Post-tonsillectomy bleeding rate decreases with limitation in maximum post-operative ibuprofen dosage: A quality improvement study.

OBJECTIVE: The objective of this study is to investigate the effect of a reduction in the prescribed post-operative ibuprofen dosage on frequency of post-tonsillectomy bleeding. METHODS: A quality improvement study was conducted at a single tertiary care pediatric hospital with patients weighing >40 kg undergoing tonsillectomy. The intervention was limiting the post-operative ibuprofen dosage to a maximum of 400 mg per dose. Data was collected on all patients returning to the hospital with bleeding after tonsillectomy. The primary outcome was the rate of post-tonsillectomy bleeding. Statistical analysis was conducted using nonparametric comparisons and a run chart. RESULTS: A total of 199 tonsillectomy patients >40 kg were included in the study. There were 119 (59.8 %) females and 80 (40.2 %) males total. The pre-intervention group had a total of 56 patients while the post-intervention group had a total of 143 patients. There was no statistical difference in age, weight, or sex between the pre- and post-intervention groups (p > .05). The post-tonsillectomy hemorrhage rate was 11/56 (19.6 %) before the intervention, and 11/143 (7.7 %) after the intervention (p = .016). Children who experienced a bleeding event were significantly older (mean 15.9 years, 95 % CI 14.5-17.3) than those who did not (13.5 years, 95 % CI 12.9-14.1; p = .011). The run chart revealed that the intervention resulted in a nonrandom decrease in rate of post-tonsillectomy bleeding. CONCLUSIONS: Post-tonsillectomy bleeding rate decreased with a ceiling post-operative ibuprofen dose of 400 mg/dose in this quality improvement study. Further research is warranted.

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

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

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

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

Pediatric Esophageal Foreign Bodies and Caustic Ingestions.

Foreign body ingestions commonly occur in children aged under 6 years. While serious complications of ingestions are rare, sharp objects, caustics, multiple magnets, and button batteries can be associated with poorer outcomes including gastrointestinal (GI) obstruction, perforation, necrosis, and fistula formation. Initial workup should include history, physical examination, and plain film radiographs that will identify radiopaque objects. Removal of the foreign body is typically warranted if the object is high risk, it is located higher up in the GI tract, the patient is symptomatic, or the object is retained for a prolonged amount of time.

Pediatric Bronchoscopy for Airway Foreign Bodies in the ACS NSQIP-P: Morbidity and Mortality 2014-2019.

OBJECTIVE: Examine morbidity and mortality associated with bronchoscopy for pediatric airway foreign body (AFB). Identify factors associated with adverse events. METHODS: A retrospective analysis from 2014 to 2019 using the multicenter public data set from the American College of Surgeons National Surgical Quality Improvement Program- Pediatric. Patients under 18 who underwent bronchoscopy for AFB were identified. Demographics, comorbidities, perioperative events, length of stay, and complications were collected. Regression analysis was used to identify factors associated with adverse events. RESULTS: 2302 patients were included; 1427 (62%) males and 875 (38%) females. Mean age was 3.9 years. (95% CI 3.7-4.1). 2025 (88%) retained AFB as the postoperative diagnosis. Comorbidities included structural pulmonary abnormalities in 234 (10.5%), asthma in 149 (6.5%), and impaired cognitive status in 134 (5.8%). Most common complications were pneumonia in 19 (0.8%) and reintubation in 10 (0.4%). 10 (0.4%) had a prolonged LOS >30 days. Nine (0.4%) children died within 30 days of surgery; 7 (78%) were ventilated and 6 (67%) had CPR prior to surgery. 18 (0.8%) returned to OR and 15 (0.7%) were readmitted for related reasons. Linear regression showed an association between ASA class (ß = 0.708, p < 0.001), operative time (ß = 0.015, p = 0.013) and reintubation (ß = 10.5, p < 0.001) with LOS. Time in the OR was associated with return to OR (ß = .008, p = 0.004) through logistic regression. CONCLUSION: Morbidity is low in children with AFB and mortality is usually associated with preoperative lifesaving maneuvers. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:689-693, 2023.

