Credentialing and training advanced practice providers for advanced tertiary care pediatric otolaryngology: A curriculum for hospital and ambulatory practice.

OBJECTIVES: Inclusion of advanced practice providers (APPs) in hospital-based pediatric otolaryngology has been growing rapidly, aligning with a 70% increase in physician assistants in all surgical subspecialties in recent years. A post-graduate training program is developed to reflect these growing and changing responsibilities. METHODS: Curriculum development took place at one institution over eight years for 16 APPs following a standard Six Step Approach to medical curriculum: 1) Problem Identification and General Needs Assessment, 2) Targeted Needs Assessment, 3) Goals & Objectives, 4) Education Strategies, 5) Implementation, and 6) Evaluation and Feedback. This was integrated into an onboarding process for new hires and a continuing education plan for established providers. Gaps were identified throughout the process to improve education, skills required for competency, and readiness for independent practice. RESULTS: The curriculum incorporated a subset of goals and objectives from the familiar resident curriculum with significant differences in orientation and onboarding. A Clinical Competency Checklist was used initially for feedback and later to support credentialing after completion of the curriculum. A Procedure Rating Form was used for feedback and documentation of the number of performances required for credentialing. Self-Assessment was utilized to further identify readiness for independence and tailor additional education to meet practice needs. CONCLUSION: The curriculum and onboarding process presented can be used for any advanced practice provider joining an individual or team of pediatric otolaryngology providers. A standardized curriculum is helpful to the supervisors and trainees. Further collaboration between institutions and development of benchmarks will help ensure excellence in education and in care of pediatric otolaryngology patients.

Multicenter Interrater Reliability in the Endoscopic Assessment of Velopharyngeal Function Using a Video Instruction Tool.

OBJECTIVE: Assess interrater agreement of endoscopic assessment of velopharyngeal (VP) function before and after viewing the video instruction tool (VIT). We hypothesized improvement in interrater agreement using the Golding-Kushner scale (GKS) after viewing the VIT. STUDY DESIGN: Prospective study. SETTING: Multi-institutional. METHODS: Sixteen fellowship-trained pediatric otolaryngologists who treat velopharyngeal insufficiency (VPI) rated 50 video segments using the GKS before and after watching the VIT. Raters assessed gap size percentage and lateral pharyngeal wall (LPW), soft palate (SP), and posterior pharyngeal wall (PPW) movement. Intraclass correlation coefficient was estimated for these continuous measures. Raters also indicated the presence of a palatal notch, Passavant's ridge, and aberrant pulsations (categorical variables). Fleiss κ coefficient was used for categorical variables. Wilcoxon signed-rank test was performed on the difference between the pre/post individual video ratings. RESULTS: Reliability improved for all continuous variables after watching the instructional video. The improvement was significant for PPW (0.22-0.30, P < .001), SP (left: 0.63-0.68, P < .001 and right: 0.64-0.68, P = .001), and LPW (left: 0.49-0.54, P = .01 and right: 0.49-0.54, P = .09) but not significant for gap size (0.65-0.69, P = .36). Among categorical variables, agreement on Passavant's ridge significantly improved (0.30-0.36, P = .03). CONCLUSION: Exposure to a video instruction tool improves interrater agreement of endoscopic assessment of VP function. Significant improvement was observed in our primary end points, specifically posterior pharyngeal wall movement, soft palate movement, and lateral pharyngeal wall movement. There was less impact of the VIT on the interrater agreement of the categorical variables, palatal notch, Passavant's ridge, and aberrant pulsations.

Velopharyngeal incompetence: role in paediatric swallowing deficits.

PURPOSE OF REVIEW: The purpose of this manuscript is to highlight the latest advances in diagnosis and management of velopharyngeal incompetence (VPI) as it pertains to swallowing deficits in children. This is timely and relevant as otolaryngologists are often amongst the first to diagnose and treat VPI. Although nasal regurgitation of a bolus is frequently transient, persistent problems can be associated with other swallowing problems and other significant medical problems. Furthermore, velopharyngeal incompetence has implications for speech production. RECENT FINDINGS: Persistent VPI associated with a swallowing deficit can be an isolated anomaly with or without a cleft palate or submucous cleft palate. VPI may be secondary to a cranial neuropathy, esophageal abnormality or associated with another airway anomaly, any of which may further contribute to dysphagia. Findings of additional anomalies may be suggestive of a syndrome. Workup should explore these potential causes. When velopharyngeal incompetence is associated with dysphagia, fiberoptic endoscopic evaluation of swallow (FEES) and videofluoroscopic swallow study (VFSS) can be helpful in diagnosis and management. The advantages and disadvantages of FEES and VFSS have been well delineated over the past few years. Similarly, nasopharyngoscopy and fluoroscopy are increasingly used in diagnosis and management of VPI that is associated with hypernasal resonance disorders. SUMMARY: Concurrent medical diagnoses or syndrome manifestations are often associated with or contribute significantly to the cause of dysphagia in children with VPI. As VPI can be a sign of brainstem vagal neuropathy, the clinician should investigate by imaging the CNS if other correlative symptoms of dysphagia and examination findings are present. Endoscopy is advocated for evaluation of vocal fold function. Fluoroscopy is best for further assessment of airway protection or safety of swallow. And, whenever indicated, additional workup is recommended to determine an underlying cause of the swallowing disorder.

A Chronic Glottic Foreign Body Diagnosed by Radiograph after 9 Months of Symptoms.

