Persistent sleep disordered breathing after adenoidectomy and/or tonsillectomy: a long-term survey in a tertiary pediatric hospital.

PURPOSE: To determine the long-term prevalence of persistent sleep disordered breathing (SDB) in children, after adenoidectomy, tonsillectomy or adenotonsillectomy, and to assess the relationship between baseline characteristics and persistent nocturnal symptoms. METHODS: The clinical charts of children operated for adenoidectomy and/or tonsillectomy in a tertiary hospital, between January 2000 and March 2016, were retrospectively reviewed. All patients who had signs of SDB prior to surgery received a six-question validated pediatric questionnaire, the Hierarchic Severity Clinical Scale (HSCS). RESULTS: A total of 4000 children showing SDB prior to surgery were selected out of 5809 (68.9%); 1176 parents returned the questionnaire (29.4%), with a mean age at surgery of 4.3 ± 2.2 and age at survey of 9.6 ± 3.6. Complete resolution of SDB was subjectively reported in 798 patients (67.9%), and mild SDB was suspected in 301 children (25.6%, HSCS > 0 with chronic snoring), while 77 (6.5%) had a HSCS > 2.72, suggesting persistent obstructive sleep apnea. In non-syndromic children, male sex, history of sole adenoidectomy, or sole tonsillectomy, and early age of surgery (< 2 years-old) were associated with higher HSCS scores (p < 0.05). Moreover, symptoms had a tendency to decrease from 1 to 6 years, re-occur at age 7-8, and also after 13, with boys reporting more severe symptoms, at a younger age. CONCLUSIONS: Surgical excision of lymphoid tissue to treat SDB in childhood seems to be effective in the long term in two-thirds of subjects, while partial surgeries, specific age groups and early surgery are more likely to have persistent or recurrent symptoms.

Ceftriaxone for refractory acute otitis media: impact of a clinical practice guideline.

OBJECTIVE: To determine the effect of a clinical practice guideline (CPG) on the use of ceftriaxone for the treatment of refractory acute otitis media (AOM) at a tertiary care pediatric hospital. METHODS: Charts of all patients aged 3 to 60 months referred from an emergency department to a day treatment center for management of refractory AOM with ceftriaxone were reviewed. Data were collected during two 18-month periods before and after implementation of a CPG developed by a local group of experts. Ceftriaxone was indicated for children with symptomatic AOM despite 48 hours of treatment with high-dosage amoxicillin or amoxicillin-clavulanate (>75 mg/kg per day) or despite receiving 1 of these 2 antibiotics over the previous month. Overall treatment was considered adequate if patients met these indications for ceftriaxone, if at least 3 daily doses had been prescribed, and if all doses were within the 40- to 60-mg/kg range. RESULTS: Thirty-two emergency physicians referred 127 patients to the day treatment center (60 preimplementation and 67 postimplementation of the CPG). The mean (SD) patient ages were 16.7 (7.4) and 19.7 (12.4) months in the preimplementation and postimplementation groups, respectively. Indications for prescription of ceftriaxone were adequate in 16.7% of the preguideline and 22.4% of the postguideline groups (P = 0.4). Physicians were twice as likely to use ceftriaxone adequately after the guideline's implementation, but this result was not statistically significant (crude odds ratio, 2.2; 95% confidence interval, 0.5-9.0). CONCLUSIONS: Implementation of a CPG for the treatment of refractory AOM with ceftriaxone did not improve indications for its use.

Characteristics of children with refractory acute otitis media treated at the pediatric emergency department.

INTRODUCTION: Refractory acute otitis media (rAOM) is defined as the persistence of signs and symptoms of AOM for more than 48 to 72 hours after the initiation of antibiotic treatment. These patients are often referred to the pediatric emergency department (PED). We sought to study rAOM cases referred to our PED, and to evaluate their clinical characteristics and response to our local management guidelines. METHODS: A retrospective chart review of all children treated for rAOM between 1/2012-3/2014 was performed. Data recorded included demographics, clinical presentation, antibiotic treatments, need for surgery, and culture results. RESULTS: A total of 255 patients were included with a mean age of 19 months. Prior to admission, all the children had received at least one course of antibiotics. Amoxicillin was the most common first-line antibiotic prescribed while amoxicillin-clavulanic acid was the most common second and third-line antibiotic given. Intravenous ceftriaxone was the treatment administered at the PED. Myringotomy and pressure equalizing tube (PET) insertion were required in 60% of cases. Middle ear cultures (55 ears) were positive for Streptococcus pneumoniae in two, and Moraxella catarrhalis in only one culture. There were no differences between the mean age of children who had PET insertion and those who did not with regards to fever, rhinorrhea, and preschool or school attendance. Children presenting with otorrhea were less likely to undergo surgery (P = 0.013). CONCLUSIONS: This is the first study evaluating the established local practice guideline with regards to clinical characteristics and need for surgical management. We showed that myringotomy and PET insertion due to antibiotic failure is commonly performed for cases of rAOM. The majority of the middle ear cultures were sterile.