Foreign Body Aspiration Complicated by Pneumothorax in Children: HCUP-KID Perspective.

OBJECTIVE: Children with airway foreign bodies (AFB) occasionally have pneumothorax complicating their course. We aimed to compare the clinical course of these children to those without this complication. METHODS: Data was obtained from the 2016 Kids' Inpatient Database of Healthcare Cost Utilization Project. ICD-10 code of T17XXXX was used to locate records. They were grouped based on the presence of preoperative pneumothorax, postoperative pneumothorax, or none. Variables included demographics, AFB type, AFB location, length of stay (LOS), pneumothorax treatment modality, mortality, hospital setting, primary payor, and total charges. RESULTS: A total of 4165 children with AFB were identified, 57.8% male and 42.2% female. Of these 75 (1.8%) patients presented with preoperative pneumothorax, 29 (0.7%) with postoperative pneumothorax, and 4061 (97.5%) with no pneumothorax. The preoperative pneumothorax patients were older than the postoperative pneumothorax and unaffected AFB patients (mean age = 9.5 [95% CI 7.7-11.3] vs 8.2 [95% CI 5.4-11.1] vs 5.5 [95% CI 5.3-5.7]; P < .001). Preoperative pneumothorax patients incurred higher total charges than the other groups (mean US = $939K [95% Cl 673K-1,204K] vs $599K [95% Cl 377K-821K] vs $228K [95% Cl 211K-244K]; P < .001), had a longer LOS in days (mean = 37.7 [95% Cl 28.7-46.7] vs 31.6 [95% Cl 16.9-46.2] vs 15.8 [95% CI 15.0-16.7]; P < .001), and had a higher mortality rate (16% vs 0% vs 3.7%, P < .001). CONCLUSION: Pneumothorax can significantly impact a child's hospital course, and preoperative pneumothorax should alert clinicians to the potential for increased mortality risk.

Does Medical School Rank Impact Matching into Otolaryngology?

OBJECTIVE(S): To describe how medical school rank may be associated with matriculation into otolaryngology residency programs. METHODS: A list of medical students who matched into otolaryngology residencies in 2020, 2021, and 2022 was obtained from Otomatch (Otomatch.com). For each student, their medical school, U.S. News & World Report Best Medical School (Research) ranking, and region based on the U.S. Census divisions were recorded. The medical schools were divided into four Tiers according to rank: 1-40 (Tier 1), 41-80 (Tier 2), 81-124 (Tier 3), and 125-191 (Tier 4). Residency programs were also grouped by region, whether they were large (>3 residents/year) or small (<3 residents/year), and their Doximity reputation ranking: 1-31 (Tier 1), 32-61 (Tier 2), 62-91 (Tier 3), and 92-125 (Tier 4). RESULTS: Nine hundred and ninety-five medical students were included in this study. The majority of residency matriculants were MDs (N = 988, 99.3%) who came from Tier 1 (N = 410, 41.2%) or Tier 2 (N = 313, 31.5%) medical schools. Those who attended higher-tier medical schools were more likely to match into higher-tier residency programs (p < 0.001). 57.8% (N = 237) of the applicants who attended Tier 1 medical schools matriculated into a Tier 1 residency program, whereas only 24.7% (N = 42) of the applicants from Tier 4 medical schools matriculated into a Tier 1 residency program. CONCLUSION: Applicants who attend top-tier medical schools represent significantly more residents at top-tier otolaryngology residency programs than those from lower tier medial schools. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3353-3357, 2023.

Parents' Opinions About Pediatric Otolaryngology on Social Media.

