Opioid and non-opioid analgesic prescribing practices for pediatric adenotonsillectomy in a tertiary care center.

IMPORTANCE: The U.S. is in an opioid epidemic with greater than 40,000 deaths annually. Pediatric adenotonsillectomy is one of the most common and painful otolaryngology surgeries performed, often associated with opioid prescriptions. OBJECTIVE: To understand postoperative prescribing practices of adenotonsillectomy in a tertiary care institution and associated postoperative emergency department (ED) visits. DESIGN: Descriptive analysis of retrospective cohort data. SETTING: Tertiary academic healthcare institution. PARTICIPANTS: Pediatric patients <18yo undergoing adenotonsillectomy between 2013 and 2016. INTERVENTIONS/EXPOSURES: Postoperative analgesic regimens assessed including opioid and non-opioid analgesic prescriptions upon discharge from tonsillectomy surgery. MAIN OUTCOMES AND MEASURES: Main outcomes included ED presentation within 30-days of surgery and reoperation. Secondary outcomes included reason for ED presentation and relation to prescribed analgesics. Data was analyzed between November 2021-February 2022. RESULTS: 200 patients were included in the study with 69% prescribed opioids, and 51% prescribed non-opioid analgesics. Number of opioid doses ranged widely with a median of 37 (Q1, Q3: 0, 62). There were no demographic differences in patients prescribed opioids from those who were not. Of those patients who presented to the ED, 81% were not specifically prescribed acetaminophen (p < 0.001). Regression analysis models were not predictive of postoperative analgesic regimen or 30-day ED presentation (p > 0.05) CONCLUSIONS: Wide ranges of post tonsillectomy prescribing practices currently exist in our institution. Prescribing acetaminophen may help to reduce 30-day ED presentation rate. Larger prospective studies are needed to optimize pain control regimens and reduce variability of opioid prescribing practices. Standardization of postoperative pain medication doses may also reduce postoperative ED presentations.

Pre- Versus Post-Tonsillectomy Intraoperative Bupivacaine Injection in the Pediatric Population: An Age- and Surgical Indication-Stratified Analysis.

OBJECTIVES: Postoperative respiratory depression is of concern in children undergoing adenotonsillectomy receiving postoperative opioids and may be mitigated with intraoperative bupivacaine. This study aims to compare the impact of bupivacaine on postoperative pain and sedation in various pediatric age and surgical indication subgroups. METHODS: This is a case series with chart review of 181 patients <18 years old undergoing adenotonsillectomy at a tertiary care center (2013-2016). Postoperative outcomes were compared between those who received intraoperative bupivacaine before (pre-tonsillectomy) or after (post-tonsillectomy) tonsil removal and those who did not (none) using χ2 test and analysis of variance. Subanalysis was performed after stratifying into age and surgical indication subgroups. RESULTS: Ninety-eight patients were included in the pre-tonsillectomy group, 47 in the post-tonsillectomy group, and 36 in the none group. The number of postanesthesia care unit opioid doses (P = .159) and pain scores at arrival (P = .362) or discharge (P = .255) were not significantly different between treatment groups overall. Among 0- to 5-year-olds, pre-tonsillectomy injection was associated with lowest mean (SD) discharge pain score of 0.55 (1.29) pre-tonsillectomy versus 0.71 (1.37) post-tonsillectomy versus 2 (1.63) none group (P = .004). Among 12- to 17-year-olds, no injection was associated with lowest mean (SD) discharge pain score of 2.33 (0.52) pre-tonsillectomy versus 5 (2.65) post-tonsillectomy versus 1.63 (1.60) none group (P = .020). Injection in patients with obstructive sleep apnea and/or sleep-disordered breathing did not improve postoperative outcomes. CONCLUSION: Intraoperative bupivacaine may improve pain scores in younger pediatric populations, though it may not impact the amount of postoperative opioid use. Prospective analysis with a larger sample size is warranted to better outline opioid usage and pain control in this group.

Practice patterns in supraglottoplasty and perioperative care.

