Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department.

BACKGROUND: Most cases of pediatric epistaxis are spontaneous and self-resolve. However, a subset of children may experience significant bleeding and require procedural or medical intervention. OBJECTIVE: We aim to identify risk factors associated with moderate and severe epistaxis in the emergency department (ED) and explore management outcomes. METHODS: We retrospectively reviewed all patients under 22 years old with epistaxis who presented to our ED between 2013 and 2022. Epistaxis severity was defined as mild (required nasal compression or intranasal medications), moderate (required cautery or packing), or severe (required factor replacement, transfusion, hospital admission, or surgery). We performed univariable and multinomial regression analyses, with risk factors and outcomes analyzed according to severity. RESULTS: Of 858 visits, 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Patients with moderate epistaxis were older than those with mild and severe epistaxis (median 15.6 vs. 8.3 vs. 10.7 years, p < 0.001). In regression analysis, moderate epistaxis was associated with older age, prior ED visit within 72 h, and antiplatelet medication use (p < 0.01). Severe epistaxis was associated with bleeding disorders, nasal procedures within 30 days, and anticoagulation medication use (p ≤ 0.001). Bleeding over 30 min prior to arrival was associated with both moderate and severe epistaxis (p < 0.05). Of the 67 patients with severe epistaxis, 10 (15%) required factor replacement, 28 (42%) required transfusion, 52 (77%) required hospital admission, and 5 (7%) underwent surgery. CONCLUSION: Epistaxis severity is associated with certain risk factors. However, most cases of pediatric epistaxis are mild and do not require intervention or ED evaluation.

Evaluating the Impact of the Novel Geographic Preferences Section on Interview Rate and Residency Match Outcomes.

BACKGROUND: The American Association of Medical Colleges trialed residency application initiatives including geographic preferences and preference signals in 2022. OBJECTIVE: To assess the impact of geographic preferences on application outcomes during the 2022 residency match year. DESIGN: Cross-sectional. PARTICIPANTS: Applicants to categorical and preliminary internal medicine during the 2022 application cycle who completed the Texas Seeking Transparency in Applications to Residency survey. MAIN MEASURES: The primary outcome was interview rate (interview offers/total applications) and whether an application resulted in a match. The key dependent variables were geographic preferences and program-specific preference signals. We also assessed differences in utilization of geographic preferences between specialties. KEY RESULTS: A total of 970 applicants into categorical (n = 884) and preliminary (n = 86) internal medicine were included in our study. A total of 704 (72.6%) applicants submitted at least one geographic preference and 424 (43.7%) submitted three preferences. On average, applicants who submitted a geographic preference had a higher interview rate than those who did not (46.0% vs. 41.8%). Applications submitted with both a preference signal and geographic preference were significantly more likely to receive an interview offer (OR: 3.2, p < 0.01) and match (OR: 6.4, p < 0.01) than applications with neither a preference signal nor a geographic preference. Geographic preferences were associated with an increase in the odds of an application receiving an interview offer, even in the setting of a preference signal (OR: 1.4, p < 0.01). CONCLUSIONS: Both preference signals and geographic preferences have significant associations with odds of an application receiving an interview and matching for both categorical and preliminary internal medicine applicants. This study can be used to inform applicants, advisors, and programs how novel application strategies can affect important application outcomes for US medical school graduates. As more specialties pilot alternative processes, it will be important to study all application outcomes among varying applicant populations.

Does Geographic Region of Away Rotations Predict Otolaryngology Match Outcomes?