A six-year-old girl presented to an emergency room after describing choking on a rubber band. She was in no distress and was discharged. Over the course of the next 9 months, she had numerous outpatient and emergency room visits due to intermittent stridor, difficulty breathing, and hoarseness. Eventually, dedicated airway films revealed a laryngeal foreign body. During rigid bronchoscopy, a two-centimeter rubber band was discovered in the larynx. It extended from the supraglottis, through the glottis, and into the subglottis. It was successfully removed. The patient was asymptomatic 24 hours later. This case highlights the appropriate evaluation and management of a child with stridor.

Older siblings are at increased risk for foreign bodies.

A prospective, case-control study was performed to describe the role that siblings play in foreign bodies of the head and neck and to recognize situations in which children are most at risk for foreign bodies. Any child or adolescent (0 to 17 years old) with a foreign body removed from the head or neck was included. The data collected included location of the foreign body, location of acquisition (e.g., home), and the number of and ages of siblings. Controls were matched by age, sex, and location of removal (clinic, operating room, or emergency department). Thirty-four patients were enrolled (20 male, 14 female). The average age was 5.25 years (range: 10 months to 15 years). The average age of patients with foreign bodies in the ear was 5.98 years (n = 23), esophagus 4.34 years (n = 6), and nose 2.97 years (n = 5). Nineteen (56%) of the foreign bodies were acquired at home and 17 (50%) under supervision by parents. Children with a younger sibling have a significantly increased risk of acquiring a foreign body compared with children without a younger sibling (odds ratio = 4.00, p = 0.04). We conclude that although acquisition of foreign bodies should become less common as children mature, older siblings (i.e., children who have a younger sibling) are at increased risk for foreign body acquisition. Most foreign bodies are acquired at home under supervision by parents. Increased awareness of this finding may help prevent foreign bodies in the head and neck.

Otolaryngologic manifestations of craniofacial syndromes.

This review describes important aspects of the most commonly encountered craniofacial syndromes. The goal is to provide otolaryngologists and other health care providers with critical information necessary to manage these patients appropriately. The algorithm provided in this article should be helpful in guiding the treatment of craniofacial patients based on their unique otolaryngologic characteristics. The principles highlighted in the algorithm can be applied to other craniofacial syndromes not addressed here, including Pierre Robin sequence and Down syndrome.

Wound healing in the paranasal sinuses after Coblation, Part II: evaluation for endoscopic sinus surgery using a sheep model.

BACKGROUND: A previous study on wound healing with a rabbit model showed thermal injury to sinus mucosa with complete respiratory re-epithelialization by postoperative day (POD) 29. This study was designed to further understand the pattern of injury using the bipolar radiofrequency plasma process used by the Coblator and evaluate postprocedure healing. METHODS: Based on experience with our rabbit model, three sheep underwent endoscopic sinus surgery. Coblation was applied to inferior turbinate mucosa in three areas for 2, 4, or 6 seconds. After resection of the contralateral middle turbinate and ethmoidectomy, Coblation was applied to the lateral wall or lamina papyracea for 2 seconds. The ethmoid and turbinate specimens were resected en bloc during necropsy immediately for the first sheep and on POD 14 for the others. RESULTS: Coblation resulted in immediate loss of surface respiratory epithelium and thermal-type injury to the underlying seromucinous glands. On POD 14, the Coblation site showed re-epithelialization with respiratory epithelium. The underlying seromucinous glands were replaced by mild fibrosis. A small, well-defined zone of injury was shown. Longer use did not result in a deeper injury. Rather, the depth of injury was dependent on the type of submucosal tissue present. Underlying bone was associated with reactive, regenerative changes. No histological changes were shown in the orbit. CONCLUSION: The effects of Coblation on sheep mucosa show a similar injury and healing pattern to that shown on rabbit mucosa. Based on this work and the previous rabbit study, the Coblator may be an additional tool for use in endoscopic sinus surgery.

Wound healing in the rabbit paranasal sinuses after Coblation: evaluation for use in endoscopic sinus surgery.

BACKGROUND: Bipolar radiofrequency can be used surgically to excise and cauterize tissue simultaneously. It has potential for use in endoscopic sinus surgery (ESS). This study was performed to determine the extent and pattern of injury in the paranasal sinuses with bipolar radiofrequency and evaluate wound healing. METHODS: Eight rabbits underwent Coblation of maxillary sinus mucosa with biopsy immediately, on postoperative day (POD) 3, 7, 14, or 29. Maxillary mucosa was exposed through the nasal dorsum, and a Coblator PROciseXP wand used on a power setting of 7 for 2 seconds. Three of the rabbits also had Coblation of ethmoid mucosa over the lamina papyracea, after extending the maxillary ostomy, with biopsy immediately. RESULTS: Coblation resulted in immediate loss of surface respiratory epithelium and thermal-type injury to the underlying seromucinous glands. On POD 3, the site showed reepithelialization with squamous metaplastic epithelium. The seromucinous glands underwent coagulative necrosis. At POD 7, there was partial replacement of overlying epithelium by respiratory epithelium. The underlying seromucinous glands were lost and replaced by fibroblastic proliferation, with less fibrosis than the mechanically created ostomy site. The underlying bone had reactive, regenerative changes. On PODs 14 and 29, there was further regeneration of respiratory epithelium. Fibrosis was mild. Coblation resulted in gross violation of the bony wall in one maxillary sinus. There were no histological changes in the orbit. CONCLUSION: Rabbit paranasal sinus mucosa heals appropriately after Coblation injury.