OBJECTIVES: Supraglottoplasty is the first-line surgical treatment for severe laryngomalacia. The purpose of this study is to determine the current trends of practice patterns in managing children who require supraglottoplasty. METHODS: A 25-question survey regarding supraglottoplasty techniques and perioperative management was sent by e-mail to 274 physician members of the Society for Ear, Nose and Throat Advances in Children (SENTAC). RESULTS: 101 surgeons responded and 72% of respondents were in academic practice (p < 0.0001). All four United States regions, Canada and the United Kingdom were represented. The most commonly reported age of patients undergoing supraglottoplasty was 1-3 months (62% of respondents). Indications include worsening airway symptoms (43%), failure to thrive (41%) and worsening feeding (10%). The majority of respondents (89%) treat these patients for reflux with 54% prescribing PPIs and 41% prescribing H2 blockers. Cold steel is the most popular surgical technique (73%) followed by laser (14%), microdebrider (10%) and coblator (3%) (p < 0.0001). Most respondents (92%) administer intraoperative steroids with the majority of them choosing dexamethasone (99%). Perioperative antibiotics are administered by 23% of respondents. Almost all respondents admit their patients for post-operative observation (99%) and 53% of these admit to PICU rather than step-down or floor status. The level of care is associated with the number of supraglottoplasties performed per year (p = 0.009) and with the geographic region (p = 0.02). Surgeons who perform fewer supraglottoplasties tend to admit to a higher level of care. Those in the South and Northeast regions tend to admit more to floor status. Only 13% routinely keep patients intubated post-operatively. CONCLUSIONS: This provider survey study highlights some significant variations and trends in practice patterns of otolaryngologists who perform supraglottoplasty. The majority utilizes anti-reflux pharmacotherapy; however, there is no consensus in which type. The method for supraglottoplasty also varies with cold steel being the most popular, although no single method has been shown to be superior. There is variation in post-operative care with trends for keeping patients extubated and admitting them to an intensive care. With the importance of safe, effective, and also cost-conscious care, further studies are needed to understand the optimal management of those who undergo supraglottoplasty.

Influence of electronic medical record implementation on provider retirement at a major academic medical centre.

RATIONALE, AIMS AND OBJECTIVES: The push for electronic medical record (EMR) implementation is grounded on increasing efficiency and cost savings. Our objective was to investigate the effect of EMR implementation on provider attrition. METHODS: We completed a retrospective study investigating whether medical provider attrition, clinical MD or equivalent, coincided with EMR implementation. We analysed monthly provider attrition rates and mean age at attrition 24 months preceding the EMR 'go-live' date at our institution and 12 months after. RESULTS: 208 provider departures occurred between July 2011 and June 2014. The attrition categories were classified as 'departure' (n = 137, 65.9%), 'emeritus' (n = 30; 14.4%), 'no specified reason' (n = 26; 12.5%) and 'not reappointed' (n = 15; 7.2). The most common degree held by departing providers was 'MD' (n = 170; 81.7%). Most departures occurred in June 2013 (n = 24). The mean provider age at departure was 46.4 years ± 2.9 years for June 2012, 48.1 years ± 2.5 years for June 2013 and 45.0 years ± 4.1 years for June 2014. Our data indicate a trend for both an increase in number of departing providers, as well as an increased mean age in the month immediately prior to EMR implementation. CONCLUSION: To date, no other investigation of the effect of EMR implementation of provider retirements have been published. We demonstrate a peak in provider attrition in the month prior to EMR implementation that may not be explained by normal attrition patterns with an academic calendar. LEVEL OF EVIDENCE: Level 5 - qualitative or descriptive study.

Bilateral cochlear implantation: current concepts.

PURPOSE OF REVIEW: The goal of this review is to examine the most recent literature exploring the indications, outcomes, and long-term benefit of bilateral cochlear implantation in children and adults. The indications for cochlear implantation have expanded, as many unilaterally implanted individuals are able to achieve open-set word recognition. Despite the benefits seen in unilateral implantation, many individuals have difficulty perceiving speech in noisy environments. Bilateral cochlear implantation has made great strides in providing individuals access to sound information from both ears, allowing improved speech perception in quiet and in noise, as well as sound localization. Recently, the House Cochlear Implant study group released a position statement in which the group strongly endorsed bilateral cochlear implantation. RECENT FINDINGS: Improved speech perception in quiet has also been demonstrated by many groups with bilateral implantation. Improved sound localization abilities have been shown to be dependent on interaural level differences. The binaural benefits of head shadow and summation have been long shown in bilaterally implanted individuals. Recently, a growth in squelch has been seen in these individuals likely as a result of increased experience with both implants. This may indicate neural integration of the inputs over time. SUMMARY: The literature supports the binaural benefit of bilateral cochlear implantation with demonstrated improved speech perception outcomes in quiet and in noise, sound localization data, and subjective benefits.

Hearing-in-noise benefits after bilateral simultaneous cochlear implantation continue to improve 4 years after implantation.