OBJECTIVE: To assess whether the geographic region where medical students complete an away rotation predicts the same site, region-specific, or overall interview offers and match success in otolaryngology. STUDY DESIGN: Cross-sectional. SETTING: US medical schools. METHODS: We queried the Texas Seeking Transparency in Application to Residency database to analyze outcomes of otolaryngology applicants during the 2018 to 2020 and 2022 match cycles. Outcomes included a number of interviews offered, geographic location of interviews, and match results, including region-specific and overall match success rate. RESULTS: Of 455 otolaryngology applicants, 402 (90.3%) completed an away rotation. Among these, 368 (91.8%) were offered an interview and 124 (30.9%) matched to the program where they completed an away rotation. Applicants who completed away rotations outside their home region received more interview offers from that region than those who did not (Northeast: 4.2 vs 2.9; South: 4.3 vs 3.0; Central: 4.8 vs 3.0; West: 3.8 vs 1.6, P < .01 for all). Completing a remote away rotation increased the odds of receiving an interview from and matching within that region. After excluding programs where an away rotation was completed, a remote away rotation increased the odds of receiving an interview in the central and western regions (Central: odds ratio [OR]: 1.2 [1.1, 1.5]); West OR: 1.9 [1.7, 2.2]; and the odds of matching in the western region (OR: 2.9 [1.2, 7.4], all P < .01). CONCLUSION: Away rotations are associated with increased odds of interviewing and matching at that away program, with possible associations across the region, most evident for the West coast.

Impact of Applicants' Characteristics and Geographic Connections to Residency Programs on Preference Signaling Outcomes in the Match.

PURPOSE: To assess the impact of applicant and residency program characteristics on preference signaling outcomes in the Match during the first 2 years of implementation across 6 specialties. METHOD: Data were obtained from the Texas Seeking Transparency in Application to Residency survey for applicants applying into otolaryngology during the 2020-2021 and 2021-2022 application cycles and into dermatology, internal medicine (categorical and preliminary year), general surgery, and urology during the 2021-2022 application cycle. The primary outcome was signal yield, defined as the number of interviews at signaled programs divided by the total number of signals sent. Associations with applicant-reported characteristics and geographic connections to residency programs were assessed using Wilcoxon rank sum testing, Spearman's rank correlation testing, and ordinary least squares regression. RESULTS: 1,749 applicants with preference signaling data were included from internal medicine (n = 884), general surgery (n = 291), otolaryngology (n = 217), dermatology (n = 147), urology (n = 124), and internal medicine preliminary year (n = 86). On average 60.9% (standard deviation 32.3%) of signals resulted in an interview (signal yield). There was a stepwise increase in signal yield with the percentage of signals sent to programs with a geographic connection (57.3% for no signals vs. 68.9% for 5 signals, P < .01). Signal yield was positively associated with applicant characteristics, such as United States Medical Licensing Exam Step 1 and 2 scores, honors society membership, and number of publications ( P < .01). Applicants reporting a lower class rank quartile were significantly more likely to have a higher percentage of their interviews come from signaled programs ( P < .01). CONCLUSIONS: Signal yield is significantly associated with geographic connections to residency programs and applicant competitiveness based on traditional metrics. These findings can inform applicants, programs, and specialties as preference signaling grows.

Assessment of Artificial Intelligence Performance on the Otolaryngology Residency In-Service Exam.

Objectives: This study seeks to determine the potential use and reliability of a large language learning model for answering questions in a sub-specialized area of medicine, specifically practice exam questions in otolaryngology-head and neck surgery and assess its current efficacy for surgical trainees and learners. Study Design and Setting: All available questions from a public, paid-access question bank were manually input through ChatGPT. Methods: Outputs from ChatGPT were compared against the benchmark of the answers and explanations from the question bank. Questions were assessed in 2 domains: accuracy and comprehensiveness of explanations. Results: Overall, our study demonstrates a ChatGPT correct answer rate of 53% and a correct explanation rate of 54%. We find that with increasing difficulty of questions there is a decreasing rate of answer and explanation accuracy. Conclusion: Currently, artificial intelligence-driven learning platforms are not robust enough to be reliable medical education resources to assist learners in sub-specialty specific patient decision making scenarios.

Association of Virtual Away Rotations With Residency Applicant Outcomes in Otolaryngology.

