Comparison of Pediatric Otolaryngology clinical and operative case volume among surgical specialties in the COVID-19 pandemic.

OBJECTIVES: To report changes in clinical and surgical volume impacting a Pediatric Otolaryngology division one year prior to and following the onset of the COVID-19 pandemic in comparison to five other pediatric surgical subspecialties. METHODS: The number of clinical visits and surgical cases per month for six pediatric surgical specialties (Otolaryngology, Orthopedic Surgery, Urology, Neurosurgery, Plastic Surgery, and General Surgery) for 12 months prior to the pandemic and 12 months following the onset of the pandemic was collected. Poisson regression analysis was performed for the number of visits and cases per season adjusting for specialty, season, staffing changes, and the pandemic to determine adjusted rate ratios (aRR) post-pandemic for the surgical fields compared to Otolaryngology. RESULTS: A percentage decrease in median visits per paired month (-15.63%, IQR = -23.01, -1.66) and operative cases (-19.86%, IQR = -29.39, -10.17) was seen for Pediatric Otolaryngology. Regression analysis showed a significant negative effect on the number of visits (aRR = 0.74, 95% CI = 0.70-0.77) and cases (aRR = 0.65, 95% CI = 0.60-0.71) due to the pandemic. While many of the other specialties had predicted reductions in volume (notably Orthopedics), they all experienced significant predicted increases in productivity following the pandemic compared to Otolaryngology. CONCLUSIONS: These findings suggest that Pediatric Otolaryngology is particularly vulnerable to this change in clinical pattern, which could be due to a decline in community infections from mask wearing and social distancing, and may result in a longer-term volume deficit when compared to other pediatric surgical subspecialties.

The Impact of Cognitive and Implicit Bias on Patient Safety and Quality.

Humans use cognitive shortcuts, or heuristics, to quickly assess and respond to situations and data. When applied inappropriately, heuristics have the potential to redirect analysis of available information in consistent ways, creating systematic biases resulting in decision errors. Heuristics have greater effect in high-pressure, high-stakes decisions, particularly when dealing with incomplete information, in other words, daily medical and surgical practice. This article discusses 2 major categories: cognitive biases, which affect how we perceive and interpret clinical data; and implicit biases, which affect how we perceive and respond to other individuals, and also discusses approaches to recognize and alleviate bias effects.

National Multispecialty Survey Results: Comparing Morbidity and Mortality Conference Practices within and outside Otolaryngology.

Objective The objective is to describe variations in the otolaryngology morbidity and mortality (M&M) conference and to compare with other specialties. Design Cross-sectional survey. Setting The setting included otolaryngology departments across the United States and nonotolaryngology medical and surgical departments at 4 academic medical centers. Subjects and Methods Participants were members of a national otolaryngology quality/safety network and nonotolaryngology quality leaders at 4 large academic hospitals. Surveys were administered January 2017. Respondents described M&M conference practices, goals, and educational role. Results Twenty-eight of 39 individuals representing 28 institutions completed the otolaryngology survey (72% response rate). Of 197 individuals, 60 (30% response rate) representing 11 surgical and 20 nonsurgical specialties completed the comparison survey. Twenty-seven of 28 otolaryngologists (46 of 60 nonotolaryngologists) worked in academic settings. All otolaryngology programs conducted an M&M conference: 54% discussed all adverse events and errors; 32% used standard case selection processes; 70% used structured discussion, usually root cause analysis (64%); and 32% classified harm level. In comparison with other specialties, otolaryngology programs were more likely to discuss all adverse events and errors ( P = .01). Most conferences led to quality projects and intrainstitutional communication: 22% communicated to patients and families; 73% of respondents thought that M&M conferences should be standardized or use "best practices." In both surveys, improving patient care was rated the conference's most important function, followed by trainee education and culture change. Patient care and practice-based learning were rated the most relevant Accreditation Council for Graduate Medical Education Core Competencies in both surveys. Conclusions Academic otolaryngology M&M practices generally align with other specialties, but specifics vary widely, making collaborative quality improvement challenging. Educational and administrative priorities cross specialties. Most respondents thought that standardization and best practices are worthwhile. Nonacademic practice data are needed.

