Decannulation in Revision Pediatric Laryngotracheal Reconstruction

OBJECTIVES: To evaluate how patient characteristics and surgical techniques influence the rate of and time to decannulation after pediatric revision laryngotracheal reconstruction. METHODS: The study was a retrospective cohort investigation of children with a history of laryngotracheal stenosis treated between 2008 and 2021 with revision open airway surgery. The primary outcome evaluated was decannulation. The secondary outcome analyzed was time to decannulation. RESULTS: Thirty-nine children were included in the study with median age 49 months; 61.5% were male. Children undergoing single stage revision surgery were far more likely to be decannulated (OR 6.25, 95% CI 1.33-45.97, p = 0.0343). Rolling logistic regression of the probability of decannulation stratified by time between open surgeries demonstrated significantly decreased chance of decannulation with reoperation within 6 months. Children managed with anterior/posterior grafting compared with a single graft were observed to have an increased time to decannulation, (HR 0.365, 95% CI 0.148-0.899, p = 0.005, Log-Rank). CONCLUSION: We observe that in the case of revision pediatric open airway surgery, chance of decannulation is improved when surgery is performed in a single stage as well as 6 months after the most recent procedure. Patients and families should be counseled that complex stenosis requiring double stage procedures or anterior/posterior grafting is associated with a decreased probability of decannulation and increased postoperative time with a tracheostomy, respectively. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023

Ceftriaxone use for acute otitis media: Associated factors in a large U.S. primary care population

BACKGROUND: Clinicians in the authors\u27 primary care academic practice have anecdotally perceived an increased use of intramuscular (IM) ceftriaxone, particularly for otitis-conjunctivitis in recent years (pre-pandemic). Increasing rates of ceftriaxone administration for acute otitis media (AOM) may be an important marker of antimicrobial resistance. OBJECTIVE: We aimed to characterize the population of patients who received ceftriaxone for treatment of AOM, testing our hypothesis that patients with concomitant conjunctivitis would have increased rates of ceftriaxone receipt. DESIGN/METHODS: We reviewed cases of AOM at a large U.S. primary care practice from August 2017 to July 2019. We determined the association between each of the following variables and ceftriaxone injection using multivariate analysis: age at AOM diagnosis, provider type, insurance (public vs private), season of year, and presence of conjunctivitis. RESULTS: There were 6028 AOM episodes in 5195 patients resulting in a total of 7688 patient encounters. Of these episodes, 642 (10.7%) had a concurrent diagnosis of conjunctivitis; 362 (6.0%) ultimately received ceftriaxone. Conjunctivitis was the strongest predictor of treatment with ceftriaxone. The proportion of episodes with conjunctivitis treated with ceftriaxone was 14.5% (93/642) versus 5.0% (269/5386) without conjunctivitis (p \u3c 0.0001). Patients who received ceftriaxone were younger; mean age (SD) for patients receiving ceftriaxone was 14.0 (8.8) months versus 25.0 (23.4) months (p \u3c 0.0001). CONCLUSION(S): There is a strong correlation between the presence of conjunctivitis and receipt of IM ceftriaxone in this large U.S. academic primary care clinic. Younger age was also associated with ceftriaxone treatment. Further study on emerging resistance patterns and implications for management of AOM in young children is warranted

Confirmatory Auditory Brainstem Responses Testing Results in Discordant Outcomes: Implications for Timely Care

OBJECTIVES: The purpose of this study is to evaluate for discrepancies in diagnostic auditory brainstem responses (ABR) between Children\u27s National Hospital (CNH), a pediatric medical center, and outside facilities (OSF) that referred patients to CNH for confirmatory evaluation. Such discrepancies impact early hearing detection and intervention (EHDI) timelines. METHODS: A retrospective chart review was conducted from an internal database of patients who underwent diagnostic ABR from 2017 to 2021. Only patients with ABR results from both CNH and OSF were analyzed. Demographic data, external and internal test results, and intervention data were obtained. Hearing loss (HL) severity was graded on a scale of 0 to 8, where 0 indicated normal hearing and 8 indicated profound. Each ear was analyzed separately. RESULTS: Forty-nine patients met the inclusion criteria, and each ear was evaluated separately. Median HL severity was 1.0 [0.0, 4.3] at CNH compared to 3.0 [1.8, 6] at OSF (p = 0.004). Forty-seven ears (48.0%) showed lower severity at CNH. Twenty-seven patients (55%) received hearing amplification devices. The median age at time of hearing intervention was 220 days. CONCLUSION: Our results showed statistical significance in the median severity of HL between CNH and OSF. A substantial proportion (70%) of children in our dataset who received amplification via cochlear implant or hearing aids were shown to have discrepancies in ABR findings from CNH and OSF. These findings have implications with regards to the appropriate usage of health care resources and maintaining EDHI timelines. LEVEL OF EVIDENCE: 4 (Retrospective Cohort Study) Laryngoscope, 2023

Predicting failure of detection of peritonsillar abscess with ultrasound in pediatric populations

