Tympanostomy Tubes Under Local Versus General Anesthesia for Children: A Prospective Long-Term Study.

OBJECTIVES: Tympanostomy tube insertion (TTI) under local anesthesia (LA) is gaining popularity but literature comparing long-term outcomes for children undergoing TTI under LA versus general anesthesia (GA) is limited. This study compares the long-term quality of life (QoL) between LA and GA in children undergoing TTI. Secondary objectives included long-term behavioral changes, parental satisfaction, tube durability, and postoperative complications. METHODS: We prospectively followed children aged under 6 who underwent TTI, under LA or GA, 2 years prior. We assessed QoL using validated scales (OM6, PedsQL), analyzed behavioral changes and parental satisfaction through qualitative scales, and retrieved data on tube durability and non-immediate complications. RESULTS: A total of 84 children (LA = 42; GA = 42) had complete data and a minimum of 1 year of follow-up. Demographic data were similar, except for younger patients in the LA group (1.4 vs. 1.9 years, p = 0.02). LA group exhibited increased fear of health care professionals following TTI (LA: Likert scale 2.1/5, GA: 1.5/5, p = 0.04). Tube retention rate was shorter in the LA group (at 15 months: GA:72%, LA:50%, p = 0.039). Two years post-TTI, there were no differences regarding QoL (OM-6 score; LA: 15.2/100, GA: 21.4/100, p = 0.18, and PedsQL score; LA: 84.3/100, GA: 83.8/100, p = 0.90), parental satisfaction with anesthesia (GA: 4.5/5, LA: 4.6/5, p = 0.56), and postoperative complications (GA: 3/42, LA: 7/42, p = 0.18). CONCLUSIONS: TTI under LA in children is associated with an increased fear of health care professionals and shorter functionality of tympanostomy tubes as compared to GA. No difference was observed in long-term QoL, parental satisfaction, and complications rate. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Prefabricated Fibula Flap vs Bone-Driven and Delayed Implant Installation for Jaw Reconstruction.

Importance: Restoration of dental occlusion and oral rehabilitation is the ultimate goal of functional jaw reconstruction. Objective: To evaluate the prefabricated fibula flap (PFF) technique in occlusion-driven jaw reconstruction for benign or previously treated malignant disease. Design, Setting, and Participants: This cohort study was conducted from January 2000 to December 2019 at the University of Alberta Hospital and Institute of Reconstructive Sciences in Medicine in Edmonton, Alberta, Canada, among patients who underwent PFF or bone-driven and delayed osseointegrated implant installation (BDD). Patients were followed up for a minimum of 1 year after occlusal rehabilitation. Data were analyzed from July 2021 to June 2022. Exposures: Patients underwent BDD or PFF, which consists of osseointegrated dental implant installation and skin grafting of the fibular bone 3 to 6 months before jaw tumor resection or defect reconstruction. The implant osseointegration is completed at the time of jaw reconstruction, allowing for full reconstruction, loading, and restoration of the dental occlusion in the immediate postoperative period. Main outcomes and Measure: Safety, effectiveness, accuracy, timeliness of occlusal reconstruction, and aesthetic appeal were compared between PFF and BDD. Groups were compared for the following variables: postoperative complications, number of bony segments used, number of procedures needed, total operative time, time to occlusal rehabilitation, and number of implants installed, exposed, lost, and used (ie, exposed implants - lost implants). Aesthetic appeal was assessed using standardized full-face and profile digital photographs taken before and 6 to 12 months after the operation and analyzed by 3 naive raters. Results: Among 9 patients receiving PFF (mean [SD] age, 43.3 [13.0] years; 7 men [77.8%]) and 12 patients receiving BDD (mean [SD] age, 41.9 [18.0] years; 8 men [66.7%]), the overall complication rate was similar (4 patients [44.4%] vs 3 patients [25.0%], respectively; relative risk, 1.78 [95% CI, 0.52 to 6.04]). The number of patients with implant loss was similar between PFF and BDD groups (0 patients vs 3 patients [25.0%], respectively; difference, -25.0 percentage points [95% CI, -48.4 to 9.7 percentage points]). PFF had a clinically meaningful faster mean (SD) occlusal rehabilitation compared with BDD (12.1 [1.9] months vs 60.4 [23.1] months; difference, -48.3 months [95% CI, -64.5 to -32.0 months]). The mean (SD) difference in preoperative to postoperative aesthetic score was similar between PFF and BDD groups (-0.8 [1.5] vs -0.2 [0.8]; difference, -0.6 [95% CI, -1.6 to 0.4]). Conclusions and Relevance: This study found that PFF compared with BDD was a safe, effective, and aesthetic reconstructive option for patients with benign or previously treated jaw malignant tumors. This technique may provide rapid occlusal reconstruction and oral rehabilitation.