Objective: To examine how virtual away rotations might influence interview and match outcomes in otolaryngology. Study Design: Cross-sectional retrospective analysis of survey-based study. Setting: United States medical students applying to otolaryngology residency in the 2020 to 2021 cycle. Methods: The Texas Seeking Transparency in Application to Residency database was queried to identify otolaryngology applicants during the 2020 to 2021 cycle. The primary outcome was mean number of interview offers. χ 2 tests, 2-sided t tests, logistic regression models, and ordinary least squares regression models were used to examine associations with virtual away rotations. Results: Among 115 otolaryngology applicants identified, 35 (30.4%) applicants reported completing 1 or more virtual away rotations. Applicants who completed at least 1 virtual away rotation received significantly more interview offers than their counterparts who did not participate in virtual away rotations (mean [SD], 14.9 [8.2] vs 11.6 [7.9]; P < .03). Each virtual away rotation completed was associated with an incremental increase of 2 additional interview offers (ß coefficient: 2.29 [95% confidence interval, CI: 0.8-3.7; P < .01]). Applicants who completed a virtual away rotation were more likely to receive an interview from that program (62.7% vs 16.8%, P < .01) and to match there (odds ratio 7.7 [95% CI: 2.7-21.7]; P < .01) when compared to applicants who had not done the away rotation. Participation in virtual away rotations was not associated with significant improvement in match success (82.9% vs 67.5%; P = .09). Conclusion: Virtual away rotations were associated with improved program-specific interview and match outcomes, as well as a higher overall number of interview offers.

Impact of applicant and program factors on preference signaling outcomes in otolaryngology.

Objectives: To assess the impact of applicant and program characteristics on preference signaling outcomes during the 2021 and 2022 application cycles in otolaryngology. Methods: The Texas Seeking Transparency in Applications to Residency survey was used for otolaryngology applicants during the 2021 and 2022 match years. The primary outcome of interest was signal yield, defined as the number of interviews at signaled programs divided by the total number of signals sent. Associations with applicant-reported characteristics, geographic connections to programs, and program reputation were assessed. Results: On average 59.5% of signals resulted in an interview (signal yield). There was a positive correlation between the number of signals sent to a program with a reported geographic connection and signal yield, with each additional signal resulting in a 3.4% increase in signal yield (p = .03). Signal yield was positively associated with number of publications (p < .001); number of abstracts, posters, and presentations (p = .04); and whether the applicant took a research year (p = .003). Applicants with higher USMLE Step 1 (p = .01) and Step 2 (p = .003) scores, publications (p = .03), volunteer (p = .008) and leadership (p = .001) experiences received a lower percentage of their total interviews from signaled programs whereas applicants from the 3rd (p < .001) and 4th (p = .03) cumulative class ranked quartiles received a higher percentage of their total interviews from signaled programs. Conclusions: Signal yield appears to have a significant association with geographic connections to programs and applicant competitiveness. This study may help applicants, advisors, and programs maximize the benefit of the preference signaling system.Levels of evidence: Level 4.

Hearing Loss in Children: Critical Medical Education Delivered as Massive Open Online Course (MOOC).

Purpose: Although early identification of pediatric hearing loss is crucial, a formal online training course has not been freely accessible to a global audience. In response, we created a novel course for health professionals worldwide. Method: Course development occurred from February 2019 to May 2020. Seventeen multidisciplinary experts provided video lectures and demonstrations, including a tour of ear anatomy, operating footage of cochlear implant insertion, and demonstrations of children undergoing hearing testing. Content also included steps for interpreting audiograms, an overview of early screening programs, interviews with Deaf/Hard of Hearing children, and an introduction to public health/educational infrastructure. The course was hosted on Coursera and launched on May 4, 2020. Results: The course was approved for 11.5 Continuing Medical Education (CME) and American Board of Pediatrics Maintenance of Certification (MOC)-Part 2 credits and spanned five modules comprised of 50 video learning segments: 1) Ear Anatomy, 2) Hearing Loss and Assessments, 3) Hearing Loss Diagnosis and Impact on Speech and Language Development, 4) Interventions for Hearing Loss, 5) Pediatric Vestibular System and Balance. Since its launch, 6,556 learners have enrolled and 1,540 have fully completed the course; Fifty percent were 25-34 years old, 62% were female, and 43% were from Asia. Average rating was 4.9/5 (n=180 reviews). Conclusions: We created a freely accessible course for a global audience that provides a broad overview of pediatric hearing loss. Our multidisciplinary approach addresses an educational gap and can serve as a model for developing other online courses.