Applying cost accounting to operating room staffing in otolaryngology: time-driven activity-based costing and outpatient adenotonsillectomy.

OBJECTIVES: (1) To describe the application of a detailed cost-accounting method (time-driven activity-cased costing) to operating room personnel costs, avoiding the proxy use of hospital and provider charges. (2) To model potential cost efficiencies using different staffing models with the case study of outpatient adenotonsillectomy. STUDY DESIGN: Prospective cost analysis case study. SETTING: Tertiary pediatric hospital. SUBJECT AND METHODS: All otolaryngology providers and otolaryngology operating room staff at our institution. RESULTS: Time-driven activity-based costing demonstrated precise per-case and per-minute calculation of personnel costs. We identified several areas of unused personnel capacity in a basic staffing model. Per-case personnel costs decreased by 23.2% by allowing a surgeon to run 2 operating rooms, despite doubling all other staff. Further cost reductions up to a total of 26.4% were predicted with additional staffing rearrangements. CONCLUSION: Time-driven activity-based costing allows detailed understanding of not only personnel costs but also how personnel time is used. This in turn allows testing of alternative staffing models to decrease unused personnel capacity and increase efficiency.

Inhaled cidofovir as an adjuvant therapy for recurrent respiratory papillomatosis.

A previously healthy, full-term, 4-month-old boy presented with progressively weakening cry, hoarseness, and increased work of breathing. Flexible fiberoptic laryngoscopy revealed glottic papillomas, which were endoscopically removed with a microdebrider in the operating room (Derkay score 23). The patient was diagnosed with recurrent respiratory papillomatosis that disseminated throughout his airway. Despite biweekly serial microdebridements, intralesional cidofovir, and systemic interferon-α, the patient's health declined substantially (Derkay score 40), culminating in a 47-day hospitalization due to complications of his disease. Inhaled cidofovir was initiated after all conventional treatments had failed. Within 6 weeks of therapy (40 mg daily per treatment, 12 days on and 2 days off), the papillomatous disease improved substantially (Derkay score 23). While inhaled cidofovir appeared to significantly reduce papillomatous disease burden in this patient, further investigation into its long-term effectiveness and safety profile is necessary.

A preliminary investigation of four-dimensional ultrasound for evaluation of middle ear ossicles: an in vitro study.

OBJECTIVE: Temporal bone imaging in children has several inherent limitations. Computed tomography has the disadvantage of ionizing radiation, possible sedation, cost and accessibility. Magnetic resonance imaging has most of these disadvantages, with the exception of radiation, and provides bone images of limited resolution. Recent advances in ultrasound have led to its increased application in numerous medical fields. The purpose of this study was to investigate the ability of four-dimensional ultrasound (4DUS) to image middle ear ossicles in vitro and determine if this technology should be adapted for future clinical use. METHODS: Thirty cadaveric ossicles (10 malleus, 10 incus, and 10 stapes) were randomized and measured by two evaluators under a microscope. The ossicles were then immersed in a cold water bath and imaged, randomized, and measured using four-dimensional ultrasound by the same two evaluators. A separate cadaveric temporal bone, modified to allow the ultrasound probe to rest on the tympanic membrane, was imaged to visualize the ossicles in situ and evaluate whether or not the tympanic membrane and malleus would impede visualization of more medial structures. RESULTS: Microscopic measurements were: malleus (h=8.0 mm+/-0.32, w=2.7 mm+/-0.20), incus (h=6.8 mm+/-0.41, w=5.3 mm+/-0.46), stapes (h=3.5 mm+/-0.34, w=2.4 mm+/-0.17). Inter-rater reliability was 0.8. Measurements were in agreement with previously published values. Ultrasound measurements were: malleus (h=8.0 mm+/-0.51, w=2.9 mm+/-0.27), incus (h=6.8 mm+/-0.49, w=5.5 mm+/-0.42), stapes (h=3.6 mm+/-0.41, w=2.5 mm+/-0.19). Inter-rater reliability was 0.7. Mean intra-class correlation coefficient for microscopic and ultrasound measurements was 0.7. Images of the ossicular chain in continuity in the temporal bone specimen were not as clear as images of individual ossicles that were disarticulated and imaged under water. CONCLUSIONS: 4DUS provides reasonable images of ossicles disarticulated and mounted in underwater medium. However, images of the intact ossicular chain in a modified cadaveric temporal bone were not as clear, making interpretation difficult. Further investigation into the development of a thinner ultrasound probe that can pass through the external auditory canal and into overcoming limitations of air in the middle ear cleft are warranted. This could allow for a clinically relevant, faster, lower cost and lower risk alternative to current imaging techniques.

