to children following adenotonsillectomy. A QIP was implemented 3 months into the observation, with the goal to standardize nonnarcotic analgesics and reduce the volume of narcotics prescribed. Caregivers were called 2 to 3 weeks postoperatively to assess pain control and caregiver satisfaction. RESULTS: Over an 8-month period, 118 patients were recruited (66 before the QIP, 52 after induction). Prior to the QIP, 47% of patients were prescribed postoperative narcotics, as opposed to 27% after the QIP (P < .05). There was a significant reduction in the volume of narcotics prescribed before (mean ± SD, 300 ± 150 mL) versus after (180 ± 111 mL) the initiative (P < .05). The per-kilogram dose did not change over the study time frame. On a 5-point Likert scale, there was no difference in the caregivers' satisfaction regarding pain control before (4.37 ± 0.85) versus after (4.35 ± 1.0) the project started. DISCUSSION: A system shift was identified with the establishment of a posttonsillectomy pain control protocol associated with a reduction in prescribed narcotics without a significant change in caregiver satisfaction. IMPLICATIONS FOR PRACTICE: Implementing a standardized plan for the use of nonnarcotic medications was associated with reduced frequency and volume of narcotics prescribed. Future work will further standardize our postoperative pain regimen.

Expert Consensus Statement: Pediatric Drug-Induced Sleep Endoscopy.

OBJECTIVE: To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep. METHODS: Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized. RESULTS: The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research. CONCLUSION: Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

Impact of the novel coronavirus on surgical practices at a tertiary pediatric hospital: A 3 year cross-sectional study.

OBJECTIVE: The novel coronavirus (COVID-19) forced unprecedented changes in pediatric otolaryngology workflow in the early pandemic, particularly due to the postponement of elective procedures. In turn, this has impacted timely treatment of patients and ability to train residents and fellows. The objective is to characterize how surgical practices in pediatric otolaryngology have been impacted by the pandemic through a cross sectional analysis over three years. METHODS: This cross-sectional study focuses on patients who underwent surgical procedures within the department of otolaryngology at a single tertiary pediatric hospital. Descriptive statistical analysis was used to compare subsets of patients from pre-pandemic in 2019, early-pandemic in 2020, and late-pandemic in 2021. RESULTS: Operative volume decreased by 87.57% in the early pandemic and 36.86% in the late pandemic. In the early pandemic, the greatest decreases were seen in airway reconstruction (100%), adenotonsillectomy (96.4%), adenoidectomy (94.7%), myringotomy with tympanostomy tube insertion (94.6%), frenulectomy (94.1%), and sinonasal procedures (93.3%), while in the late-pandemic adenotonsillectomy (42.4%) and myringotomy with tympanostomy tube insertion (70.1%) remained reduced when compared to pre-pandemic volume. Increased average case lengths in the early-pandemic (78.28 ± 51.95 min) and late-pandemic (71.91 ± 70.76 min) were observed when compared to pre-pandemic (52.26 ± 39.20 min) (p < 0.001). An increased proportion of multidisciplinary cases were completed in 2020 and 2021 (p < 0.001). In the 2020, 25% of cases were completed without trainee involvement. There was an overall decrease in case numbers for trainees and increase in cases without their involvement when compared to 2019 and 2021. CONCLUSION: The COVID-19 pandemic resulted in a decrease in pediatric otolaryngology surgical procedures, particularly at the onset of the pandemic. While surgical trainees saw a dramatic reduction in case numbers early on, one year into the pandemic case volume is increasing and trending to pre-pandemic numbers. More complex cases, as represented by patients requiring longer operative times, inpatient status, and more frequently multidisciplinary care, were seen in the early pandemic, while drastic reductions were seen in routine outpatient procedures.

Robotic-assisted transmaxillary approach for removal of juvenile nasopharyngeal angiofibroma of the pterygopalatine and infratemporal fossa.

Endoscopic transmaxillary approaches to remove juvenile nasopharyngeal angiofibromas (JNAs) have been described previously and are used for tumors that extend laterally in the pterygopalatine fossa (PPF) and infratemporal fossa (ITF). There is no previous description of robotic-assisted JNA removal in the literature. The video will demonstrate the success of this technique. Robotic transmaxillary approaches to the lateral PPF and ITF are easily achieved through an extended Caldwell-Luc antrostomy. Total operative time was 519 minutes. Total robotic operative time was 283 minutes. The endoscopic approach provided no assistance in tumor dissection or removal. Robotic-assisted transmaxillary JNA removal allows the operating surgeon to control the endoscope and to operate free of collisions from the robotic console while having an active assistant surgeon at the patient bedside. A video demonstrating the technique is found on Head & Neck's web site.

Decision Quality Among Parents Who Are Offered Ventilation Tube Insertion for Their Children.

OBJECTIVE: To develop a Decision Quality (DQ) tool to measure parents' DQ concerning ventilation tube (VT) insertion in their children. METHOD: Parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic comparing a validated Decisional Conflict (DC) scale with a DQ instrument including Shared Decision-Making (SDM) scale, parental treatment goals, and knowledge about VT. RESULTS: Of 100 parent participants, 83% were mothers and 14% were fathers. 94% elected VT insertion, 6% elected monitoring or deferred the decision. 44% of the patients were <18 months, 42% were 19 months to 3 years, and the rest were older. The mean DC score was 8.26 out of 100 (95% CI 4.82-11.69), indicating low DC. Mean DQ score was 82.45 out of 100 (95% CI 80.18-84.72), including mean SDM of 87.71 (95% CI 83.53-91.88,), mean knowledge score of 87.5% (95% CI 84.56-91.59) and mean values score of 7.16 (95% CI 6.90-7.41). Comparisons between those who elected VT and those who did not showed that electors had lower DC scores (7.15 vs 24.74, P < .001), higher DQ scores (83.00 vs 72.61, P = .028) with higher SDM scores (88.70 vs 70.22, P = .044) and higher values score (7.20 vs 6.36, P = .034). Cronbach alpha for the DQ scale was 0.76. Spearman's rho for DQ score versus DC score was -0.458, P < .001. CONCLUSIONS: DQ, as measured with this tool, was higher when parents chose to place tubes. Our DQ instrument has potential use for study of why parents may decline VT when their child meets criteria for them.