Cost of the Otolaryngology Residency Application Process: Comparison With Other Specialties and Equity Implications.

Objective: This study aims to assess trends in applicant-reported costs of the otolaryngology residency application process between 2019 and 2021 and evaluate the impact of application costs on number of interview offers. Study Design: Cross-sectional study. Setting: US allopathic and osteopathic medical schools. Methods: Survey data from applicants were obtained from the Texas STAR database (Seeking Transparency in Application to Residency) for the years 2019 to 2021. Outcomes included total cost, interview cost, other costs, application fees, and number of interview offers. Simple and multivariable linear regression was used to identify novel predictors of cost and assess the correlation between cost and interview offers. Results: Among 363 otolaryngology applicants, there was a 74% reduction in total costs and a 97% reduction in interview costs in the 2021 cycle vs the 2020 cycle. Significant predictors of total cost among otolaryngology applicants included the number of away rotations (P < .01), the number of research experiences (P = .04), and couples matching (P < .01). During the 2019 and 2020 application cycles, there was a significant association between applicant-reported total spending and number of otolaryngology interview offers (P < .01), which was not present during the 2021 cycle (P = .35). Conclusion: Number of otolaryngology interview offers appears to be directly correlated with applicant-reported total costs regardless of number of applications or interviews attended, which may be a source of inequality in the application process. There was a drastic reduction in total costs, interview costs, and other costs during the COVID-19 pandemic, which was likely driven by virtual interviewing and the absence of away rotations.

A national pediatric otolaryngology fellowship virtual dissection course using 3D printed simulators.

OBJECTIVE: Our objective was to create and evaluate a novel virtual platform dissection course to complement pediatric otolaryngology fellowship training in the setting of the COVID-19 pandemic. METHODS: A four-station, four-simulator virtual course was delivered to pediatric otolaryngology fellows virtually using teleconferencing software. The four stations consisted of microtia ear carving, airway graft carving, cleft lip repair, and cleft palate repair. Fellows were asked to complete pre- and post-course surveys to evaluate their procedural confidence, expertise, and attitudes towards the course structure. RESULTS: Statistical analysis of pre-course survey data showed fellows agreed that simulators should play an important part in surgical training (4.59 (0.62)); would like more options for training with simulators (4.31 (0.88)); and would like the option of saving their simulators for later reference (4.41 (0.85)). Fellows found the surgical simulators used in the course to be valuable as potential training tools (3.96 (0.96)), as competency or evaluation tools (3.91 (0.98)), and as rehearsal tools (4.06 (0.93)). Analysis showed a statistically significant improvement in overall surgical confidence in performing all four procedures. CONCLUSION: This virtual surgical dissection course demonstrates 3D printed surgical simulators can be utilized to teach fellows advanced surgical techniques in a low-risk, virtual environment. Virtual platforms are a viable, highly-rated option for surgical training in the setting of restricted in-person meetings and as a mechanism to increase access for fellows by reducing costs and travel requirements during unrestricted periods.

Opportunity for Improved Transparency on Otolaryngology Residency Websites for Prospective Applicants.

OBJECTIVE: Otolaryngology residency applicants often struggle to gauge their competitiveness at programs due to the lack of information available, resulting in a rising number of applications. We aimed to evaluate otolaryngology websites for information pertaining to prospective applicants. STUDY DESIGN: Systematic content analysis. SETTING: Web. METHODS: We reviewed 50 otolaryngology websites from June to July 2021. We searched for information pertaining to the application process, including requirements, screening and/or selection processes, and average interviewee or matched resident statistics. RESULTS: All websites had a page for prospective applicants. Under half (n = 24, 48%) explicitly listed required application components. Only 23 (46%) mentioned the desired number of letters of recommendation, and only 2 (4%) noted the need for a letter from the department chair. The majority (n = 35, 70%) provided no information regarding the number of applications received or interviews granted. Most (n = 35, 70%) did not mention how candidates are evaluated. A minority (n = 14, 30%) provided very general metrics on which candidates are scored or ranked. Almost all (n = 49, 98%) did not mention screening processes in place to select applicants for interview. None provided information about the academic characteristics or demographics of their interviewed applicants, and only 1 (2%) included this information for matched applicants. CONCLUSION: Otolaryngology websites contain limited information pertaining to the residency application process for prospective applicants, making it difficult for candidates to discern their competitiveness at programs and potentially contributing to match inefficiency.

