Proposed Quality Indicators for Aspects of Pediatric Acute Otitis Media Management.

BACKGROUND: The high incidence of pediatric acute otitis media (AOM) makes the implications of overdiagnosis and overtreatment far-reaching. Quality indicators (QIs) for AOM are limited, drawing from generalized upper respiratory infection QIs, or locally developed benchmarks. Recognizing this, we sought to develop pediatric AOM QIs to build a foundation for future quality improvement efforts. METHODS: Candidate indicators (CIs) were extracted from existing guidelines and position statements. The modified RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness methodology was used to select the final QIs by an 11-member expert panel consisting of otolaryngology-head and neck surgeons, a pediatrician and family physician. RESULTS: Twenty-seven CIs were identified after literature review, with an additional CI developed by the expert panel. After the first round of evaluations, the panel agreed on 4 CIs as appropriate QIs. After an expert panel meeting and subsequent second round of evaluations, the panel agreed on 8 final QIs as appropriate measures of high-quality care. The 8 final QIs focus on topics of antimicrobial management, specialty referral, and tympanostomy tube counseling. CONCLUSIONS: Evidence of variable and substandard care persists in the diagnosis and management of pediatric AOM despite the existence of high-quality guidelines. This study proposes 8 QIs which compliment guideline recommendations and are meant to facilitate future quality improvement initiatives that can improve patient outcomes.

Endoscopic cauterisation and injection of Voicegel for treatment of congenital pyriform fossa sinus tracts.

OBJECTIVE: To demonstrate our experience in treating pyriform fossa sinus tracts (PFST) using a novel technique of endoscopic cauterisation of the pyriform fossa sinus opening combined with injection of sodium carboxymethylcellulose gel (VoiceGel) lateral to the tract to encourage tight closure. METHODS: Over a 48-month period, we used this technique on 11 patients who were diagnosed with PFST at BC Children's Hospital, a tertiary paediatric centre in Vancouver, BC, Canada. RESULTS: The 11 patients included 8 males and 3 females, and mean age at presentation was 69 months (range 22-108 months). Mean time from beginning of symptoms till diagnosis was 15 months (range 12-22 months). Ten PFST were on the left side of the neck and one on the right. Nine patients presented with recurrent neck infections and two had suppurative thyroiditis. All patients had endoscopic cauterisation of their PFST opening combined with injection of carboxymethylcellulose lateral to the sinus tract to cause tract collapse. Mean follow up was 15.8 months (range 8-24). All patients are asymptomatic without recurrence at the last follow-up visit. No post-operative complications were reported. CONCLUSIONS: Endoscopic management of paediatric PFST combined with the injection of sodium carboxymethylcellulose gel lateral to the sinus tract appears to be a safe and effective treatment option for PFST.

Necrotizing epiglottitis with necrotizing fasciitis in a child: A case report and review of literature.

Necrotizing epiglottitis (NE) is a rare but extremely serious variant of acute bacterial epiglottitis. So far, it has been reported mostly in immunocompromised adults and only seldomly in the pediatric population. We describe the case of a 15-month-old immunocompetent child who presented to our tertiary referral center with necrotizing epiglottitis. This manuscript emphasizes the need for rapid recognition and surgical management of this unusual condition, as well as the importance of laryngeal preservation when facing overwhelming necrosis around the laryngeal cartilaginous framework. A review of the literature using MEDLINE, Embase and Web of Science databases was performed to discuss the epidemiology, bacteriology, treatment and prognosis of NE.

Quality indicators for the diagnosis and management of pediatric tonsillitis.

INTRODUCTION: Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options. METHODS: A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology - head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology. RESULTS: Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care. CONCLUSIONS: This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

Systematic Review of Endoscopic Obliteration Techniques for Managing Congenital Piriform Fossa Sinus Tracts in Children.

BACKGROUND: Piriform fossa sinus tracts (PFSTs) are a recognized cause of recurrent deep neck infections in the pediatric population. Conventional management has historically required open resection, but over recent years minimally invasive endoscopic approaches to obliterate the pharyngeal opening of the sinus have been performed in many centers. However, there is a lack of clear evidence regarding the success rate and safety of these approaches. OBJECTIVE: To determine the success rate of endoscopic management of PFST through a systematic review of the existing literature. DATA SOURCES: MEDLINE (1964-2014) and bibliographies of identified papers. REVIEW METHODS: Two authors independently reviewed 170 abstracts and identified relevant studies for full-text review. Data were independently extracted from those studies, and the Oxford Centre for Evidence-Based Medicine guidelines were used to classify the level of evidence. RESULTS: Thirteen studies met the inclusion criteria, comprising a total of 84 patients. All included studies were evidence level 4 (case series). Various methods of obliterating the PFST were described: electrocautery (n = 39), laser (n = 19), trichloroacetic acid (n = 19), silver nitrate (n = 4), combination of silver nitrate and laser (n = 2), and fibrin glue (n = 1). The success rate for endoscopic management of PFST was 89.3% overall (90.5% in primary cases and 85.7% in revision cases). The only adverse event reported was temporary vocal cord immobility in 2.4% (n = 2) of cases. CONCLUSION: Endoscopic management of pediatric PFST appears to be safe and effective, as a primary option and for revision after open surgery.

Stapes surgery in profound hearing loss due to otosclerosis.

OBJECTIVES: This study was designed to determine the effectiveness of stapes surgery in patients with profound hearing loss related to far-advanced otosclerosis and if improvement in hearing is sufficient to avoid the need for cochlear implantation. STUDY DESIGN: Retrospective chart review. METHODS: We retrospectively studied the charts of 16 patients who had stapes surgery in 1 or 2 ears between 2005 and 2010 for far-advanced otosclerosis. These patients were all candidates for a cochlear implant according to our institution's criteria but were offered stapes surgery first. Preoperative and postoperative audiologic data, surgical data, postoperative satisfaction, and telephone use were noted. RESULTS: Sixteen patients were included, 3 of which had had bilateral surgery. Status of the oval window was evaluated at the time of surgery. Sixteen footplates had bipolar otosclerosis, and 3 had obliterative otosclerosis. Average gain in air-conduction threshold pure-tone average was 33 dB (range, 13-52 dB) and average gain in speech perception scores was 54.4% (range, 0%-93%); 94% of the patients were satisfied by the surgery, and 94% were able to use the phone postoperatively. Overall, 87% of the patients had sufficient improvement to no longer be candidates for cochlear implantation. CONCLUSION: Stapes surgery in patients with profound hearing loss due to otosclerosis is safe and can restore enough hearing to make ears aidable and averting the need to consider cochlear implantation. LEVEL OF EVIDENCE: 3, Retrospective series.