A novel “Modified TCA Alloderm™ Myringoplasty” (TCA myringoplasty) technique for reconstruction of uncomplicated chronic tympanic membrane (TM) perforations is described.
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.
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.
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.
•TCA AlloDerm myringoplasty is a novel technique to repair chronic TM perforations.•This technique may reduce postoperative pain, complications, and OR time.•Graft rigidity improves precision of placement.•This technique is useful for large perforations & those in unfavorable locations.•Future study of a larger cohort is needed to compare with Type I tympanoplasty.
Abstract
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.
Repeat tympanostomy tubes in children with Down syndrome Omar, Mahmoud; McCoy, Jennifer L.; McCormick, Andrew A. ...
International journal of pediatric otorhinolaryngology,
September 2021, 2021-09-00, 20210901, Volume:
148
Journal Article
Peer reviewed
Children with Down syndrome (DS) have a higher incidence of tympanostomy tube insertion (TTI) than children in the general population. As there were no studies investigating factors that are ...associated with multiple TTIs in children with DS, we sought to determine what factors increase or decrease the likelihood of repeat TTI in children with DS.
A retrospective case-control study was performed on consecutive children with DS from 2007 to 2018 with first TTI at a large tertiary children's hospital and follow-up duration at least 27 months since first TTI.
277 patients met the inclusion criteria. Repeat TTI rate was 61.4%. Having an indication of chronic otitis media with effusion (COME) at first TTI was an adjusted risk factor for increased rate of repeat TTI (OR: 2.01, 95%CI: 1.15–3.51, p = .014), while being older at first TTI was an adjusted protective factor for decreased rate of repeat TTI (OR: 0.84, 95%CI: 0.74–0.95, p = .004). Adenotonsillectomy at or before first TTI was not an adjusted protective factor for decreased rate of repeat TTI (OR: 0.915, 95%CI: 0.448–1.872, p = .809) and bilateral intra-operative fluid was not an adjusted risk factor for repeat TTI (OR: 1.97, 95%CI: 0.99–3.90, p = .054).
Children with DS were more likely to undergo repeat TTI if they were of younger age and if the indication for surgery was COME. The repeat TTI rate for children with DS was high at 61.4%. Prospective studies are warranted to more precisely investigate factors associated with repeat TTIs in this unique patient population.
Objectives:
Extensive literature exists documenting disparities in access to healthcare for patients with lower socioeconomic status (SES). The objective of this study was to examine access ...disparities and differences in surgical wait times in children with the most common pediatric otolaryngologic surgery, tympanostomy tubes (TT).
Methods:
A retrospective cohort study was performed at a tertiary children’s hospital. Children ages <18 years who received a first set of tympanostomy tubes during 2015 were studied. Patient demographics and markers of SES including zip code, health insurance type, and appointment no-shows were recorded. Clinical measures included risk factors, symptoms, and age at presentation and first TT.
Results:
A total of 969 patients were included. Average age at surgery was 2.11 years. Almost 90% were white and 67.5% had private insurance. Patients with public insurance, ≥1 no-show appointment, and who lived in zip codes with the median income below the United States median had a longer period from otologic consult and preoperative clinic to TT, but no differences were seen in race. Those with public insurance had their surgery at an older age than those with private insurance (P < .001) and were more likely to have chronic otitis media with effusion as their indication for surgery (OR: 1.8, 95% CI: 1.2-2.5, P = .003).
Conclusions:
Lower SES is associated with chronic otitis media with effusion and a longer wait time from otologic consult and preoperative clinic to TT placement. By being transparent in socioeconomic disparities, we can begin to expose systemic problems and move forward with interventions.
Level of Evidence:
4
Objectives/Hypothesis
To determine if the amount of opioid prescribed and postoperative outcomes after adenotonsillectomy changed following implementation of mandated opioid consent forms.
Study ...Design
Retrospective cohort study.
Methods
Patients undergoing adenotonsillectomy 6 months before and after implementation of mandated opioid consent forms at a tertiary‐care pediatric hospital were studied. Demographics, operative data, weight‐based opioid dosage, and postoperative outcome measures, including nursing calls, emergency department (ED) visits, hospital readmission, and bleed rates, were collected and analyzed.