A Longitudinal Comparison of Telemedicine Versus In-Person Otolaryngology Clinic Efficiency and Patient Satisfaction During COVID-19.

OBJECTIVES: Telemedicine was increasingly adopted in otolaryngology as a result of the COVID-19 pandemic, but how it compares to in-person visits over the longitudinal course of the pandemic has not been characterized. This study compares telemedicine visits to in-person visits on measures of clinical efficiency and patient satisfaction. METHODS: We examined all in-person and telemedicine encounters that occurred during the 13-month period from April 1, 2020 to April 30, 2021 at a pediatric otolaryngology clinic associated with a large tertiary care children's hospital. We compared patient demographics, primary encounter diagnoses, completions, cancellations, no-shows, cycle time, and patient satisfaction. RESULTS: A total of 19 541 (90.5%) in-person visits and 2051 (9.5%) telemedicine visits were scheduled over the study period. There was no difference in patient age or gender between the visit types. There was a difference in race (75% White or Caucasian for in-person and 73% for telemedicine, P = .007) and average travel distance (53.3 miles for in-person vs 71.0 for telemedicine, P = .000). The most common primary diagnosis was Eustachian tube dysfunction for in-person visits (11.8%) and sleep disordered breathing for telemedicine visits (13.7%). Completion rate was greater for telemedicine visits (52.4% in-person vs 62.5% telemedicine). Cancellations were greater for in-person visits (42.6% in-person vs 24.2% telemedicine), but no-shows were greater for telemedicine (5.0% in-person vs 13.3% telemedicine, all P = .000). Average cycle time was shorter for telemedicine visits (56.5 minutes in-person vs 47.6 minutes telemedicine, P = .000). Patient satisfaction with provider interactions and overall care experience was high for both visit types. CONCLUSIONS: Telemedicine was utilized more during months of heightened COVID-19 cases, with higher completion rates, fewer cancellations, shorter cycle times, saved travel distance, and comparable patient satisfaction to in-person visits. Telemedicine has the potential to remain an efficient mode of care delivery in the post-pandemic era.

Creating a 'choose your topic' massive open online course: an innovative and flexible approach to delivering injury prevention education.

BACKGROUND: A pediatric injury prevention course has not been available as a massive open online course (MOOC). Creating a comprehensive topic course is particularly challenging because the traditional, week-by-week linear curriculum design is often a barrier to learners interested in only specific topics. We created a novel, flexible course as both a 'choose your topic' MOOC for the public learner and a Small Private Online Course (SPOC) for medical students. METHODS: We describe creating 'Injury Prevention for Children and Teens', a course of 59 video learning segments within eight modules taught by a multidisciplinary panel of 25 nationally-recognized experts. Completion tracking and course evaluations were collected. RESULTS: In 2.5 years, 4,822 learners from 148 countries have enrolled. Two-thirds of learners were female. Median age of learners was 31 years. For engagement, 19.3% (n = 932) of learners attempted quizzes, and 5.2% (n = 252) participated in online forum discussions. Medical professionals (n = 162) claimed an average of 13 credit hours per learner. Over 200 senior medical students have taken the SPOC. CONCLUSION: 'Injury Prevention for Children and Teens' is a novel approach to injury prevention education that is broad, science-based, accessible, and not cost-prohibitive for a diverse group of global learners.

Adoption of Telemedicine for Multidisciplinary Care in Pediatric Otolaryngology.

