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INTRODUCTION: Botox is frequently used for sialorrhea in patients with compromised airways and those with etiologies causing difficulty with secretion management (i.e. strokes, neurologic disorders, etc.). There are no published studies regarding the use of botulinum toxin (BoNT) in the neonate population. We aim to discuss our experience and safety of BoNT use in the neonate population in regards to alleviating secretion management and airway protection. METHODS: Retrospective review of neonates admitted to the neonatal intensive care unit (NICU) ≤12 months of age who received BoNT injection to submandibular (SMG) and parotid (PG) glands for sialorrhea/dysphagia. BoNT was administered under ultrasound (u/s) guidance by interventional radiology. RESULTS: 6 children were examined. 2 (33 %) were male. Avg NICU stay was 87.5 ± 33.1 days. 2 underwent surgical airway intervention prior to injection. Mean age at initial BoNT was 1.5 ± 0.7 months. Avg weight at injection was 4 ± 1.1 kg. Each PG and SMG were injected in 5/6 cases. Bilateral SMG were unidentified on u/s in 1 case and thus not injected. Dose range injected per gland was 5-15u. 100 % required tube feeds, 50 % with tubes distal to stomach (NJT/NDT). 83 % were completely NPO prior to injection and there was no noted clinical improvement in oral skills post injection. All had noted desats/apneas prior to injection and 83 % had reported decreased events post injection. 50 % had reported decrease O2 requirements and frequent suctioning 2wks after injection, however 2 (33 %) required surgical airway intervention after injection (trach, SGP/MDO). 4/6 (67 %) trialed medical therapy, anticholinergics being the most common. 50 % underwent 2nd injection (age = 6.5 ± 0.3 months) avg. 4.7 ± 0.7mo after 1st injection, and the same 3pts underwent 3rd injection (age = 12.5 ± 2.4 months) avg. 6.1 ± 2.5mo after 2nd injection. 1 pt. had a total 6 injections. There were no injection related complications. CONCLUSION: BoNT injection is a safe, non-invasive alterative for management of sialorrhea in neonates. Further extensive study needs to be performed to identify the optimal dose per gland in this population.
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Toxinas Botulínicas Tipo A , Transtornos de Deglutição , Sialorreia , Humanos , Sialorreia/tratamento farmacológico , Sialorreia/etiologia , Estudos Retrospectivos , Masculino , Feminino , Recém-Nascido , Toxinas Botulínicas Tipo A/administração & dosagem , Transtornos de Deglutição/tratamento farmacológico , Transtornos de Deglutição/etiologia , Lactente , Resultado do Tratamento , Glândula Submandibular , Glândula Parótida , Unidades de Terapia Intensiva NeonatalRESUMO
OBJECTIVES: To compare the mean pre-operative air-bone gaps (ABG), mean post-operative ABGs, and extrusion rates between pediatric recipients of partial ossicular reconstruction prostheses (PORPs) and pediatric recipients of total ossicular reconstruction prostheses (TORPs) via a systematic review and meta-analysis. METHODS: A quantitative systematic review last updated on September 29, 2021 of PubMed, Scopus, and Embase databases was conducted for studies reporting mean post-operative ABGs or numbers of children with post-operative ABG ≤ 20 dB following PORP and TORP procedures in at least five children aged 0-18 years. Studies were excluded if they were review articles, conference abstracts, or not in English. Studies that primarily reported data on congenital aural atresia, stapedectomy/stapedotomy, congenital stapes fixation, or juvenile otosclerosis were also excluded. NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess for risk of bias. Review Manager (RevMan) version 5.4.1 was used to perform the meta-analysis and generate forest plots. RESULTS: Out of 648 unique abstracts retrieved, 11 papers were included in this systematic review with meta-analysis. Data from 449 children (247 TORP recipients and 202 TORP recipients) are represented among the various analyses. Data from nine studies, representing 84.2 % of all children in the systematic review, demonstrated that PORP recipients presented with a pre-operative ABG 6.30 dB less than TORP recipients (mean difference: -6.30, 95 %CI: -7.4, -5.18, p < 0.01). Data from these same children demonstrated that PORP recipients had a 1.80 dB less post-operative ABG compared to TORP recipients (mean difference: -1.80 dB, 95 %CI: -2.84, -0.77, p < 0.001). Data from seven studies, representing 49.4 % of all children in the systematic review, demonstrated that PORP recipients were more likely to have a successful closure of the post-operative ABG to ≤20 dB (OR: 2.12, 95 %CI: 1.18, 3.79, p = 0.01). In these same children, 62.5 % of PORP recipients had a post-operative ABG ≤ 20 dB and 48.3 % of TORP recipients had a post-operative ABG ≤ 20 dB. There was no difference in extrusion rates between PORP recipients compared to TORP recipients (OR: 1.08, 95 %CI: 0.31, 3.78, p = 0.90) from five studies representing 45.9 % children in the systematic review. CONCLUSION: Children who receive a PORP have better pre-operative hearing baselines and post-operative hearing outcomes compared to those who receive TORP with similar rates of extrusion. More pediatric studies should report their mean pre- and post-operative ABGs stratifying by various material types, surgical indications, and surgical details to facilitate future meta-analyses.