Results
Of 300 patients, opioid prescription was provided for 211 patients (70.3%), 112 preconsent (74.7%) and 99 postconsent (66.0%). Mean (standard deviation) total opioid prescribed (milligrams/kilogram) was significantly higher preconsent 4.8 (5.6) than postconsent 3.2 (4.7), (P = .003). There were no differences between number of nursing calls (P = .134) or ED visits (P = .083). Interestingly, preconsent patients had more hospital readmission for pain/dehydration (odds ratio OR: 368, P = .016) and bleeding concerns (OR: 244, P = .003).
Conclusions
A mandated consent form prior to opioid prescription was associated with decreased overall opioid prescription without resultant increase in postoperative complications in pediatric patients. These data provide support for minimizing opioid prescription on a systems‐based level.
Level of Evidence
4
Laryngoscope, 129:1477–1481, 2019
Dysphagia in Pediatric Patients with Tracheostomy Luu, Kimberly; Belsky, Michael A.; Dharmarajan, Harish ...
Annals of otology, rhinology & laryngology,
05/2022, Volume:
131, Issue:
5
Journal Article
Peer reviewed
Objective:
Post-tracheotomy swallowing function has not been well described in the pediatric population. This study aims to (1) determine differences in swallowing functioning pre- and ...post-tracheotomy and (2) examine the association between postoperative dysphagia and indication for tracheotomy, age at the time of tracheotomy, and time between tracheotomy and modified barium swallow (MBS).
Methods:
A retrospective chart review was performed on 752 patients who underwent a tracheotomy from 2003 to 2018 and had adequate documentation for review. Patients were included if they received a post-operative MBS. Descriptive statistics, logistic regression, and Fisher’s exact test were used to analyze the data.
Results:
The cohort included 233 patients. The mean age at the time of tracheotomy was 25 months (±50.5). The indications for the tracheotomy were upper airway obstruction (110/233, 47.2%), chronic respiratory failure (104/233, 44.6%), and neurologic disease (19/233, 8.2%). The mean time from tracheotomy to post-operative MBS was 224 days (±297.7). Of the patients who had documented pre- and post-tracheotomy diets, nearly half of patients had improvement in their swallowing function after tracheotomy placement (82/195; 42.1%). Post-tracheotomy MBS recommended thickened liquids in 30.9% of the patients (72/233) and 42.5% (99/233) were recommended thin liquids. The remainder (62/233, 26.6%) remained nothing by mouth (NPO). Patients with neurological disease as the indication for the tracheotomy were more likely to remain NPO (P = .039).
Conclusion:
A tracheotomy can functionally and anatomically affect swallowing in pediatric patients. The majority of our studied cohort was able to resume some form of an oral diet postoperatively based on MBS. This study highlights the need for objective measurements of swallowing in the postoperative tracheotomy patient to allow for safe and timely commencement of an oral diet.
Level of Evidence
Level 3.
Investigate associations between socioeconomic indicators of healthcare access with family compliance with cleft-related otologic and audiologic care within an interdisciplinary model.
Retrospective ...case series.
Children born 2005-2015 who presented to the Cleft-Craniofacial Clinic (CCC) at a quaternary care children's hospital.
Associations between main outcome measures and Area Deprivation Index (ADI), median household income for zip code, distance from hospital, and insurance status were evaluated.
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.
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.
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.
Coblation and electrocautery are two common techniques used for adenotonsillectomy (T&A). Numerous studies have assessed surgical outcomes of coblation versus electrocautery and overall, ...postoperative complications are similar with the exception of a decrease in patient reported postoperative pain for coblation. Instrumentation required for coblation is significantly more expensive than that required for electrocautery. With minimal outcome differences, justification for the additional instrumentation costs is difficult. We performed this study to assess if there is a difference between operative & postoperative costs of electrocautery and coblation.
300 patient medical records were reviewed from 2015 to 2017 with equal numbers of electrocautery and coblation surgeries. Outcome measures included finance information, duration and cost of OR and Phase I and Phase II post-anesthesia care unit (PACU), in-hospital pharmacy costs, and postoperative complications. Logistic regression was used for analysis.
The median patient age for each surgical technique was 6 years old. Electrocautery resulted in more time in the OR compared to coblation, (OR:1.11,95%CI:1.07–1.15, p < .001), with greater associated costs, p < .001. Electrocautery patients were under anesthesia longer and had a longer surgical duration, p < .001. These same patients had longer duration in Phase II PACU, p = .028, and were given pain medications an increased number of times, p < .001. Total costs including operative expense, physician charges, OR and anesthesia times, pharmacy, and instrument were significantly higher for electrocautery patients, p = .003. There were no differences in ED visits, post-tonsillectomy bleed, or additional surgery between techniques, p > .05.
