Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families.

OBJECTIVE: We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner. METHODS: Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days. RESULTS: Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children's study results. DISCUSSION: Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner. IMPLICATIONS FOR PRACTICE: With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.

Changes in intracuff pressure of cuffed endotracheal tubes while positioning for adenotonsillectomy in children.

BACKGROUND: When using cuffed endotracheal tubes (cETTs), changes in head and neck position can lead to changes in intracuff pressure. AIM: The aim of this study was to assess the combined effect of neck extension, shoulder roll placement, and Crowe-Davis retractor use during adenotonsillectomy on the intracuff pressure of cETTs in children. METHODS: Patients <18 years of age undergoing adenotonsillectomy under general anesthesia following the placement of a cETT were included in the study. After inflation of the cuff to seal the trachea, using the leak test, baseline intracuff pressure was recorded and then continuously monitored. After neck extension, placement of a shoulder roll, insertion of the Crow-Davis retractor, suspension from a Mayo stand, and positioning for surgery, the intracuff pressure was recorded again. RESULTS: The study cohort included 84 patients, ranging in age from 0.9 to 17 years (5.7 ± 3.9 years). In 46 patients (54.8%), the intracuff pressure increased from baseline after positioning for adenotonsillectomy. In 12 of these patients (14.3%), the intracuff pressure was >30 cm H2O. The intracuff pressure decreased in 28 patients (33.3%), while no change was noted in 10 patients (11.9%). Overall, the general trend was an increase in intracuff pressure from 15.9 ± 7.8 cm H2O to 18.9 ± 11.6 cm H2O. CONCLUSION: Both increases and decreases in the intracuff pressure may occur following positioning of the pediatric patient for adenotonsillectomy. An increase in intracuff pressure may result in a higher risk of damage to the tracheal mucosa. A decrease in the intracuff pressure can result in an air leak resulting in inadequate ventilation, increased risk of aspiration, and even predispose to airway fire if oxygen-enriched gases are used. Continuous intracuff pressure monitoring or rechecking the intracuff pressure after positioning for adenotonsillectomy may be indicated.

Plastic bronchitis arising from solitary influenza B infection: A report of two cases in children.

Plastic bronchitis (PB) is characterized by thick, inspissated, tracheobronchial casts. It is classified as either inflammatory or acellular based on the content of the endobronchial casts. PB has never been reported in a healthy child with solitary influenza B infection. This study is a retrospective case series of two children who presented to our institution in acute respiratory distress. Emergency rigid bronchoscopy was performed with extraction of casts from the L mainstem bronchus in both patients. Influenza B was the only isolate identified. In otherwise healthy children with respiratory distress, influenza B-mediated inflammatory PB must be considered in the differential diagnosis.

Short- and long-term outcomes after silastic medicalization laryngoplasty: are arytenoid procedures needed?

OBJECTIVE: To evaluate short- and long-term vocal outcomes after medialization laryngoplasty (ML) using a silastic implant in patients with unilateral vocal fold paralysis (UVFP). DESIGN AND METHODS: Prospective study of consecutive patients undergoing ML with silastic (MLS) diagnosed with UVFP from 2009 till 2012 and with at least 9 months follow-up. Pre- and post-treatment maximum phonation time (MPT) and voice handicap index (VHI) scores were compared to assess the impact of ML on these outcomes. Patients with high vagal lesions or lateralized vocal folds (very low MPT) were compared with the entire group and the literature. RESULTS: A total of 124 patients with UVFP underwent MLS. Forty-six patients were excluded as they either had a Gore-Tex implant (eight), short follow-up (20), or the primary case was a revision (18). Seventy-eight patients were included. Pretreatment mean VHI (total score) was 67 for the entire cohort. Postoperative VHI score was significantly lower both in short-term (3-8 weeks) follow-up, mean score 27 (paired t-test, P < 0.05) and in long-term follow-up (9-12 months), mean score 22 (P < 0.05). MPT was significantly improved from 8.3 pretreatment to 22.6 at short-term follow-up (P < 0.05) and to 24.2 long-term follow-up (P < 0.05). There were no significant differences between entire cohort and patients with a lateralized vocal fold or high vagal lesion. Comparable results were present when compared with the literature using similar metrics in patients undergoing an arytenoid procedure with/without medialization. CONCLUSION: MLS alone is effective in managing UVFP in most patients.

A review of the evaluation and management of velopharyngeal insufficiency in children.