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Prótese Ossicular , Substituição Ossicular , Cirurgia do Estribo , Criança , Humanos , Substituição Ossicular/métodos , Estudos Transversais , Resultado do Tratamento , Estudos RetrospectivosRESUMO
PURPOSE: A novel "Modified TCA Alloderm™ Myringoplasty" (TCA myringoplasty) technique for reconstruction of uncomplicated chronic tympanic membrane (TM) perforations is described. MATERIALS AND METHODS: Descriptive surgical technique for TCA myringoplasty on 12 total patients from 1/1/2020 to 12/31/2020. 3 patients were excluded for incomplete records. Statistical analysis employed Wilcoxon signed-rank tests. Both structural (pre/post visual inspection and tympanogram) and functional (pre/post pure tone average, PTA) outcome measures are reported. RESULTS: 12 total ears were analyzed from 9 patients. Average age at surgery was 6 (range 3-22). Perforation size ranged from 10 to 60 %. Rate of structural success was 100 %. Functionally, postoperative PTA were significantly decreased from preoperative (mdn(range) = 18.44(13.13-24.38) vs mdn(range) = 11.25(6.25-22.50), p = .008). Only one TM required >1 procedure to achieve closure. CONCLUSIONS: Chronic TM perforations are typically reconstructed via Type I tympanoplasties with temporalis fascia, reserving myringoplasty for favorable perforations (<25 % in size and posterior). Our novel TCA myringoplasty technique has excellent outcomes independent of size and location. We apply a chemical peel concept to a modified myringoplasty technique, obviating incisions and graft harvest. Advantages of Alloderm™ include: 1) a more rigid graft, facilitating manipulation and precise placement; 2) various size and thickness options, especially useful for dimeric tympanic membranes, tympanolysis of adhesions, and bilateral perforations; 3) no donor morbidity and harvest time; 4) autologous tissue preservation. The sole disadvantage of cost is mitigated by reduced operative time and complication management. This study revealed encouraging proof-of-concept preliminary data warranting prospective and sufficiently powered analysis, supporting the technique as a viable alternative to the gold standard.
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Perfuração da Membrana Timpânica , Membrana Timpânica , Humanos , Criança , Membrana Timpânica/cirurgia , Miringoplastia/métodos , Ácido Tricloroacético , Estudos Prospectivos , Resultado do Tratamento , Estudos Retrospectivos , Perfuração da Membrana Timpânica/cirurgiaRESUMO
OBJECTIVE: Puberty has been shown to accelerate growth of vascular malformations, including lymphatic (LM) and venous malformations (VM). This study aims to compare the number of procedures performed before and after puberty in patients with LM and VM to assess whether the onset of puberty results in higher treatment frequency. METHODS: A retrospective review of head and neck LM and VM patients who were evaluated between January 2009 and December 2019 was performed. Patient demographics, lesion characteristics, and procedural details were recorded. For the purposes of this study, 11 years or older in females and 12 years or older in males were the established cut-offs for the onset of puberty. RESULTS: After initial screening of 357 patients, 83 patients were included in the study based on inclusion criteria. There were 34 patients with LM (41 %) and 49 with VM (59 %). The mean age at diagnosis was 6.1 ± 10.9 years (LM: 4.2 ± 7.0, VM: 7.4 ± 12.9, p = 0.489). 68 patients underwent treatments, which included sclerotherapy, surgical excision, and/or laser. For all patients, the average number of lifetime treatments when initiated before puberty was 3.78 ± 2.81 and when initiated after puberty was 2.17 ± 1.37 (p = 0.022). Patients diagnosed pre-puberty were more likely to undergo treatments vs. those diagnosed after puberty (OR 10.00, 95 % CI: 2.61-38.28, p < 0.001). CONCLUSION: We found that the number of treatments was fewer in those who started treatment after puberty. This finding suggests that providers may elect to proceed with observation in asymptomatic patients, given that waiting until after the onset of puberty has not shown an increase in the procedural load on patients.
