Relationship between Insurance Type and Delays in Tympanostomy Tube Placement.

OBJECTIVE: To investigate the role of insurance carriers and changes in insurance on rates of cancelation and rescheduling of tympanostomy tube surgery. METHODS: Retrospective cohort study between January 1, 2013 and December 31, 2018 at a single tertiary care academic pediatric otolaryngology practice of pediatric patients (≤18 years) who underwent tympanostomy tube placement for any indication. Patients had to have insurance providers recorded both at clinic visit and at the time of surgery. Rates of cancelation and postponement of tympanostomy tube placement were assessed. Logistic regression was performed to determine factors associated with cancelation or postponement of surgery. RESULTS: Of the 5080 patients, 2961 patients had Medicaid and 2012 patients had private insurance at the time of surgery. A total of 197 (3.96%) patients switched insurance between clinic appointment and date of surgery. Time to surgery was nearly 2 weeks more for those who had a change in insurance vs. those who did not (33 vs. 20 days, P < .001). Those who switched insurance were nearly twice as likely to have to reschedule surgery than those who did not (OR 1.95, CI 1.42-2.67). Patients who had Medicaid as the primary payer also had increased odds of needing to reschedule and postpone surgery (OR 1.39, 95% CI 1.17-1.63). CONCLUSION: Difference in insurance carrier and loss/change of insurance appear to be associated with delays in tympanostomy tube placement. Standardization of re-enrollment schedules across insurance providers or a single payer model may be useful in addressing these delays in care.

Tracheostomy Care Education for the Nonsurgical First Responder: A Needs-Based Assessment and Quality Improvement Initiative.

OBJECTIVES: To perform a needs-based assessment for tracheostomy care education for nonsurgical first responders in the hospital setting and to implement and assess the efficacy of a targeted tracheostomy educational program. METHODS: A prospective observational study conducted between October 2017 and May 2018 including emergency medicine (EM) residents, internal medicine (IM) residents, and intensive care unit (ICU) advanced practice providers at 2 tertiary hospitals. Needs-based assessments were conducted, leading to specialty specific curricula. One-hour educational sessions included didactics and case-based simulation. A pre- and posttest objective knowledge quiz and self-assessment were administered, and a posttest was repeated at 6 months. RESULTS: There were 85 participants (13 ICU, 40 EM, 32 IM). Significant improvement (P < .05) in mean objective knowledge score was seen across all groups between pre- and postintervention assessments with relative but not significant improvement at 6 months. There were significant increases in comfort level from pre- to postintervention. At 6-month follow-up, comfort level remained significantly increased for the majority of questions for the EM group and for select questions for IM and ICU advanced practice provider groups. DISCUSSION: Nonsurgeons are often first responders to critical airway situations yet receive limited formal education regarding tracheostomy. We demonstrated improvement in knowledge and comfort after a targeted educational module for tracheostomy care and management. IMPLICATIONS FOR PRACTICE: Although tracheostomy care is multidisciplinary, specialty-specific education may provide a more relevant foundation on which to build skills. Prompt and effective management of tracheostomy emergencies by first responders may improve patient safety and reduce mortality.

3-Dimensional printed haptic simulation model to teach incomplete cleft palate surgery in an international setting.

INTRODUCTION: Cleft palate is one of the most common congenital anomalies, yet surgical repair remains challenging and can lead to significant complications in the hands of inexperienced surgeons. There is a great need for the development of a simulation model that will allow surgeons worldwide to learn and practice the intricate skills needed for cleft palate surgery. OBJECTIVES: 1. To develop a low-cost incomplete cleft palate simulation model using additive manufacturing technology (3D printing). 2. To evaluate its validity and utility to teach palatoplasty in a global health care setting. METHODS: Three-dimensional models of a soft palate cleft and an incomplete hard and soft palate cleft were developed using 3D printing and silicone casting. The cost and time of assembly of the 3D printed models were calculated. The models were then assessed for validity by cleft surgeons and trainees during a cleft mission in Ecuador. 3D models were assessed for resemblance to anatomy and tissue characteristics, the ability to incise the soft tissue, dissect and reposition the palatal flaps, and the ease of suture placement. Models were rated using the Likeness to Human Tissue Scale. RESULTS: Cleft palate simulators were successfully developed using 3D printing and silicone casting. Participants reported that models provided a realistic representation of human anatomy and were adequate for novice surgeons to practice the procedure. The models were portable, low cost, and easily assembled. CONCLUSION: The use of 3D printed haptic simulation models for teaching and learning cleft palate repair techniques could enhance skill acquisition and possibly improve surgical outcomes. In outreach settings, it could help achieve local, sustainable comprehensive care for cleft palate patients.