OBJECTIVE: Social media is a novel tool that many parents turn to when looking for a new healthcare provider. The purpose of this study is to assess how parents of children attending a pediatric otolaryngology practice engage with social media. STUDY DESIGN: Survey. SETTING: Two pediatric otolaryngology clinics associated with a tertiary care children's hospital in Buffalo, NY. METHODS: Parents of children aged <18 years were surveyed. The survey consisted of 25 questions divided into 5 categories: demographics, social media accounts, social media use, use of social media to interact with pediatric otolaryngologists, and perception of pediatric otolaryngologists' social media accounts. Frequencies were calculated. RESULTS: Three hundred five parent participants were included. 247 (81.0) were female and 57 (18.97) were male. 258 (84.6%) of the participants reported use of Facebook, which was the most popular social media platform. 238 (78.0%) of participants indicated that they would want to see medical posts and 98 (32.1%) participants indicated that they would want to see personal posts on the pediatric otolaryngologist's social media page. Younger parents were statistically more likely to check social media more often (P = .001) and seek a pediatric otolaryngologist's social media before seeing them (P = .018). CONCLUSION: Use of social media by pediatric otolaryngologists may positively impact the way a small percentage of their patients' parents perceive them. Social media accounts do not appear to be a vital part of pediatric otolaryngology practice in 2022.

Assessing the Accuracy of Otomatch.com Data for Individuals Applying to Otolaryngology Residency.

OBJECTIVES: Otomatch.com is an online forum for residency applicants to discuss the otolaryngology match process including academic metrics. The purpose of this study is to assess the accuracy of self-reported match data on Otomatch relative to official data reported by the National Residency Match Program (NRMP) and the Association of American Medical Colleges (AAMC). METHODS: Data was collected from publicly editable Otomatch forums (2017-2018, 2018-2019, 2019-2020) and curated Otomatch survey responses (2018-2019, 2019-2020) whose results are released after Match Day. Aggregated data was collected from the NRMP 2018 and 2020 Charting Outcomes in the Match and AAMC Report on Residents (2017-2018, 2018-2019). Measures of interest included Step 1 scores, Step 2 CK scores, publications, number of interview invitations, number of interviews attended, and AOA status. ANOVA and 2 tailed T tests were performed to compare variables within each match year. RESULTS: Average Step 2 CK score was significantly higher on publicly editable Otomatch forums than AAMC in 2017-2018 (257vs 253, P < .05) and 2018-2019 (258vs 252, P < .05). Interviews attended were significantly higher on Otomatch survey responses than the publicly editable forum in 2019-2020 (13vs 9, P-value < .05). Step 1 scores, interview invitations, and AOA status were not statistically significantly different when data was available. CONCLUSION: Applicant statistics from online forums, online surveys, NRMP, and AAMC are consistent, except for Step 2 CK scores. Self-reported data on the Otomatch forum is an accurate estimate of academic metrics of otolaryngology residency applicants.

A Case of Pediatric Auricular Erythromelalgia.

Erythromelalgia is a rare clinical syndrome involving erythema, warmth, and burning pain in one or more of the extremities. Primary erythromelalgia is idiopathic and can begin during childhood or adulthood. In the pediatric population, auricular erythromelalgia is rare, and its etiology is not well understood. We present a case of a four-year-old boy who presented with recurrent episodes of red, painful pinnae. We also discuss previous literature on red ear syndrome and erythromelalgia.

Impact of COVID-19 Pandemic on Expenses of Medical Students Applying to Otolaryngology Residency Programs.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has led to many changes in the residency application process. The purpose of this study was to determine the impact of these changes on the cost of applying to otolaryngology residency programs.  Materials and Methods: A retrospective, cross-sectional analysis was conducted using the Texas Seeking Transparency in Application to Residency (Texas STAR) Dashboard database to determine the differences in residency application costs from 2019 to 2022. Applicant information and cost data including application fees, interview expenses, away rotation expenses, total expenses, and geographic regions were collected. Median expenses and interquartile ranges were reported for each year and geographic region. Non-parametric comparisons were conducted. RESULTS: Data from 499 otolaryngology applicants were collected from the Texas STAR database. The total expenses, interview expenses, and away rotation expenses of applicants from 2019 to 2022 were significantly decreased (p < 0.001) in all regions of the United States with the greatest decrease between 2020 and 2021. Application fees (p = 0.005) were not significantly different among regions of the United States throughout the time period studied. CONCLUSION: The COVID-19 pandemic significantly decreased the total expenses of applying to otolaryngology residencies including away rotation and interview expenses.