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Soluções Esclerosantes , Malformações Vasculares , Masculino , Feminino , Humanos , Criança , Adolescente , Resultado do Tratamento , Pescoço , Cabeça , Malformações Vasculares/terapia , Estudos RetrospectivosRESUMO
OBJECTIVE: Investigate associations between socioeconomic indicators of healthcare access with family compliance with cleft-related otologic and audiologic care within an interdisciplinary model. DESIGN: Retrospective case series. SUBJECTS AND SETTING: Children born 2005-2015 who presented to the Cleft-Craniofacial Clinic (CCC) at a quaternary care children's hospital. INTERVENTIONS: Associations between main outcome measures and Area Deprivation Index (ADI), median household income for zip code, distance from hospital, and insurance status were evaluated. MAIN OUTCOME MEASURES: Cleft types, ages at presentation to outpatient clinic (cleft, otolaryngology, and audiology), and ages at procedures (first tympanostomy tube insertion (TTI), lip repair, and palatoplasty) were measured. RESULTS: Most patients were male (147/230, 64%) with cleft lip and palate (157/230, 68%). Median age at first cleft, otolaryngology, and audiology visits were 7 days, 86 days, and 5.9 months, respectively. Private insurance predicted lower no-show rates (p = .04). Age at first CCC visit was younger for patients with private insurance (p = .04) and older for those who lived further from the hospital (p = .002). Age at lip repair was positively correlated with national ADI (p = .03). However, no socioeconomic status (SES) proxy or proximity to hospital was associated with delays in first otolaryngology or audiology examination or TTI. CONCLUSION: Once children become established within an interdisciplinary CCC, SES appears to bear little influence on cleft-related otologic and audiologic care. Future efforts should aim to elucidate which aspects of the interdisciplinary model maximize multisystem cleft care coordination and increase access for higher risk populations.
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OBJECTIVE: Up to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure. METHODS: Patients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups. RESULTS: A total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010. CONCLUSION: Closure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.
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Fístula Cutânea , Doenças da Traqueia , Adolescente , Adulto , Criança , Pré-Escolar , Fístula Cutânea/etiologia , Fístula Cutânea/cirurgia , Humanos , Lactente , Recém-Nascido , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Doenças da Traqueia/etiologia , Doenças da Traqueia/cirurgia , Traqueostomia/efeitos adversos , Traqueostomia/métodos , Adulto JovemRESUMO
OBJECTIVE: Evidence supporting the use of acid suppression therapy (AST) for laryngomalacia (LM) is limited. The objective of this study was to determine if outpatient-initiated AST for LM was associated with symptom improvement, weight gain, and/or avoidance of surgery. METHODS: A retrospective cohort was reviewed at a tertiary-care children's hospital. Patients were included if they were diagnosed with LM at ≤6 months of age, seen in an outpatient otolaryngology clinic between 2012 and 2018, and started on AST. Primary outcomes were improvement of airway and dysphagia symptoms, weight gain, and need for surgery. Severity was assessed by symptom severity. RESULTS: Of 2693 patients reviewed, 199 met inclusion criteria. Median age of diagnosis was 4 weeks (range: 0-29 weeks). LM was classified as mild/moderate (71.4%) and severe (28.6%) based on symptom severity. Severity on flexible fiberoptic laryngoscopy (FFL) was not associated with clinical severity. Weight percentile, airway symptoms, and dysphagia symptoms improved within the cohort. In total, 26.1% underwent supraglottoplasty (SGP). In multivariate analysis, only severe LM on FFL was predictive of SGP (OR: 7.28, 95%CI: 1.91-27.67, p = .004). CONCLUSION: Clinical symptom severity did not predict response to AST raising the question of utility of AST in LM. Severity of LM based on FFL, not clinical severity, was associated with decision to pursue SGP. Prospective randomized trials are needed to better understand the role of AST in LM. LEVEL OF EVIDENCE: Level 3.
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Transtornos de Deglutição , Laringomalácia , Criança , Transtornos de Deglutição/tratamento farmacológico , Transtornos de Deglutição/etiologia , Humanos , Lactente , Recém-Nascido , Laringomalácia/complicações , Laringomalácia/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Aumento de PesoRESUMO
OBJECTIVES: To determine if children with cystic fibrosis (CF) who are otitis media prone and treated with tympanostomy tube placement (TTP) follow the natural course of non-CF children regarding the incidence of tympanostomy tube otorrhea (TTO) (21-34%). METHODS: All CF patients seen at a large tertiary pediatric hospital were retrospectively reviewed from 2010 to 2019. A total of 483 patients were identified and seventeen met the inclusion criteria and were included in the analysis. Data collected included demographics, CF diagnosis history including date of diagnosis and genotype, TTP notes, and otorrhea found in otolaryngology clinic and pediatrician clinic notes for up to 18 months post-TTP. RESULTS: CF was diagnosed at a median age of 13 days (0 days to 6 years). In terms of surgical frequency, 14/17 (82.4%) patients had one TTP, 2/17 (11.8%) had two TTPs, and 1/17 (5.9%) had five TTPs. The median (range) age at first TTP was 2 years (3 months to 13 years). After the first TTP, TTO occurred in 5 (29.4%) patients at 3 months, 6 (35.3%) at 6 and 9 months, and 7 (41.2%) at 12 and 18 months at median (range) = 1 (0-5) otolaryngology appointments and median (range) = 0 (0-8) pediatrician appointments. CONCLUSION: To our knowledge this is the first study to report that CF children are more likely to be severely affected with recurrent acute otitis media (RAOM), to require TTP, and to exhibit a natural history of TTO commensurate with the non-CF population.