This article highlights the most common causes of velopharyngeal insufficiency (VPI), and discusses routine evaluation and treatment algorithms for the management of VPI in children. VPI is a multifactorial condition that occurs commonly in syndromic and non-syndromic children. The most common features of VPI are audible hypernasal speech, facial grimacing, decreased speech intelligibility, nasal regurgitation, and nasal emission from failure to produce oronasal separation. Work-up of VPI typically involves radiologic and endoscopic testing performed with the assistance of a speech-language pathologist. Management of VPI involves initial speech therapy followed by operative repair with sphincter or pharyngeal flap pharyngoplasty, if needed.

The cost of screening for synchronous thyroid disease in patients presenting with primary hyperparathyroidism.

OBJECTIVE: To use decision analysis to compare the costs associated with minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE) in patients with primary hyperparathyroidism with regard to treatment of incidental synchronous thyroid disease. DESIGN: We developed a decision tree model to evaluate the cost of managing thyroid pathology in primary hyperparathyroidism with the following 3 approaches: MIP, MIP with preoperative ultrasonography, and routine BNE with intraoperative thyroid evaluation. We tested the robustness of the optimal decision with sensitivity analyses. SETTING: A tertiary care academic medical center. MAIN OUTCOME MEASURE: Total costs from a provider perspective. RESULTS: Minimally invasive parathyroidectomy without an active search for thyroid abnormalities was determined to have the lowest expected cost ($5275 per patient). Parathyroid surgery with routine preoperative thyroid ultrasonography and further thyroid treatment as indicated had an expected cost of $5910 per patient. Bilateral neck exploration with intraoperative thyroid evaluation and treatment of the thyroid gland had an expected cost of $5916 per patient. Sensitivity analyses confirmed the robustness of the results across a reasonable range of surgical and imaging costs. CONCLUSIONS: Minimally invasive parathyroidectomy is not contraindicated on the basis of cost by an inability to screen for synchronous thyroid disease. In addition, ultrasonographic screening of the thyroid glands of patients undergoing MIP is not cost prohibitive and, in fact, is less costly than BNE. Ultrasonography has the added advantage of confirming the location of the offending parathyroid.

The effect of single agent oral fusaric acid (FA) on the growth of subcutaneously xenografted SCC-1 cells in a nude mouse model.

OBJECTIVE: To determine whether oral administration of fusaric acid (FA) inhibits tumor growth in an animal model of head and neck cancer (HNSCC). DESIGN: In vivo murine model, two arm controlled study. METHODS: Thirty-eight (38) 5-week-old athymic nude mice were randomly assigned to a fusaric acid treatment group (1 mg/mL) (n = 19) or a sterile saline group (n = 19). A left, lateral flank subcutaneous injection of 2.0 x 10(6) UM-SCC-1 cells were administered to all mice on day 1. Both groups were gavaged daily with either 0.25 mLs of oral FA or sterile saline throughout the experiment (32 days). Latency to a measurable tumor (> or =65 mm3), and tumor volumes were recorded after tumor xenografting. Tumor weights were recorded at the conclusion of the experiment. Tumor volume growth curves were modeled as polynomial functions of time with treatment interaction effects. Survivorship functions for time to measurable tumor were estimated using the Kaplan-Meier product limit estimator. RESULTS: Survival analysis showed mice treated with FA developed measurable tumors after a significantly longer interval post-xenografting than control mice (p = 0.00451). By Day 9, all mice in the control group had developed measurable tumors in comparison to only 78% of mice in the FA group. Likewise, estimated growth curves for both groups suggested that mice receiving FA demonstrated significantly slower tumor growth rates throughout the entire study period (p < 0.0001). At the conclusion of the experiment, tumor weights from both the control and FA groups were also significantly different (p = 0.0142). CONCLUSIONS: Single agent oral fusaric acid (1 mg/mL) is an inhibitor of UM-SCC-1 in a murine model. As an orally active agent, it may have a potential role in the treatment of human squamous cell carcinoma of the head and neck.

The cost-effectiveness of additional preoperative ultrasonography or sestamibi-SPECT in patients with primary hyperparathyroidism and negative findings on sestamibi scans.