Initial findings of shortwave infrared otoscopy in a pediatric population.

OBJECTIVE: To evaluate the feasibility of Shortwave infrared (SWIR) otoscopy in a pediatric population and establish differences with visible otoscopy. METHODS: Pediatric patients 3 years of age and older seen in the otolaryngology clinic with an audiogram and tympanogram obtained within a week of the visit were recruited for video otoscopy using visible light otoscopy and SWIR otoscopy. Videos were rated by two otolaryngologists based on ability to identify the promontory, ability to identify the ossicular chain and presence or absence of middle ear fluid. RESULTS: A total of 74 video recordings of ears were obtained in 20 patients. We obtained interpretable images in 63/74 (85.1%) ears. There was no statistical significance between ability to perform SWIR otoscopy versus white light video otoscopy as indicated by a p-value of 0.376. There was high inter-rater agreement for identification of both the promontory and the ossicular chain with Kappa values of 0.81 and 0.92 respectively. There was statistical significance between SWIR otoscopy and visible otoscopy in the ability to image the promontory (p = 0.012) and the ossicular chain (p = 0.010). Increased contrast of middle ear fluid was seen in SWIR otoscopy when compared to visible otoscopy. CONCLUSION: SWIR otoscopy is feasible in a pediatric population and could offer some advantages over visible light otoscopy such as better visualization of the middle ear structures through the tympanic membrane and increased contrast for middle ear effusions.

Opioid Prescribing Patterns among Otolaryngologists.

Objectives To evaluate national trends in opioid prescribing patterns by otolaryngologists for postoperative pain control after common otolaryngologic procedures. Study Design Cross-sectional; survey. Subjects and Methods A survey to determine opioid prescribing patterns for the treatment of postoperative pain following common otolaryngologic procedures was distributed to all members of the American Academy of Otolaryngology-Head and Neck Surgery. Results The most common pain medication prescribed for adults postoperatively was hydrocodone-acetaminophen (73%), followed by oxycodone-acetaminophen (39%). The most common pain medication prescribed postoperatively for children was acetaminophen (67%), followed by nonsteroidal anti-inflammatory drugs (65%). Overall, there was a wide variation in quantity of opioids prescribed for each surgery, ranging from 0 to more than 60 doses. Mean opioid prescriptions were greatest for tonsillectomy (37 tablets) and least for direct laryngoscopy (5.3 tablets). Conclusion This study identifies nationwide variations in opioid prescribing patterns among otolaryngologists. While otolaryngology is a relatively small specialty, we still have an obligation to work with all physicians to help combat the current opioid epidemic. By evaluating nationwide postoperative pain regimens, we are moving closer toward understanding how to reduce the opioid burden.

Using simulators to teach pediatric airway procedures in an international setting.

INTRODUCTION: There has been a growing shift towards endoscopic management of laryngeal procedures in pediatric otolaryngology. There still appears to be a shortage of pediatric otolaryngology programs and children's hospitals worldwide where physicians can learn and practice these skills. Laryngeal simulation models have the potential to be part of the educational training of physicians who lack exposure to relatively uncommon pediatric otolaryngologic pathology. OBJECTIVES: The objective of this study was to assess the utility of pediatric laryngeal models to teach laryngeal pathology to physicians at an international meeting. METHODS: Pediatric laryngeal models were assessed by participants at an international pediatric otolaryngology meeting. Participants provided demographic information and previous experience with pediatric airways. Participants then performed simulated surgery on these models and evaluated them using both a previously validated Tissue Likeness Scale and a pre-simulation to post-simulation confidence scale. RESULTS: Participants reported significant subjective improvement in confidence level after use of the simulation models (p < 0.05). Participants reported realistic representations of human anatomy and pathology. The models' tissue mechanics were adequate to practice operative technique including the ability to incise, suture, and suspend models. CONCLUSION: The pediatric laryngeal models demonstrate high quality anatomy, which is easy manipulated with surgical instruments. These models allow both trainees and surgeons to practice time-sensitive airway surgeries in a safe and controlled environment.

Reemergence of the Natural History of Otolaryngologic Infections: Lessons Learned from 2 American Presidents.