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Fibrose Cística/complicações , Ventilação da Orelha Média/métodos , Otite Média/cirurgia , Doença Aguda , Fatores Etários , Otorreia de Líquido Cefalorraquidiano/epidemiologia , Otorreia de Líquido Cefalorraquidiano/etiologia , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Ventilação da Orelha Média/efeitos adversos , Otite Média/etiologia , Gravidade do Paciente , Recidiva , Estudos Retrospectivos , Fatores de TempoRESUMO
OBJECTIVE: To determine if barriers to cochlear implantation (CI) exist with respect to Amish children and to describe unique considerations associated with CI and subsequent otologic care in the Amish population. METHODS: Out of all patients who underwent CI at a tertiary care pediatric hospital from 2008 to 2019, Amish children were age-matched to the remainder of the cohort to compare demographics and care-related metrics including etiology of hearing loss, age at time of initial hearing-related appointment and at CI, total number of pre- and post-operative audiologic and otologic appointments, and post-operative complications. Social considerations that may pose barriers to care were collected for descriptive analysis. RESULTS: Since 2008, 232 children underwent CI, of which 8 implants were performed on Amish children. Six (75%) Amish children underwent newborn hearing screening and 3(38%) were found to have syndromic etiology for hearing loss. While Amish patients had a lower number of both audiologic (15 vs 33.5, p<.001) and otologic (4.5 vs 8.5, p=.028) appointments when compared to age-matched controls, median age at the time of implantation for the whole sample was not different between groups (2.5 vs 2.0 years, p=.211). From a social standpoint, limitations in transportation, telephone communication, and ability to recharge processor batteries must be considered in the Amish population. CONCLUSION: Amish children undergoing CI face unique barriers to care including transportation and technologic limitations, leading to overall fewer hearing-related appointments when compared to an age-matched cohort. Understanding societal differences is important to facilitate optimal care for Amish children with hearing loss.
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Amish , Implante Coclear , Acessibilidade aos Serviços de Saúde , Perda Auditiva/cirurgia , Fatores Etários , Agendamento de Consultas , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Perda Auditiva/diagnóstico , Perda Auditiva/epidemiologia , Perda Auditiva/etiologia , Testes Auditivos , Humanos , Lactente , Recém-Nascido , Masculino , Fatores SociológicosRESUMO
PURPOSE: Recent data have challenged the historical paradigm that cystic fibrosis (CF) protects against otitis media (OM). These findings raised questions about the pathogenesis of this ostensible change. In this study our aim is to characterize acute OM (AOM) risk based on CF genotype. METHODS: A retrospective chart review was completed at a tertiary care pediatric hospital. Charts of 159 CF patients seen at our facility from 2010 to 2019 were reviewed. Data collected included demographics, AOM infections, cystic fibrosis transmembrane conductance regulator (CFTR) allele mutations, pulmonary exacerbations (PE), and pancreatic insufficiency (PI) status. Mutation alleles were divided into five classes based on CF guidelines, which were further classified as severe (classes I-III) or mild (classes IV-V). RESULTS: 54% of patients had at least one episode of AOM with a mean of 1.5 episodes of AOM (standard deviation = 2.3). 86% of patients had severe/severe (S/S) alleles and 14% had severe/mild (S/M). S/S patients had significantly more PE (p = .004) and increased rates of PI (p < .001). Of the 131 patients with S/S mutations, 57% had an episode of AOM while only 46% the 22 S/M patients had an AOM episode (p = .357). CONCLUSIONS: To our knowledge this is the first report showing a clinical trend towards increased middle ear disease in patients with severe CFTR mutations. Future prospective studies will be powered to demonstrate whether this trend is statistically significant. Patients with S/S mutations not only have more severe clinical phenotypes but may have additional unexpected complications such as middle ear disease.