T&A electrocautery technique was found to have increased overall indirect costs. Costs of instrumentation in addition to increased operative time, use of analgesics and post-operative care contribute to costs associated with electrocautery and coblation should be used when assessing surgical costs.
Objective:
To evaluate the associations between proxy measures of socioeconomic status (SES) and usage of cochlear implants.
Study Design:
Retrospective case series.
Methods:
Usage outcomes were ...measured among patients with a cochlear implant and data logging at a tertiary care children’s hospital between 2002 and 2017. Time per day with cochlear implant turned on, coil off, and listening to speech in noise and speech in quiet were extracted from audiology records, averaging right and left ear usage for those with bilateral implants. Associations between cochlear implant usage and demographic factors such as insurance type and median household income for zip code were assessed.
Results:
There were 142 total patients; 74 had bilateral usage data. Mean on air time was 10.76 hours (SD: 4.4). Those with private insurance had 1.2 hour more on air time/day (P = .047) and 0.9 hour more quiet time/day (P = .011) compared to those with public insurance. Younger age at last visit was associated with increased speech in quiet (B = −.08; 95% CI: −0.12-−0.05, P < .001) and coil off (B = −0.06; 95% CI: −0.11-−0.02, P = .006). Younger age at implant was associated with longer duration since last data logging visit (B = −10.46; 95% CI: −18.41-−2.51, P = .010), more daily use (on air; B = −0.23; 95% CI: −0.43-−0.03, P = .026), and increased time spent listening to speech in noise (B = −0.07; 95% CI: −0.14-−0.01, P = .024). No other significant associations between datalogging output and each proxy SES factor were found.
Conclusions:
Lack of private insurance and older age at implantation decreased access to binaural hearing for children and young adults with cochlear implants.
The prevalence of pregnant patients with congenital heart disease (CHD) is increasing, and these patients are at high risk for cardiac morbidity.
This study aimed to examine the pregnancy outcomes in ...patients with congenital heart disease before and after the establishment of formal cardio-obstetrics collaboration between adult congenital heart disease and maternal-fetal medicine programs.
This was a retrospective cohort study of pregnant patients with congenital heart disease from 2002 to 2020 at a single urban academic institution in the United States. This study included patients with a singleton pregnancy who continued a pregnancy beyond 20 weeks of gestation. The primary outcome was a composite adverse maternal cardiac outcome, compared before (2002-2010) and after (2011-2020) the program. The secondary outcomes included gestational age at delivery, mode of delivery, rate of labor induction, use of diuresis after delivery, and a composite maternal morbidity outcome.
The number of pregnant patients with congenital heart disease increased after formalization of the cardio-obstetrics program (200 postprogram group vs 84 preprogram group; 0.48% of all deliveries in the postprogram group vs 0.25% of all deliveries in the preprogram group; P<.001). The postprogram group was more likely to undergo labor induction than the preprogram group (126 63% vs 34 41%, respectively; P<.001). There were fewer patients in the postprogram group than in the preprogram group who were New York Heart Association class II to IV (23 12% vs 17 22%, respectively; P=.04) or with systemic ventricular dysfunction (8 4% vs 12 16%, respectively; P=.001). There was no difference in the primary outcome (38 19% in the postprogram group vs 14 17% in the preprogram group; P=.64), even after adjusting for confounders, including New York Heart Association class >I and systemic ventricular dysfunction (adjusted odds ratio, 2.3; 95% confidence interval, 0.96-5.4). Patients in the postprogram group were more likely to receive diuresis after delivery than patients in the preprogram group, even in the absence of heart failure or pulmonary edema (9 4.5% vs 0 0.0%, respectively; P=.04).
In the period after the establishment of a formal cardio-obstetrics program between adult congenital heart disease and maternal-fetal medicine, the number of patients with congenital heart disease delivering at our institution increased significantly. Overall, fewer patients entered pregnancy with advanced-stage heart failure or systemic ventricular dysfunction, possibly suggesting improved prepregnancy cardiac care or improved preconception counseling. Composite maternal cardiac outcomes were similar, but the rates of postpartum diuresis increased significantly, suggesting increased attention to volume status in the postpartum period. Formalized collaboration between congenital heart disease and maternal-fetal medicine may help better optimize patients' care before conception, during pregnancy, and after delivery.
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