Computed tomography and magnetic resonance imaging in pediatric unilateral and asymmetric sensorineural hearing loss.

OBJECTIVE: To compare temporal bone computed tomography (CT) with temporal bone and central nervous system magnetic resonance (MR) imaging in children with unilateral or asymmetric sensorineural hearing loss (SNHL). DESIGN: Retrospective chart study. SETTING: Tertiary-care children's hospital. PATIENTS: A total of 131 children with unilateral or asymmetric SNHL, seen consecutively by a single practitioner over 36 months. INTERVENTION: Imaging studies were read by a pediatric neuroradiologist and reviewed by the evaluating otolaryngologist. MAIN OUTCOME MEASURE: Prevalence of clinically significant CT or MR imaging findings. RESULTS: The prevalence of CT abnormalities was 35% for unilateral SNHL, 52% for asymmetric SNHL, and 41% for all patients together. The prevalence of MR imaging abnormalities was 25% for unilateral SNHL, 50% for asymmetric SNHL, and 30% for all patients together. Among 42 subjects who underwent both studies, there were 4 cases in which abnormalities were seen only on MR images and 9 cases in which abnormalities were seen only on CT scans. CONCLUSIONS: Temporal bone and/or central nervous system abnormalities were detected in 42% of 131 patients. When both CT scans and MR images were obtained (n = 42), results were concordant in 69% of cases, and one imaging modality detected clinically significant abnormalities not identified by the other in 31% of cases. The ideal imaging algorithm for children with unilateral or asymmetric SNHL is controversial. We suggest that all children with unilateral or asymmetric SNHL have a high-resolution temporal bone CT scan and that brain and temporal bone MR imaging be obtained in select cases.

Speech recognition abilities in noise for children with severe-to-profound unilateral hearing impairment.

OBJECTIVE: The purpose of this research was to compare the signal-to-noise ratio required for equal performance for children (aged 6-14 years) with normal hearing (N=17) versus those with severe-to-profound unilateral hearing impairment (N=20) who can be at a disadvantage, particularly when sounds are presented to the impaired ear. The listening environment is designed to approximate that which is encountered in a typical classroom. METHODS: All signals (Hearing in Noise Test-Children and Nonsense Syllable Test) were presented in the sound field from various azimuths with continuous noise presented from all quadrants. The children were required to repeat twenty items, from each test, in each listening condition. The intensity of the presentations was varied based on the accuracy of previous items. Average signal-to-noise ratios are compared between and within groups. RESULTS: (1) In most listening conditions, significantly greater signal-to-noise ratios were needed by those with unilateral hearing impairment than those with normal hearing, on both speech tests. (2) In every listening condition, both groups required significantly greater signal-to-noise ratios to perform equally well on the Nonsense Syllable Test as on the Hearing-In-Noise Test-Children. (3) For the Hearing-In-Noise Test-Children, children with normal hearing required significantly greater signal-to-noise ratios when facing the signal than when the signal was presented to a normally hearing ear (monaural direct). (4) On both tests, the children with unilateral hearing impairment required significantly greater signal-to-noise ratios when facing the signal than in the monaural direct condition. (5) On both tests, the children with unilateral hearing impairment required significantly greater signal-to-noise ratios when the signal was presented to the impaired ear (monaural indirect) than when facing the signal. CONCLUSIONS: (1) The children with unilateral hearing impairment require a more advantageous listening condition to perform equally as well as their normally hearing counterparts. (2) All of the children benefited from signals delivered in a monaural direct condition. (3) The children with unilateral hearing impairment performed best in the monaural direct condition or when facing the signal at zero degrees. (4) Significantly greater signal-to-noise ratios were needed for both groups when restricted contextual cues were available versus when sentential cues were available.