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Regulador de Condutância Transmembrana em Fibrose Cística/genética , Fibrose Cística/genética , Mutação , Otite Média/genética , Adolescente , Alelos , Criança , Pré-Escolar , Fibrose Cística/complicações , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Otite Média/epidemiologia , Otite Média/etiologia , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: Geographic information systems (GIS) provide a unique set of tools to spatially analyze health care and identify patterns of health outcomes to help optimize delivery. Our goal is to create maps of pediatric tracheostomy patients using GIS to assess socioeconomic and other factors that impact postoperative care after discharge to home. METHODS: A retrospective study was performed on patients (≤21 years old) who underwent tracheostomy at a tertiary care pediatric hospital from January 1, 2015 to December 31, 2020. Using GIS, we geocoded patient addresses and conducted spatial analyses of the relationship between patients and access to health care providers as well as vulnerable population factors including poverty, educational attainment, and single-parent households. RESULTS: A total of 156 patients were included. Patients initially discharged to transitional care (108/156, 69.2%) had significantly higher likelihood of presenting to the ED regardless of socioeconomic status (OR: 2.28, 95% CI: 1.03-5.05; p = 0.042). There was no relationship between ED visit rate and median household income, poverty level, and percentage of uneducated adults (p = 0.490; p = 0.424; p = 0.752). Median distance to the tertiary care pediatric hospital was significantly longer for patients with no ED visit (median = 61.28 miles; SD = 50.90) compared with those with an ED visit (median = 37.75 miles; SD = 35.92) (p = 0.002). CONCLUSION: The application of GIS could provide geo-localized data to better understand the healthcare barriers to access for children with tracheostomies. This study uniquely integrates medical record data with socioeconomic factors and social determinants of health. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1919-1925, 2024.
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Sistemas de Informação Geográfica , Renda , Adulto , Criança , Humanos , Adulto Jovem , Estudos Retrospectivos , Fatores Socioeconômicos , Acessibilidade aos Serviços de SaúdeRESUMO
INTRODUCTION: Subperiosteal orbital abscesses (SPOA) are the most common suppurative complications of acute bacterial sinusitis. Medial SPOAs arise from infection of the ipsilateral ethmoid sinus and favor initial conservative management reserving surgical drainage for patients who do not demonstrate clinical improvement. No standard algorithm defining medical versus surgical treatment of medial SPOAs exist in the pediatric population. OBJECTIVES: To identify a size cutoff for medial SPOAs to predict the likelihood for surgical drainage. METHODS: This is a retrospective review of patients with medial SPOAs at a tertiary care center from 2003 to 2017. Diagnosis of SPOA was based on radiographic findings. Variables included are patient demographics, antibiotic therapy, surgical intervention, and length of stay. RESULTS: 82 patients with a medial SPOA were included with an average age at presentation of 6.27 (range 0-15) years were included in this study. 62 patients were male (75.6 %), and 20 were female (24.4 %). The average abscess length was 16.1 mm, range 4.5-30.7 mm. The average abscess width was 4.17 mm, range 1.5-14.6 mm. The odds ratio for surgical treatment with every 1 mm increase in abscess width was 1.89 (95CI:1.33-2.69, p < 0.001). Abscesses over 3.6 mm width were 6.65 times more likely to undergo surgical drainage than those less than 3.6 mm (OR:6.65, 95CI:2.52-17.54, p < 0.001). The average(SD) length of stay was 5.4(3.0) days for patients who underwent surgery and 4.0(0.9) days for patients treated with conservative measures, p < 0.001. CONCLUSION: Medial SPOAs greater than 3.6 mm were more likely to undergo surgical drainage; however there was no difference in the likelihood of drainage between anteriorly and posteriorly based medial abscesses. These findings help further characterize the landscape of pediatric subperiosteal abscesses that are managed with surgical drainage.