OBJECTIVE: The COVID-19 pandemic has introduced a period of social isolation that has challenged the ability of providers to uphold in-person patient care. Although commonplace in pediatric otolaryngology, multidisciplinary clinics pose a unique challenge during this time due to increased infection risk from multiple patient-provider interactions. Guidance on the application of telemedicine for multidisciplinary clinics in pediatric otolaryngology is limited. METHODS: We provide comprehensive guidance on best practices for conducting telemedicine visits for a number of multidisciplinary otolaryngology clinics using our experiences at a single tertiary care children's hospital. A review of literature to support the adoption of telemedicine in multidisciplinary pediatric otolaryngology is also incorporated. RESULTS: Telemedicine was successfully adopted for 7 multidisciplinary pediatric clinics with a variety of specialists: aerodigestive disorders, congenital hearing loss, microtia/aural atresia, orofacial clefting, sleep disorders, tracheostomy care, and velopharyngeal dysfunction. CONCLUSIONS: Telemedicine is feasible for a variety of multidisciplinary clinics and its optimization is critical for providing care to complex pediatric otolaryngology patients during the COVID-19 pandemic and beyond.

Tongue protrusion as the presenting symptom of parapharyngeal abscess.

Deep neck space infections are commonly seen in the pediatric population. The diagnosis, however, can be challenging to make and requires a high degree of suspicion because of developmental and age-related factors in children and non-specific presenting symptoms. Diagnosis becomes further complicated in patients whose comorbid conditions mask some of the more severe systemic symptoms. We present a case of a 2-year-old female with Trisomy 21 who presented with a chief concern of "tongue swelling" per parents. After initially failing treatment for presumed angioedema caused by an angiotensin-converting enzyme inhibitor, she was ultimately diagnosed with a parapharyngeal abscess with extension and mass effect causing tongue protrusion. This case represents a novel early presentation of a common infection and highlights the challenges of diagnosing deep neck space infections in children.

Otolaryngology Curriculum During Residency Preparation Course Improves Preparedness for Internship.

OBJECTIVES/HYPOTHESIS: Residency preparation courses (RPCs) have become a widely adopted practice to ease the transition of medical students into residency, but these courses often lack training in skills expected of subspecialty interns. To fill this gap, a simulation-based curriculum in otolaryngology (ORL) was implemented at the University of Michigan Medical School. The curriculum aimed to improve confidence and perceived ability to perform common ORL skills for graduating students prior to internship. STUDY DESIGN: Cross-sectional study. METHODS: Six basic simulations (tracheostomy, flexible laryngoscopy, otomicroscopy, myringotomy and tube insertion, epistaxis and peritonsillar abscess management) were included in the first course in 2019. The course was expanded in 2020 with the addition of three advanced simulations (ear foreign body extraction, tracheostomy complications, and "cannot intubate, cannot ventilate" situations). Pre- and postsession surveys were collected to assess individual simulations and the course overall. RESULTS: A total of 32 students participated in the ORL simulation curriculum in Spring 2019 and 2020. Paired t-tests showed significant improvement in self-perception of ability on every simulation. Qualitative feedback revealed that students particularly valued the opportunity for hands-on learning. Non-ORL students rated their baseline abilities significantly lower than ORL students on five stations, but they achieved statistically equivalent postsession ratings on all but the otomicroscopy station. CONCLUSIONS: An ORL-specific curriculum is a valuable addition to procedural RPCs. The curriculum resulted in increased confidence and perceived ability in skill performance for both students pursuing ORL residencies, as well as those pursuing other procedural specialties. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2143-E2148, 2021.

Addressing the Impact of COVID-19 on the Residency Application Process Through a Virtual Subinternship.

Senior medical students are facing an unparalleled experiential gap left by COVID-19 restrictions. Due to a shared commitment to safety, equity, and well-being, away rotations are actively being discouraged or even prohibited. As a result, students transitioning to residency encounter reduced clinical training experiences and decreased access to advising, mentorship, and research opportunities. In addition, limited exposure to residency life across subspecialties and institutions poses unique challenges during the current residency application cycle. The otolaryngology-head and neck surgery community has met these unprecedented challenges by producing diverse electronic resources for specialty-specific clinical education, as well as discussing ways to increase access to advising. In this commentary, we review these initiatives and propose an institutional virtual event as a platform for meeting goals previously achieved by visiting subinternships.