Intralesional cidofovir for pediatric recurrent respiratory papillomatosis.

OBJECTIVE: To compare disease response among children with recurrent respiratory papillomatosis (RRP) who underwent combined surgical debulking and intralesional cidofovir injections vs repeated surgical debulking only. DESIGN: Retrospective medical record review; follow-up range: 16 to 56 months. SETTING: Tertiary care children's hospital. PATIENTS: Seven children with RRP, including 4 subjects treated with cidofovir and 3 controls matched for age and initial papilloma staging score. INTERVENTIONS: Subjects treated with cidofovir underwent combined surgical debulking and intralesional cidofovir injection every 2 months until disease remission. Control subjects underwent repeated surgical debulking at individually determined intervals. MAIN OUTCOME MEASURES: Intraoperative endoscopic photographs were retrospectively assigned papilloma staging scores. Cidofovir and control group comparisons were made using nonparametric 2-sample Wilcoxon rank-sum (Mann-Whitney) testing, and comparisons of initial and final papilloma staging scores were made using nonparametric matched-pair Wilcoxon signed-rank testing. RESULTS: The final cidofovir group scores were significantly lower than the control group scores (P < .05). Within-group differences between initial and final scores were not significant (cidofovir group, P = .07; control group, P = .29). CONCLUSIONS: Four children with RRP were safely and successfully treated with intralesional cidofovir injection. Consideration should be given to using cidofovir more widely for treatment of pediatric RRP. Larger numbers in the cidofovir and control groups are needed in future studies to determine the true impact of cidofovir on management of this disease.

Audiometric findings in children with a large vestibular aqueduct.

OBJECTIVE: To characterize audiometric findings in children with a large vestibular aqueduct (LVA). DESIGN: Retrospective review. METHODS: Audiometric records of children with an isolated LVA, diagnosed by computed tomography of the temporal bone, from 1995 through 1998 were reviewed. RESULTS: Nineteen children had an isolated LVA in one or both ears. In all, 26 ears with an isolated LVA were identified. An LVA was seen in association with another inner ear anomaly in an additional 7 ears. The hearing impairment was sensorineural in 22 ears (85%) with an isolated LVA and mixed in 3 (12%). The hearing was normal in 1 ear. The sensorineural hearing impairment (SNHI) was moderate-severe in 12 ears (46%) and severe-profound in 10 ears (38%). Thirteen (50%) of 26 ears had a downsloping or high-frequency SNHI, and 8 (31%) of 26 ears had a midfrequency-peaked audiogram. Bilateral LVAs were seen in 7 children, 6 of whom had bilateral and asymmetrical SNHI. Of 12 patients with a unilateral LVA, 5 had bilateral SNHI. CONCLUSIONS: In this series, the children with LVAs typically had moderate-severe or worse SNHI. An unusual midfrequency-peaked audiogram was present in approximately one third of the study patients. The majority of the patients had a unilateral LVA; however, nearly 50% of the patients with a unilateral LVA had bilateral SNHI. The patients with bilateral LVAs generally had asymmetrical SNHI.

Recurrent acute otitis media associated meningitis in a patient with a contralateral cochlear implant and bilateral cochleovestibular dysplasia.

OBJECTIVE: To illustrate that a patient with a cochlear implant may be at increased risk of meningitis secondary to developmental anatomic abnormality associated with the underlying sensorineural hearing loss, as opposed to the implant itself. METHODS: Case report. RESULTS: Our 12-year-old patient has bilateral cochlear dysplasia, profound sensorineural hearing loss and no prior history of recurrent acute otitis media or meningitis. He underwent a left cochlear implant at 8 years of age and subsequently experienced three episodes of right acute otitis media and meningitis over the next 4 years. Middle ear exploration revealed a cerebrospinal fluid leak. A right radical mastoidectomy with closure of the external auditory canal, removal of the tympanic membrane, malleus, and incus, closure of the Eustachian tube, and obliteration of the mastoid and middle ear with abdominal fat has prevented further episodes. CONCLUSION: Meningitis in a patient with a cochlear implant is not necessarily related to the implant.

Laryngomalacia induced by exercise in a pediatric patient.

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.