OBJECTIVE: The purpose of this 4-year longitudinal study was to assess the stability of the binaural benefits of head shadow, summation, and squelch for bilateral cochlear implant recipients and to quantify these benefits for the understanding of speech in noise. DESIGN: This is a prospective study of 9 patients who received simultaneous bilateral insertion of MED-EL COMBI +40 cochlear implants in a single-stage operation at the University of North Carolina, Chapel Hill, NC. Each patient had postlingual deafness of short duration before insertion of the device. Each year, the patients were tested for word recognition using consonant-nucleus-consonant words in quiet and speech perception in noise using City University of New York sentences. These tests were administered using direct audio input to the implants. Head-related transfer functions were used to simulate speech in noise testing in a spatial environment. Speech was always presented at midline (0 degrees), and the noise masker was presented at either side or midline (-90, 0, +90 degrees). RESULTS: The binaural benefits of head shadow and summation effects developed early in the postoperative period and remained stable throughout the follow-up period. Squelch developed more slowly and was first demonstrated at 12 months after implantation but continued to increase beyond the first year of follow-up. CONCLUSION: Benefits of head shadow and summation emerge early and remain stable. However, squelch has the most protracted period of development, with increasing benefit after a year or more of implant experience. These data support the idea that binaural integration continues several years after insertion of bilateral cochlear implant devices.

Her2/neu signaling blockade improves tumor oxygenation in a multifactorial fashion in Her2/neu+ tumors.

PURPOSE: Tumor hypoxia reduces the efficacy of radiation and chemotherapy as well as altering gene expression that promotes cell survival and metastasis. The growth factor receptor, Her2/neu, is overexpressed in 25-30% of breast tumors. Tumors that are Her2(+) may have an altered state of oxygenation, relative to Her2(-) tumors, due to differences in tumor growth rate and angiogenesis. METHODS: Her2 blockade was accomplished using an antibody to the receptor (trastuzumab; Herceptin). This study examined the effects of Her2 blockade on tumor angiogenesis, vascular architecture, and hypoxia in Her2(+) and Her2(-) MCF7 xenograft tumors. RESULTS: Treatment with trastuzumab in Her2(+) tumors significantly improved tumor oxygenation, increased microvessel density, and improved vascular architecture compared with the control-treated Her2(+) tumors. The Her2(+) xenografts treated with trastuzumab also demonstrated decreased proliferation indices when compared with control-treated xenografts. These results indicate that Her2 blockade can improve tumor oxygenation by decreasing oxygen consumption (reducing tumor cell proliferation and inducing necrosis) and increasing oxygen delivery (vascular density and architecture). CONCLUSIONS: These results support the use of trastuzumab as an adjunct in the treatment of breast tumors with chemotherapy or radiotherapy, as improvements in tumor oxygenation should translate into improved treatment response.

The development of frequency weighting for speech in children with a history of otitis media with effusion.

OBJECTIVES: To determine the effect of chronic (recurrent) otitis media with effusion (OME) on frequency weighting in the perception of speech in noise. It was hypothesized that children with a history of OME weight speech information in the mid frequency region higher than control children. DESIGN: This is a matched cohort study looking at differences in frequency weighting in 12 children with a history of OME 1 to 2 wks after placement of tympanostomy tubes compared with 21 control children. Children were tested on their ability to identify key words in sentences presented in speech-shaped noise. The frequency content of the sentences was manipulated to determine the relative importance of frequencies in the regions of 1, 2, and 4 kHz. The frequency bands selected were 798 to 1212 Hz (low band), 1575 to 2425 Hz (mid band), and 3000 to 5000 Hz (high band). Initial testing involved adaptive runs where a speech-shaped masker was held at a constant level and the level of the speech with all three bands present varied. Once a level corresponding to 85% to 90% correct was identified, novel sentences were then presented at this signal-to-noise ratio in fixed block runs, with all bands present, or with one of the three bands omitted. RESULTS: The children in the OME group achieved 85% to 90% correct at a lower signal-to-noise ratio than controls in the adaptive testing, where all three speech bands were present. Fixed block testing indicated that children with OME history gave more weight to speech frequencies in the region of 2000 Hz compared with the age-matched control group. CONCLUSIONS: The results are consistent with an interpretation that the development of frequency weighting in the perception of speech can be affected by a history of OME.

Allergic rhinitis--history and presentation.

Allergic rhinitis is a common disorder that results from a complex interaction of environmental and genetic causes. This disorder has a tremendous impact on the quality of life and on health care expenditures, as evidenced by a large loss of worker productivity. Care must be taken to promptly diagnose patients with this condition, evaluate them for associated conditions, and begin appropriate management to reduce its impact on the individual and the health care system. Allergic rhinitis represents only a component of the spectrum of inflammatory diseases involving the unified airway.