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Abscesso , Drenagem , Doenças Orbitárias , Humanos , Feminino , Masculino , Criança , Estudos Retrospectivos , Abscesso/terapia , Abscesso/cirurgia , Adolescente , Pré-Escolar , Drenagem/métodos , Lactente , Doenças Orbitárias/terapia , Doenças Orbitárias/cirurgia , Sinusite/terapia , Sinusite/cirurgia , Sinusite/microbiologia , Antibacterianos/uso terapêutico , Recém-Nascido , Resultado do Tratamento , Tomografia Computadorizada por Raios X , Tempo de Internação/estatística & dados numéricosRESUMO
OBJECTIVE: While management protocols of pediatric esophageal foreign bodies (EFBs) are well-delineated, resource utilization can be improved. This study's objectives were to explore hospital charges/costs for pediatric patients who present with EFBs and to identify patient risk factors associated with esophageal injury. METHODS: A retrospective chart review of patients undergoing aerodigestive foreign body removal at a tertiary-care children's hospital from 2018 to 2021 was conducted. Data collected included demographics, medical history, presenting symptoms, EFB type, surgical findings, and hospital visit charges/costs. RESULTS: 203 patients were included. 178 of 203 (87.7%) patients were admitted prior to operation. Unwitnessed EFB ingestion (p < 0.001, OR = 15.1, 95% CI = 5.88-38.6), experiencing symptoms for longer than a week (p < 0.001, OR = 11.4, 95% CI = 3.66-38.6) and the following presenting symptoms increased the odds of esophageal injury: dysphagia (p = 0.04, OR = 2.45, 95% CI = 1.02-5.85), respiratory distress (p = 0.005, OR = 15.5, 95% CI = 2.09-181), coughing (p < 0.001, OR = 10.1, 95% CI = 3.73-28.2), decreased oral intake (p = 0.001, OR = 6.60, 95% CI = 2.49-17.7), fever (p = 0.001, OR = 5.52, 95% CI = 1.46-19.6), and congestion (p = 0.001, OR = 8.15, 95% CI = 2.42-27.3). None of the 51 asymptomatic patients had esophageal injury. The median total charges during the encounter was $20,808 (interquartile range: $18,636-$24,252), with operating room (OR) (median: $5,396; 28.2%) and inpatient admission (median: $5,520; 26.0%) contributing the greatest percentage. CONCLUSIONS: Asymptomatic patients with EFBs did not experience esophageal injury. The OR and inpatient observation accounted for the greatest percentage of the hospital charges. These results support developing a potential algorithm to triage asymptomatic patients to be managed on a same-day outpatient basis to improve the value of care. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.
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Introduction Despite several pediatric tracheostomy decannulation protocols there remains tremendous variability in practice. The effect of tracheostomy capping on decannulation has been studied but the role of speaking valves (SVs) is unknown. Objective Given the positive benefits SVs have on rehabilitation, we hypothesized that SVs would decrease time to tracheostomy decannulation. The purpose of the present study was to evaluate this in a subset of patients with chronic lung disease of prematurity (CLD). Methods A retrospective chart review was performed at a tertiary care children's hospital. A total of 105 patients with tracheostomies and CLD were identified. Data collected included demographics, gestational age, congenital cardiac disease, airway surgeries, granulation tissue excisions, SV and capping trials, tracheitis episodes, and clinic visits. Statistics were performed with logistic and linear regression. Results A total of 75 patients were included. The mean gestational age was 27 weeks (standard deviation [SD] = 3.6) and the average birthweight was 1.1 kg (SD = 0.6). The average age at tracheostomy was 122 days (SD = 63). A total of 70.7% of the patients underwent decannulation and the mean time to decannulation (TTD) was 37 months (SD = 19). A total of 77.3% of the patients had SVs. Those with an SV had a longer TTD compared to those without (52 versus 35 months; p = 0.008). Decannulation was increased by 2 months for every increase in the number of hospital presentations for tracheitis ( p = 0.011). Conclusion The present study is the first, to our knowledge, to assess the effect of SVs on tracheostomy decannulation in patients with CLD showing a longer TTD when SVs are used.
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Introduction For multiple reasons, elective pediatric otolaryngology surgical procedures have declined during the COVID-19 pandemic. Objective The purpose of the present study was to assess whether the prevalence of pediatric neck abscesses managed with operative drainage decreased compared with previous years. Methods Medical records of all pediatric cases at a tertiary care children's hospital diagnosed with abscess of the neck and treated with incision and drainage were evaluated between the dates of April 1 and November 30 from 2015 to 2020. Outcomes were compared for each year from 2015 to 2019 to 2020, which included location, abscess size, duration of antibiotic treatment, microbiology, and the number of cases per year. Results A total of 201 cases were included. The mean ± standard deviation (SD) presenting age in the 2015 to 2019 group was 5.05 ± 5.03 years old and 2.24 ± 1.91 years old in the 2020 group. The mean number of cases between 2015 and 2019 was 35.6 ± 4.2, whereas the number of cases in 2020 was 23 ( p = 0.002). Of those patients who underwent IV antibiotic therapy prior to presentation ( n = 43), the mean number of days before admission was 1.98 ± 2.95 ( n = 40) from 2015 to 2019 and 12.00 ± 10.39 ( n = 3) in 2020 ( p = 0.008). The percent of cases with multiple strains cultured between 2015 and 2019 was 13.4% versus 18.2% in 2020 ( p = 0.007). Conclusion There was a decrease in the number of operative neck abscesses in 2020 compared with the mean number per year from 2015 to 2019. COVID-19 mitigation strategies leading to reduced transmission of other viral and bacterial illnesses and a tendency toward prolonged medical management to avoid surgery are two possible explanations.