Advantages of hyaluronic acid fat graft myringoplasty over fat graft myringoplasty.

OBJECTIVES: To compare hyaluronic acid fat graft myringoplasty (HAFGM) with fat graft myringoplasty (FGM) on grade I tympanic membrane perforations (TMPs) (<25% of the tympanic membrane surface) and to assess 12-month postoperative hearing outcomes in a pediatric population. DESIGN: Prospective study. SETTING: Tertiary care pediatric center. PATIENTS Ninety-two children with a TMP were included in the study and were operated on using either the HAFGM (n = 50) or FGM (n = 42) technique. Age at surgery ranged from 4 to 17 years (mean age, 11.52 years). INTERVENTIONS: Hyaluronic acid fat graft myringoplasty is a new technique for TMP repair in a pediatric population and is performed using local anesthesia at the outpatient office. MAIN OUTCOME MEASURES: Postoperative status of the tympanic membrane, hearing improvement, and incidence of complications. RESULTS: Successful closure of the tympanic membrane was achieved in 90% of the HAFGM group and in 57.1% of the FGM group (P = .004). The mean (SD) postoperative air-bone gap in the HAFGM (6.86 [8.52] dB) group was significantly lower than in the FGM (18.32 [13.44] dB) group (P < .002). The mean postoperative follow-up time was 31.5 and 34.7 months for HAFGM and FGM groups, respectively. No difference was observed between children 10 years or younger and children older than 10 years. In the 2 groups, no postoperative complications were observed. The location of the perforation was not found to be a factor indicative of failure. CONCLUSIONS: The success rate of HAFGM is superior to that of FGM alone. Hyaluronic acid fat graft myringoplasty can be performed as an office-based procedure using local anesthesia and requires no hospitalization. Because of its substantial advantages, HAFGM could be considered as the first choice for the reconstruction of a dry TMP in the pediatric population.

Tympanic membrane perforation: size, site and hearing evaluation.

OBJECTIVE: To assess different clinical scales of TM perforation size; to evaluate the effect of the size and the site of a perforation on the hearing level and frequencies. METHODS: Prospective study. Observers had subjectively estimated the size in millimeter and in percentage of a particular perforation; objectively computerized measures of TM perforations area were analyzed. Agreement between different measures was studied. Cases with postoperative intact TM and an air-bone gap (ABG) of 10 dB or less were studied. RESULTS: Global mean preoperative ABG was 21.8 ± 17 dB. Preoperative ABG was different between small-large and small-total perforations (p=0.001). Difference of the preoperative ABG was statistically significant between perforations filling up the four quadrants and perforation limited to one quadrant in the postero-inferior, antero-superior and antero-inferior site. No statistically difference between perforation sites was identified for each affected frequency. Difference is statistically significant (p=0.001) between the 250 Hz and the other frequencies for the medium, large and total perforations. After myringoplasty bone conduction improvement was statistically significant for the frequencies 500 (p=0.04), 1000 (p=0.04) and 2000 Hz (p=0.011). Agreement was large enough when TM perforation size was expressed in percentage and absent when expressed in millimeter. CONCLUSION: TM perforation can be clinically estimated quite precisely as a percentage of the TM area. Conductive hearing loss is frequency dependent; with the greatest loss occurring at the lowest sound frequencies. Hearing loss does not depend on the perforation's location.

Advantages of subannular tube vs repetitive transtympanic tube technique.

OBJECTIVES: To compare the efficiency of the subannular T-tube (SAT) vs that of the repetitive transtympanic Duravent tube (TTT) in children with recurrent or chronic otitis media (OM) with effusion or tympanic membrane retraction and to establish which population would be more likely to benefit from TTTs vs SATs. DESIGN: Medical record review. SETTING: Tertiary care pediatric center. PATIENTS: Children receiving an SAT (234 in 160 patients) or at least 2 TTTs (216 in 111 patients) between January 1, 2002, and December 31, 2006, to allow at least 4 years of follow-up from that period until 2010. MAIN OUTCOME MEASURES: Average tube duration and complication rates. RESULTS: The tubes remained in place for a median of 35 months with SAT and 7 months with TTT (P < .001). Overall complication rates were lower with SAT (otorrhea, 21.4%; perforation, 7.7%; plugged tube, 13.7%; new acute OM, 13.7%; new serous OM, 5.1%; and cholesteatoma, 1.7%) than with TTT (otorrhea, 26.9%; perforation, 5.1%; blocked tube, 20.8%; new acute OM, 23.1%; new serous OM, 37.5%; and cholesteatoma, 0.46%). Differences were statistically significant for otorrhea, blocked tube, and new acute and serous OM (P < .001). With similar rates, TTTs and SATs were used more frequently in acute (P = .26) and serous (P = .32) OM, whereas SATs were placed more often in adhesive OM and retracted tympanic membrane (P < .001). CONCLUSIONS: Insertion of an SAT is a safe and effective method for long-term middle ear ventilation in recurrent or refractory OM, adhesive OM, and retracted tympanic membrane. Associated with fewer complications, SATs offer an alternative to repeated use of the short-term TTTs without damaging the tympanic membrane.