Factors That Influence Students' Selection of Advanced Pharmacy Practice Experience.

Objective. To determine factors influencing Doctor of Pharmacy (PharmD) students' selection of advanced pharmacy practice experiences (APPEs) in one school of pharmacy. Methods. In their final year, PharmD students are required to complete a minimum of 1440 hours of experiential education, including ambulatory, community, inpatient general medicine, and hospital/health system APPEs, and elective APPEs. Third-year (P3) and fourth-year (P4) PharmD students were invited to complete an anonymous online survey to determine what factors impacted their decision process when selecting their required experiences. Students selected up to five factors that most influenced their selection of APPEs. Factors included areas of interest, size of institution, location, future employment, preceptor reputation, rotation hours, faculty rotation, non-faculty rotation, peer recommendation, cost/housing, level of difficulty, size of institution, and whether the site offered a residency program. Results. Of the 143 students enrolled, 100% responded to the survey. Students in both classes (71 P3 and 72 P4 students) selected location as the number one factor that influenced their decision when selecting required APPEs. Cost/housing was the second most important factor overall for P3 students, while peer recommendation was the second most important factor overall for P4 students. Conclusion. Location was the driving factor behind P3 and P4 pharmacy students' selection of APPE sites. Schools should consider establishing more APPE sites that offer housing to reduce cost. Further research into the factors that influence ranking on APPE electives is warranted.

Diminished expression of C/EBPalpha in skin carcinomas is linked to oncogenic Ras and reexpression of C/EBPalpha in carcinoma cells inhibits proliferation.

The basic leucine zipper transcription factor, CCAAT/enhancer binding protein alpha (C/EBPalpha) is involved in mitotic growth arrest and has been implicated as a human tumor suppressor in acute myeloid leukemia. We have previously shown that C/EBPalpha is abundantly expressed in mouse epidermal keratinocytes. In the current study, the expression of C/EBPalpha was evaluated in seven mouse skin squamous cell carcinoma (SCC) cell lines that contain oncogenic Ha-Ras. C/EBPalpha mRNA and protein levels were greatly diminished in all seven SCC cell lines compared with normal primary keratinocytes, whereas C/EBPbeta levels were not dramatically changed. Reexpression of C/EBPalpha in these SCC cell lines resulted in the inhibition in SCC cell proliferation. To determine whether the decrease in C/EBPalpha expression observed in the SCC cell lines also occurred in the carcinoma itself, immunohistochemical staining for C/EBPalpha in mouse skin SCCs was conducted. All 14 SCCs evaluated displayed negligible C/EBPalpha protein expression and normal C/EBPbeta levels compared with the epidermis and all 14 carcinomas contained mutant Ras. To determine whether oncogenic Ras is involved in the down-regulation of C/EBPalpha, BALB/MK2 keratinocytes were infected with a retrovirus containing Ras12V, and C/EBPalpha protein, mRNA and DNA binding levels were determined. Keratinocytes infected with the retrovirus containing oncogenic Ras12V displayed greatly diminished C/EBPalpha protein, mRNA and DNA binding levels. In addition, BALB/MK2 cells containing endogenous mutant Ras displayed diminished C/EBPalpha expression and the ectopic expression of a dominant-negative RasN17 partially restored C/EBPalpha levels in these cells. These results indicate that oncogenic Ras negatively regulates C/EBPalpha expression and the loss of C/EBPalpha expression may contribute to the development of skin SCCs.