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OBJECTIVE: To examine the prevalence and nature of nasal endoscopic findings in patients referred for structural nasal obstruction, and analyze how such findings influence the preoperative evaluation or operative plan. STUDY DESIGN: Cross-sectional study. SETTING: University-based academic otolaryngology practice. METHODS: Nasal endoscopy was performed by a single surgeon and the exam findings were documented. Patient demographics, variables in the patient history, Nasal Obstruction Symptom Evaluation scores, and an Ease-of-Breathing Likert Scale were tested for associations with findings on endoscopy. RESULTS: A total of 82 of 346 patients (23.7%) had findings on rigid nasal endoscopy not appreciable on anterior rhinoscopy. Prior nasal surgery (p = .001) and positive allergy testing (p = .013) were significantly associated with findings on nasal endoscopy. Endoscopic findings prompted additional preoperative studies in 50 (14.5%) patients, and a change in the operative plan in 26 (7.5%) patients. CONCLUSION: In patients referred for surgical management of nasal obstruction, findings on nasal endoscopy otherwise undetected with anterior rhinoscopy are most common in but certainly not limited to those with prior nasal surgery or allergic rhinitis. Routine nasal endoscopy should be considered for all patients being evaluated for nasal airway surgery. These results may benefit future updates of the clinical consensus statements regarding the role of nasal endoscopy in the evaluation of nasal valve compromise and septoplasty.
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Obstrução Nasal , Rinoplastia , Humanos , Obstrução Nasal/diagnóstico , Obstrução Nasal/cirurgia , Estudos Transversais , Nariz/cirurgia , Endoscopia/métodos , Rinoplastia/métodos , Septo Nasal/cirurgiaRESUMO
OBJECTIVE: PHACE is a rare syndrome that can present with airway hemangiomas. Management for these patients is variable and the utilization of operative endoscopic airway evaluation has not been described. The objectives of this study were to identify the incidence of airway symptoms in patients being evaluated for PHACE syndrome and determine the utility of operative endoscopy. METHODS: An IRB-approved retrospective cohort study was conducted on consecutive pediatric patients with head and neck infantile hemangioma (IH) evaluated in a multi-disciplinary vascular anomalies center between 2013 and 2019. Patients were included if they were being worked up for PHACE syndrome and had an otolaryngology evaluation. Demographics, clinical, and surgical variables were collected. RESULTS: There were 317 patients with head and neck IH. Thirty-six patients met inclusion criteria. The majority of patients were female (31/36; 86.1%) and less than half of the patients (15/36; 41.7%) were eventually diagnosed with PHACE syndrome. Median age at presentation was 2 months (range 0-82 months). A total of 28/36 (77.8%) of patients were managed with propranolol. The majority of the patients presented without aerodigestive symptoms; however, 16/36 (44.4%) of patients presented with symptoms such as stridor, hoarseness, and dysphagia. A total of 20/36 (55.6%) of patients underwent operative endoscopy. A total of 8/20 (40.0%) of patients who underwent operative endoscopy had operative intervention. Of the entire cohort, only 2/15 (13.3%) patients diagnosed with PHACE were found to have a subglottic hemangioma. Both patients presented with stridor. CONCLUSION: Operative endoscopy remains useful in the workup of PHACE syndrome to identify subglottic hemangiomas, however there may be relatively low yield in asymptomatic patients. In office flexible laryngoscopy may be a less invasive means to examine the subglottic region. A multi-center prospective study would be necessary to evaluate incidence of subglottic hemangiomas in asymptomatic patients evaluated for PHACE.
Assuntos
Anormalidades do Olho , Hemangioma , Neoplasias Laríngeas , Síndromes Neurocutâneas , Humanos , Masculino , Criança , Feminino , Lactente , Recém-Nascido , Pré-Escolar , Estudos Retrospectivos , Estudos Prospectivos , Sons Respiratórios , Síndromes Neurocutâneas/complicações , Síndromes Neurocutâneas/diagnóstico , Síndromes Neurocutâneas/epidemiologia , Anormalidades do Olho/complicações , Anormalidades do Olho/diagnóstico , Anormalidades do Olho/epidemiologia , Neoplasias Laríngeas/diagnóstico , Hemangioma/diagnóstico , Hemangioma/epidemiologiaRESUMO
OBJECTIVE: To report key characteristics and patterns of captive insurance claims not publicly reported in otolaryngology across a large tertiary-level academic health system over the previous 2 decades. STUDY DESIGN: Case series. SETTING: The tertiary care health system. METHODS: The internal captive insurance database at a tertiary level healthcare system was queried to identify otolaryngology-related malpractice claims regardless of final disposition (settled or dismissed) filed from 2000 to 2020. The date of the incident, date of claim, error type, patient outcome, provider subspecialty, total expenses, disposition, and final reward amount were recorded. RESULTS: Twenty-eight claims were identified. There were 11 (39.3%) claims from 2000 to 2010 and 17 (60.7%) claims from 2011 to 2020. Head and neck surgery was the most frequently implicated subspecialty (n = 9, 32.1% of all cases), followed by general otolaryngology (n = 7, 25.0%), pediatrics (n = 5, 17.9%), skull base/rhinology (n = 4, 14.3%), and laryngology (n = 1, 3.6%). Improper surgical performance was cited in 35.7% of cases (n = 10), followed by failure to diagnose (n = 8, 28.6%), to treat (n = 4, 14.3%), and to obtain informed consent (n = 3, 10.7%). While 2 cases are ongoing, a total of 17/26 (65.4%) cases were settled and 20/26 (76.9%) dismissed some or all parties. Dismissed claims had significantly higher expenses (p = .022) and duration from incident to disposition (p = .013) compared to settled claims. CONCLUSION: This study expands the malpractice landscape in otolaryngology by including data not readily available through public sources and compares it to national trends. These findings encourage otolaryngologists to better gauge current quality and safety measures that best protect patients from harm.