Nontuberculous mycobacterial cervicofacial adenitis in children: epidemiologic study.

OBJECTIVES: To determine whether there is an increase in the incidence of nontuberculous mycobacteria (NTM) adenitis at our tertiary care pediatric hospital and to determine whether there is an association between geographic location and prevalence of cases. Also, to investigate the role of nongeographic risk factors such as bacille Calmette-Guérin (BCG) vaccination in the incidence of NTM adenitis. METHOD: We conducted a retrospective chart review of 153 pediatric patients with NTM adenitis diagnosed between 1994 and 2004 and a prospective telephone survey of geographic and nongeographic risk factors for 82 patients. RESULTS: The annual incidence, calculated with the number of hospitalizations for that year as the denominator, was 25.1 in 100,000 during the 1994-1998 period and 107.4 in 100,000 for 1999-2004. A statistically significant increase in the incidence of NTM adenitis was observed after 1999, with an incidence ratio of 4.28 (95% confidence interval 2.84-6.65; p < .0000). We found a nonsignificant increase in incidence for cases in the suburbs compared with the city. The survey did not reveal any significant risk factors for NTM adenitis in our population. However, none of the affected children had had the BCG vaccination. CONCLUSION: There has been a significant increase in the incidence of NTM adenitis at our tertiary care centre, particularly since 1999. No clear risk factors could be identified to account for this increase, even though geographic location and discontinuation of BCG vaccination could be implicated. More studies are needed to confirm those hypotheses.

3-year impact of a provincial choking prevention program.

OBJECTIVE: To determine the impact of a provincial choking prevention program (CPP) on the incidence of aerodigestive foreign body cases among children. METHODS: The CPP, including posters, pamphlets, an informative video, and annual participation in the Parents & Kids Fair, was launched throughout Quebec in October 1999. The incidence rates of aerodigestive foreign body cases prior to implementation (during 1997-1998) and subsequently (2000-2002) within the province and our tertiary care centre (Sainte-Justine Hospital) were compared by estimating incidence rate ratios (IRRs) and associated 95% confidence intervals (95% CIs). RESULTS: No significant changes in the incidence of aerodigestive foreign body cases after program implementation were observed in our hospital (age-adjusted IRR 0.92, 95% CI 0.79-1.07). The provincial rates were higher after program implementation (age-adjusted IRR 1.15, 95% CI 1.05-1.25). CONCLUSIONS: To influence choking prevention habits, modifications to the campaign are required. Strategies are discussed.

Subannular ventilation tubes: retrospective study.

OBJECTIVE: To evaluate the efficiency of a subannular tube insertion technique in a group of pediatric patients with adhesive otitis or severe atelectasis of the tympanic membrane. DESIGN: Retrospective nonrandomized case series. SETTING: Tertiary referral centre. MAIN OUTCOME MEASURES: The main outcomes of this study are tube duration according to the type of tube used, the complication rate, and the audiometric gain associated with this procedure. RESULTS: The study group consisted of 190 patients (316 tubes) aged between 3 and 19 years (average 9 years old) and operated on between 1993 and 1999 by four pediatric otolaryngologists. The average follow-up was 53 months. The tubes remained in place for an average of 21.8 months, with fluoroplastic tubes lasting 17.8 months and Goode T tubes lasting 23.8 months. When used in children between 5 and 9 years of age and in cases of adhesive otitis, Goode T tubes showed statistically significantly better results than fluoroplastic tubes. The complications of this technique were otorrhea (17.7%), perforation (7.9%), a plugged tube (7.0%), and cholesteatoma (1.6%). The 5- to 9-year-old group and the reintervention group of patients showed statistically higher complication rates compared with all other groups. Sixty-four patients (128 tubes) were eligible for audiogram analysis, which showed a gain of 13.4 dB (speech reception threshold). CONCLUSIONS: The technique of subannular tube insertion is a safe and effective method for long-term middle ear ventilation in cases of adhesive otitis or severely atelectatic tympanic membrane or for patients with pathology related to dysfunction of the eustachian tube. It offers an alternative to repeated short-term tube insertions for otitis media with effusion or recurrent acute otitis media.