Presidents George Washington and Theodore Roosevelt suffered complications of epiglottitis and otomastoiditis, respectively. The introduction of antibiotics and vaccinations against Haemophilus influenzae and Streptococcus pneumoniae has significantly reduced the incidence of these otolaryngologic infections, such that the natural history of the disease is rarely encountered. However, antibiotic resistance and pathogenic evolution has raised concern about increased virulence of these common organisms. A retrospective evaluation of the complications suffered by Washington and Roosevelt provides valuable insight to the natural history of common otolaryngologic infections that may reemerge as a result of organism evolution in response to antibiotics and vaccines.

Enhanced Wnt signaling improves bone mass and strength, but not brittleness, in the Col1a1(+/mov13) mouse model of type I Osteogenesis Imperfecta.

Osteogenesis Imperfecta (OI) comprises a group of genetic skeletal fragility disorders. The mildest form of OI, Osteogenesis Imperfecta type I, is frequently caused by haploinsufficiency mutations in COL1A1, the gene encoding the α1(I) chain of type 1 collagen. Children with OI type I have a 95-fold higher fracture rate compared to unaffected children. Therapies for OI type I in the pediatric population are limited to anti-catabolic agents. In adults with osteoporosis, anabolic therapies that enhance Wnt signaling in bone improve bone mass, and ongoing clinical trials are determining if these therapies also reduce fracture risk. We performed a proof-of-principle experiment in mice to determine whether enhancing Wnt signaling in bone could benefit children with OI type I. We crossed a mouse model of OI type I (Col1a1(+/Mov13)) with a high bone mass (HBM) mouse (Lrp5(+/p.A214V)) that has increased bone strength from enhanced Wnt signaling. Offspring that inherited the OI and HBM alleles had higher bone mass and strength than mice that inherited the OI allele alone. However, OI+HBM and OI mice still had bones with lower ductility compared to wild-type mice. We conclude that enhancing Wnt signaling does not make OI bone normal, but does improve bone properties that could reduce fracture risk. Therefore, agents that enhance Wnt signaling are likely to benefit children and adults with OI type 1.

Targeting the LRP5 pathway improves bone properties in a mouse model of osteogenesis imperfecta.

The cell surface receptor low-density lipoprotein receptor-related protein 5 (LRP5) is a key regulator of bone mass and bone strength. Heterozygous missense mutations in LRP5 cause autosomal dominant high bone mass (HBM) in humans by reducing binding to LRP5 by endogenous inhibitors, such as sclerostin (SOST). Mice heterozygous for a knockin allele (Lrp5(p.A214V) ) that is orthologous to a human HBM-causing mutation have increased bone mass and strength. Osteogenesis imperfecta (OI) is a skeletal fragility disorder predominantly caused by mutations that affect type I collagen. We tested whether the LRP5 pathway can be used to improve bone properties in animal models of OI. First, we mated Lrp5(+/p.A214V) mice to Col1a2(+/p.G610C) mice, which model human type IV OI. We found that Col1a2(+/p.G610C) ;Lrp5(+/p.A214V) offspring had significantly increased bone mass and strength compared to Col1a2(+/p.G610C) ;Lrp5(+/+) littermates. The improved bone properties were not a result of altered mRNA expression of type I collagen or its chaperones, nor were they due to changes in mutant type I collagen secretion. Second, we treated Col1a2(+/p.G610C) mice with a monoclonal antibody that inhibits sclerostin activity (Scl-Ab). We found that antibody-treated mice had significantly increased bone mass and strength compared to vehicle-treated littermates. These findings indicate increasing bone formation, even without altering bone collagen composition, may benefit patients with OI.

Dysphagia, hoarseness, and a hypopharyngeal mass.

We describe a patient who developed a hypopharyngeal mass (in the setting of a cervical osteophyte) while taking clopidogrel and aspirin for coronary artery disease. He had a 2-month history of progressive dysphagia and hoarseness. Physical examination and computed tomography scan revealed a soft tissue retropharyngeal mass of unclear etiology yet with a stable airway. He was admitted to the intensive care unit for a 48-hour clopidogrel washout followed by surgery. A hematoma and cervical osteophyte were removed with scant bleeding. This case report emphasizes the need to consider the medication history of a patient when assessing the cause of an otherwise unexpected finding.

Body mass index as a predictor of postoperative complications in reduction mammaplasty.