OBJECTIVE: To determine whether the use of additional preoperative imaging was cost-effective compared with bilateral neck exploration (BNE) for the treatment of primary hyperparathyroidism in patients with negative findings on scans with technetium Tc 99m sestamibi. DESIGN: We performed a cost-effectiveness analysis. The decision whether to proceed to BNE or obtain additional preoperative imaging using ultrasonography (US) or single-photon emission computed tomography with technetium Tc 99m sestamibi (SPECT) was modeled using decision analysis. We obtained probabilities of cure, detection of pathologic glands, and the correct side of the neck from recent literature. MAIN OUTCOME MEASURES: Expected cost, cure rate, and the incremental cost per cured case using the preoperative imaging strategies compared with BNE. RESULTS: The US strategy dominated the SPECT and BNE strategies, with a lower expected cost (USD $6030 vs USD $7131 and $8384, respectively) and a greater expected cure rate (99.42% vs 99.26% and 97.69%, respectively). Threshold analysis suggests that the preoperative imaging strategies continued to dominate unless the cost of BNE was less than USD $5400 or the cost of unilateral neck exploration exceeded USD $6500. The US strategy dominated SPECT as a preoperative imaging strategy if the cost of SPECT exceeded $12 or the cost of a US test was less than $1300. CONCLUSIONS: For the treatment of primary hyerparathyroidism in the patient with negative findings on technetium Tc 99m sestamibi scans, a strategy that uses additional preoperative US imaging appears to be cost-effective compared with SPECT or BNE.

Relationship of technetium Tc 99m sestamibi scans to histopathological features of hyperfunctioning parathyroid tissue.

OBJECTIVE: To investigate the histopathological features of pathologic parathyroid specimens associated with negative preoperative technetium Tc 99m sestamibi scans. DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: One hundred fourteen patients who underwent sestamibi scans before surgical exploration for primary hyperparathyroidism between 1996 and 2001. INTERVENTIONS: Surgical exploration and removal of parathyroid adenomas. MAIN OUTCOME MEASURES: Histopathological characteristics associated with true-positive and false-negative sestamibi scans, including parathyroid specimen weight, size, relative oxyphil and chief cell content, parathyroid hormone staining patterns, cellular architecture, and various immunohistochemical staining patterns. RESULTS: Twenty-three (24%) of 98 patients with parathyroid adenomas had negative sestamibi scan results. Among 20 age- and sex-matched patients with false-negative results vs 20 patients with true-positive results, tumor size (P = .04) and oxyphil cell content (P = .03) were found to be significantly different. CONCLUSION: Parathyroid gland size and oxyphil content are descriptive and predict differences between sestamibi properties of parathyroid adenomas but have no current therapeutic implications for parathyroid surgery.

A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003.

OBJECTIVE: To systematically review the current preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism. STUDY DESIGN: A systematic literature review. RESULTS: Of the 20,225 cases of primary hyperparathyroidism reported, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and parathyroid carcinomas (CAR) occurred in 88.90%, 5.74%, 4.14%, and 0.74% of cases respectively. Tc 99m -sestamibi and ultrasound were 88.44% and 78.55% sensitive, respectively, for SA, 44.46% and 34.86% for MGHD, and 29.95% and 16.20% for DA, respectively. Postoperative normocalcemia was achieved in 96.66%, 95.25%, and 97.69% of patients offered minimally invasive radio-guided parathyroidectomy (MIRP), unilateral, and bilateral neck exploration (BNE). Intraoperative PTH assays (IOPTH) were helpful in approximately 60% of bilateral neck exploration conversion (BNEC) surgeries. CONCLUSION: The overall prevalence of multiple gland disease (MGD and DA) was lower than often suggested by conventional wisdom. Furthermore, preoperative imaging was less accurate than it is often perceived for accurately imaging MGD. MIRP and UNE were more successful in achieving normocalcemia than is typically quoted. IOPTH was a helpful but not "fool-proof" adjunct in parathyroid exploration surgery. SIGNIFICANCE: These results support a greater role for the treatment of primary hyperparathyroidism using less invasive approaches. EMB rating: B-3.

Fusaric acid: a novel agent and mechanism to treat HNSCC.

OBJECTIVE: A new class of carboxylic acids has tumoricidal activity for head and neck squamous cell cancer (HNSCC). Fusaric acid (FA) can chelate divalent cations, especially zinc, and inactivate zinc finger proteins involved in DNA repair and protein synthesis. METHODS: 2 squamous carcinoma lines were utilized for in vitro and in vivo portions of this study. Cell counting and flow cytometry were used to analyze cells in culture in treatment and control groups over 96 hours. HNSCC subcutaneous implants were created in treatment and control groups of BALB-c nude mice (N = 30). RESULTS: In vitro studies demonstrated significant changes in cell numbers and cell cycle. In vivo studies of daily intralesional therapy for 1 month also showed reduced onset of growth and overall growth compared to controls. CONCLUSION: FA appears to have a tumoristatic/tumoricidal effect on HNSCC. Further nude mice studies are needed to optimize dosing and administration regimens for FA in anticipation of clinical trials.