The Mathematical Limitations of Fetal Echocardiography as a Screening Tool in the Setting of a Normal Second-Trimester Ultrasound.

BACKGROUND: The effectiveness of screening strategies targeting pregnancies at higher risk of congenital heart disease (CHD) is reduced by the low prevalence of severe CHD, the increase in CHD detection rates by second-trimester ultrasound (U/S), and the high proportion of severe CHD in low-risk pregnancies. We aimed to determine situations in which additional screening by fetal echocardiography (FE) would result in a significant increase in sensitivity and a sizable decrease in the false-negative rate of detection of severe CHD. METHODS: We simulated the change in the numbers of detected severe CHD cases when FE is offered to women with a normal second-trimester U/S who have a higher risk of bearing a child with CHD, compared to U/S alone. The primary outcome was the increase in sensitivity. Secondary outcomes were the number needed to screen and the reduction in the rate of missed cases. RESULTS: For an U/S sensitivity of 60%, the addition of FE in pregnancies at high risk of CHD (risk ratio 3.5; range: 2 to 5) increased sensitivity by 2.4 percentage points (1.1 to 7.9). The number needed to screen to detect one additional case of severe CHD was 436 (156 to 952). The rate of additional severe CHD cases detected by FE was 4 per 100,000 pregnancies (2 to 32). CONCLUSIONS: The addition of FE to U/S for severe CHD prenatal screening in pregnancies at high risk of CHD yielded marginal benefits in terms of increased sensitivity and decreased rates of false negatives, at the expense of significant resource utilization.

CONTEXTE: L'efficacité des stratégies de dépistage ciblant les grossesses à haut risque de cardiopathie congénitale (CC) se trouve réduite par la faible prévalence des CC sévères, par l'augmentation des taux de détection des CC par l'échographie (E/G) du deuxième trimestre, et par la proportion élevée de CC sévères dans les grossesses à faible risque. Dans le cadre de la détection prénatale des CC sévères, nous avons cherché à identifier les situations pour lesquelles un dépistage supplémentaire par échocardiographie fœtale (EF) entraînerait une augmentation significative de la sensibilité et une diminution notable du taux de faux négatifs. MÉTHODES: Nous avons simulé le changement du nombre de cas de CC sévère détectées lorsque l'EF est proposée aux femmes dont l'E/G du deuxième trimestre est normal et qui présentent un risque plus élevé de porter un enfant atteint de CC, par rapport à l'examen du deuxième trimestre seul. L'issue primaire était l'augmentation de la sensibilité. Les issues secondaires étaient le nombre de dépistages nécessaires et la réduction du taux de cas manqués. RÉSULTATS: Pour une sensibilité de l'E/G de 60 %, l'ajout de l'EF pour les grossesses à haut risque de CC (rapport de risque de 3,5; intervalle: 2 à 5) a accru la sensibilité de 2,4 points de pourcentage (1,1 à 7,9). Le nombre de dépistages nécessaires pour détecter un cas supplémentaire de CC sévères était de 436 (156 à 952). La proportion de cas supplémentaires de CC sévères détectées par EF était de 4 pour 100 000 grossesses (2 à 32). CONCLUSIONS: L'ajout de l'EF à l'E/G pour le dépistage prénatal des CC sévères pour les grossesses à risque élevé de CC n'a apporté que des avantages marginaux en termes d'augmentation de la sensibilité et de diminution des taux de faux négatifs, cela au prix d'une utilisation importante des ressources.