BACKGROUND: Obesity, determined by body mass index, is known to be associated with surgical complications. This study was performed to evaluate a correlation between body mass index and postoperative complications in reduction mammaplasty. METHODS: The authors performed a retrospective analysis of consecutive reduction mammaplasties performed at the Brigham and Women's Hospital by eight surgeons between 1995 and 2007. Data regarding demographics, comorbidities, body mass index, reduction specimen weight, reduction technique, and complications were collected. Univariate and multivariate analyses were used to assess the association between body mass index and complication rates. Multivariate logistic regression analysis was used to determine the threshold body mass index value at which differential complication rates were maximal. RESULTS: A total of 675 bilateral reduction mammaplasties were analyzed; 75 complications (11 percent) were observed, including hematoma, infection, necrosis, and reoperation. Mean body mass index was 31.0 ± 6.2. A significant association was noted between body mass index and complication rate on the basis of both univariate (p = 0.036) and multivariate (p = 0.037) analyses. Trend analysis of body mass index as a categorical variable relative to complication rate was also statistically significant (p = 0.01). A cutoff point was suggested whereby patients with a body mass index of more than 35.6 experienced a significantly higher complication rate than did patients below this threshold (odds ratio = 2.002; p = 0.004). CONCLUSIONS: Body mass index is significantly associated with increased complications following reduction mammaplasty. An index value greater than 35.6 is associated with a twofold-higher risk of complications. Patients with a body mass index of 36 or above should be cautioned regarding a potential increased risk of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Erythropoietin-induced optimization of renal function after warm ischemia.

BACKGROUND AND PURPOSE: Recent preclinical data have indicated that erythropoietin (Epo) can protect organs from ischemic damage. We evaluated the ability of Epo to protect the kidney from the effects of ischemia. METHODS: Thirty dogs underwent a laparoscopic nephrectomy and were allowed to recover for 2 weeks. The dogs were then divided into five groups. Animals in groups 1 and 2 underwent 1.5 hours of abdominal insufflation with placebo (saline) injection (group 1) or Epo injection (group 2) before; groups 3 to 5 underwent 1 hour of laparoscopic renal artery clamping after placebo injection (group 3), Epo injection (group 4), or mannitol injection (group 5). Serum evaluations and 24-hour urine collections were performed weekly. After 28 days, the animals were sacrificed. Statistical analysis was performed with the Kruskal-Wallis test. RESULTS: After recovery from the initial nephrectomy, all dogs had similar serum hematocrit and creatinine levels. Hematocrit was not significantly affected by Epo administration at any time point. Immediately after the second surgery, dogs that underwent renal artery clamping (groups 3-5) had significantly lower 24-hour urine creatinine levels than those that were not clamped (groups 1-2). After 4 weeks of recovery, the dogs that had received Epo before ischemia (group 4) had recovered significantly more renal function than the dogs that received placebo or mannitol before ischemia (urine creatinine level = Epo 149.1 mg/dL v placebo 70.7 mg/dL v mannitol 80.7 mg/dL). At sacrifice, microalbuminuria was also significantly less in dogs receiving Epo before ischemia than their mannitol or placebo counterparts. CONCLUSION: The current study demonstrates that administering Epo before warm ischemia can improve the recovery of renal function after ischemia better than placebo or mannitol.

Evaluation of efficacy of novel optically activated digital endoscope protection system against laser energy damage.

OBJECTIVES: To evaluate the reliability and efficacy of a novel endoscope protection system (EPS) against direct laser energy damage. METHODS: We performed in vitro evaluations of a novel EPS prototype that uses optical feedback from the digital sensor of the DUR-D ureteroscope to terminate the laser energy on retraction of the laser fiber into the ureteroscope. We evaluated various speeds of retraction (0.5, 2.0, and 5.0 cm/s) in normal saline and various concentrations of indigo carmine and human blood. We also evaluated the protrusion distance at which shutdown occurred with the laser fiber cladding cleaved at 0, 3, and 5 mm from the end of the fiber. Twenty trials of each condition were performed. RESULTS: In normal saline and blood dilutions of up to 10 g/L, the EPS worked with 100% efficiency for all trials. For blood dilutions of 10 g/L or greater and indigo carmine concentrations of 0.16 g/L or greater, the reliability of the EPS deteriorated. Lasers stripped of 0, 3, and 5 mm of cladding initiated shutdown at 2.9 +/- 0.13, 5.1 +/- 0.09, and 8.2 +/- 0.15 mm from the ureteroscope distal end, respectively (P <0.01). A single DUR-D ureteroscope was used for all trials and remained completely intact through 120 retractions of the active laser fiber into the channel. CONCLUSIONS: In this evaluation, the novel EPS was highly effective and reliable. When using indigo carmine or high-density blood concentrations, the efficacy of the EPS was compromised. The EPS should be used to complement standard safe laser technique rather than to replace it.