Assuntos
Imperícia , Otolaringologia , Criança , Humanos , Otorrinolaringologistas , Revisão da Utilização de SegurosRESUMO
OBJECTIVE: Evaluate health-related quality of life (HR-QOL) benefits with cochlear implantation (CI) in children with unilateral sensorineural hearing loss (USNHL) versus bilateral sensorineural hearing loss (BSNHL). STUDY DESIGN: A cross-sectional survey of parents of children who underwent CI for USNHL and BSNHL. SETTING: Tertiary care academic centers. METHODS: The "Children with cochlear implants: parental perspectives" survey was administered. Parents rated responses on a 5-point Likert scale. Scores greater than 3.0 were considered favorable. Responses were recorded within 8 domains and groups were compared with respect to domain scores. Analysis of covariance models was used to compare groups while adjusting for age at implantation and duration of implant use. RESULTS: There were 31 patients with USNHL and 27 patients with BSNHL. The average age of implantation in BSNHL patients was 1.9 and 6.7 years for USNHL. Parents of all children answered favorably in all domains. When adjusted for age at implantation and duration of implant use, parents of BSNHL children responded significantly more favorably only in 2 domains. When comparing patients with older age or prolonged duration of hearing loss in the USNHL cohort, there were favorable responses in all domains with no significant differences between groups. CONCLUSION: There are HR-QOL benefits of CI in USNHL children; less pronounced favorable results were noted only in 2 domains when compared to BSNHL children. Benefits were noted with CI in USNHL children at an older age at implantation or prolonged duration of hearing loss. Therefore, these factors should not be absolute contraindications for CI in USNHL.
Assuntos
Implante Coclear , Surdez , Perda Auditiva Neurossensorial , Perda Auditiva , Humanos , Criança , Lactente , Pré-Escolar , Qualidade de Vida , Estudos Transversais , Perda Auditiva Neurossensorial/cirurgia , Surdez/cirurgia , Perda Auditiva/cirurgia , Perda Auditiva BilateralRESUMO
BACKGROUND: First health care professionals arriving at the bedside in tracheostomy-related emergencies are rarely the surgical subspecialists who placed the tracheostomy and are unfamiliar with the relevant anatomy and tracheostomy specifications for the individual patient. We hypothesized that implementing a bedside airway safety placard would increase caregiver confidence, understanding of airway anatomy, and management of patients with a tracheostomy. METHODS: A prospective survey study was performed by distributing a tracheostomy airway safety survey before and after implementation of an airway safety placard in a 6-month study period. Placards emphasizing critical airway anomalies as well as emergency management algorithm suggestions designed by the otolaryngology team at the time of tracheostomy were placed at the head of the bed and traveled with the patient during transport around the hospital. RESULTS: Of 377 staff members requested to complete the surveys, 165 (43.8%) responses were obtained, and 31 (8.2% [95% CI 5.7-11.5]) paired pre- and post-implementation responses were recorded. Differences were found in the paired responses, including increases in the domains of confidence (P = .009) and experience (P = .01) post implementation. Less experienced providers (≤ 5 y of experience) (P = .005) and providers from neonatology (P = .049) demonstrated improved confidence post implementation, which was not observed in their more experienced (> 5 y) or respiratory therapy counterparts. CONCLUSIONS: Given the limitations of a low survey response rate, our findings suggest that an educational airway safety placard initiative can be a simple, feasible, and low-cost quality improvement tool to enhance airway safety and possibly decrease potentially life-threating complications among pediatric patients with a tracheostomy. The implementation of the tracheostomy airway safety survey at our single institution warrants a larger multi-center study and validation of the survey.