Association of Opioid Quantity and Caregiver Education with Pain Control after Pediatric Tonsillectomy.

OBJECTIVE: To examine whether a service guideline reducing postoperative opioid prescription quantities and caregiver-reported education to use nonopioid analgesics first are associated with caregiver-reported pain control after pediatric tonsillectomy. STUDY DESIGN: Prospective cohort study (July 2018-April 2019). SETTING: Pediatric otolaryngology service at a tertiary academic children's hospital. SUBJECTS AND METHODS: Caregivers of patients aged 1 to 11 years undergoing tonsillectomy (N = 764) were surveyed 7 to 21 days after surgery regarding pain control, education to use nonopioid analgesics first, and opioid use. Respondents who were not prescribed opioids or had missing data were excluded. Logistic regression modeled caregiver-reported pain control as a function of service guideline implementation (December 2018) recommending 20 rather than 30 doses for postoperative opioid prescriptions and caregiver-reported analgesic education, adjusting for patient demographics. RESULTS: Among 430 respondents (56% response), 387 patients were included. The sample was 43% female with a mean age of 5.0 years (SD, 2.5). Pain control was reported as good (226 respondents, 58%) or adequate/poor (161 respondents, 42%). Mean opioid prescription quantity was 27 doses (SD, 7.9) before and 21 doses (SD, 6.1) after guideline implementation (P < .001). Education to use nonopioids first was reported by 308 respondents (80%). In regression, prescribing guideline implementation was not associated with pain control (adjusted odds ratio, 1.3; 95% CI, 0.9-2.0; P = .22), but caregiver-reported education to use nonopioids first was associated with a higher odds of good pain control (adjusted odds ratio, 1.9; 95% CI, 1.1-3.2; P = .02). CONCLUSION: Caregiver education to use nonopioid analgesics first may be a modifiable health care practice to improve pain control as postoperative opioid prescription quantities are reduced.

Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children.

IMPORTANCE: Practice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced. OBJECTIVE: To assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids. DESIGN, SETTING, AND PARTICIPANTS: This cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children. MAIN OUTCOMES AND MEASURES: The percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids. RESULTS: Among 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications. CONCLUSIONS AND RELEVANCE: These findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.

Optimal Timing of Entry-Level Otolaryngology Simulation.

OBJECTIVE: Appropriate timing of subspecialty simulation is critical to maximize learner benefit and guide resource utilization. We aimed to determine optimal timing of a simulation-based curriculum designed to teach entry-level procedural skills for otolaryngology residency. STUDY DESIGN: Simulation curriculum intervention tested among 3 comparison groups of varying clinical levels. SETTING: Academic otolaryngology training program and medical school. SUBJECTS AND METHODS: We developed a simulation-based technical skills curriculum incorporating the following task trainers: flexible laryngoscopy, peritonsillar abscess drainage, and myringotomy and tube insertion. Preclinical medical students (n = 40), subintern rotators (n = 35), and midyear interns (n = 8) completed the simulation-based curriculum. Pre- and postintervention knowledge/confidence and "level appropriateness" were rated on a 5-point Likert scale, and effect size was calculated. RESULTS: Overall self-reported knowledge/confidence levels improved in all 3 groups preintervention (1.05, 2.15, 3.17) to postintervention (2.79, 3.45, 4.38, respectively; all P < .01). Preclinical medical students uniformly reported very little to no familiarity with the procedures prior to the curriculum, while interns approached independence following the intervention. Large effect sizes were seen in all tasks for preclinical students (d = 3.13), subinterns (d = 1.46), and interns (d = 2.14). Five-point Likert scale measures of level appropriateness (1 = too challenging, 5 = too easy) for preclinical students, subinterns, and interns were 2.70 (95% CI, 2.56-2.84), 3.11 (95% CI, 2.97-3.25), and 3.75 (95% CI, 3.35-4.15), respectively. CONCLUSION: Subinternship may represent the optimal timing for entry-level skills simulation training. The proposed curriculum shows utility for clinical levels ranging from medical students to postgraduate year 1 resident levels, with large effect sizes for all tested groups.