PURPOSE: Some patients require additional imaging following ultrasound (US) to definitively diagnose a peritonsillar abscess (PTA), delaying intervention and disease resolution. We seek to evaluate patient characteristics which may predispose to a secondary imaging requirement to diagnose PTA, in order to better understand ultrasound limitations and predict who will require additional studies. MATERIALS AND METHODS: Retrospective chart review of patients with an US for suspected PTA between July 2017 and July 2020. Patient age, weight, and clinical characteristics, such as pain, trismus, and reduced neck range of motion (ROM) were collected. The need for additional imaging, subsequent surgical intervention, and hospital length of stay (LOS) were also recorded. RESULTS: Of 411 qualifying patients, 73 underwent additional imaging. Patients who required additional imaging were younger (9.8 vs 11.3 years, p = 0.026) and more likely to have decreased neck ROM (17.8 vs 5.3 %, p = 0.001). Surgical intervention was performed more commonly (27.4 vs 14.8 %, p = 0.015) and hospital LOS was longer (24.0 vs 5.0 h, p \u3c 0.001) in those with secondary imaging. CONCLUSIONS: Specific patient characteristics, such as younger age and decreased neck range of motion, are associated with a higher need for additional imaging. Additionally, the need for additional imaging is associated with a longer hospital LOS and increased likelihood of surgical intervention. Nearly 18 % of patients who underwent US evaluation of PTA required secondary imaging. Although transcervical US remains an excellent tool for diagnosing PTA, this data supports the utility of secondary imaging in certain instances

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

Barriers to Pediatric Osseointegrated Bone-Conduction Hearing Devices

OBJECTIVE: To identify social, demographic, and clinical barriers for implantation with Osseointegrated Bone Conduction Devices (OBCD) in pediatric candidates. STUDY DESIGN: Retrospective cohort study of 94 children who met standard OBCD implantation criteria. SETTING: Tertiary stand-alone children\u27s hospital. MATERIALS AND METHODS: Retrospective chart review comparing demographic (age, race, state of residence, and insurance) and clinical (severity and etiology of hearing loss, medical comorbidities, and early intervention) factors impacting implantation. Members of the existing cohort were then contacted to obtain a better understanding of qualitative factors impacting surgical decision. RESULTS: Of the identified 94 surgical candidates, 47 (50%) underwent OBCD implantation. State of residence significantly impacted implantation rates, with children from the District of Columbia and Virginia being less likely to receive an implant than those from Maryland. Private insurance, race, and ethnicity did not impact rate of implantation (OR 2.8 [95% CI 0.78-10]; 1.34 [95% CI 0.44-3.68]; and 1.0 [95% CI 0.42-2.43], respectively). Children with anotia or microtia and children younger than 10 years old were less likely to have an implant (OR 10.6 (95% CI 1.74-65). Thirty-nine children participated in the qualitative portion. Themes that emerged as reasons to forgo implantation included a child\u27s young age, planned reconstruction for microtia or atresia, and overall device functionality and usage. Thirty-seven children (39%) of the cohort declined surgery and currently wear a nonsurgical bone conduction aid regularly. CONCLUSION: Despite known benefits of implantation, only one-half of children who were candidates underwent OBCD. Unlike cochlear implantation, where insurance status is a major risk factor for implantation delay and underperformance, for OBCD, implantation barriers appear to be more multifactorial and include medical, demographic, and social factors

Trends in Natural Decannulation in Patients with Robin Sequence: A Twenty-five Year Retrospective Review

OBJECTIVE: Robin sequence (RS) consists of micrognathia and glossoptosis that result in upper airway obstruction (UAO). In RS patients who undergo tracheostomy, long-term goals include natural decannulation (ND) without further surgical airway intervention. The objective of this study was to identify long-term trends in the rate and length of time to ND. METHODS: Retrospective chart review on 144 patients with RS treated from 1995 to 2020 at a pediatric tertiary care center. Patients were grouped by year of tracheostomy. Demographic data, UAO management, postoperative care, complications, and time to decannulation were recorded. RESULTS: Thirty-six patients met the inclusion criteria. Tracheostomy was performed at a median age of 45.5 days. 19 (53%) patients experienced ND at a median time of 66.1 months. ND rate was higher in non-syndromic patients (93% non-syndromic vs 27% syndromic;  \u3c .0001) and during the first study period (1995-2006: 78%, 2007-2020: 28%;  = .003). Cox proportional-hazard regression demonstrated that white race [aHR 0.15 (0.03-0.8);  = .023] and higher birthweight [aHR 0.9 (0.8-0.98);  = .018] were associated with a higher likelihood of ND while a syndromic diagnosis had a negative association with ND [aHR 12.5 (3.3-50.0);  \u3c .001]. CONCLUSIONS: Our study documented that ND in patients with RS who underwent tracheostomy was significantly associated with ethnicity, birthweight, and syndromic status. The negative impact on successful ND was most observed in patients with syndromic associations. Additionally, ND rates are lower in the 2007 to 2020 subgroup. We suspect this is because alternative management techniques such as tongue lip adhesion and mandibular distraction osteogenesis became primary surgical treatment in severe RS upper airway obstruction at our institution starting in 2007