Non-protective immunity after standard pneumococcal vaccination series identified as a potential contributing risk factor for refractory otolaryngologic conditions in children.

OBJECTIVE: To examine the relationship between conferred immunity after standard pneumococcal series and refractory otolaryngologic infections in pediatric patients using post-vaccination antibody titers, and to identify contributory underlying conditions revealed when vaccination/re-vaccination fails to confer protective immunity. STUDY DESIGN: IRB-reviewed and "exempt" retrospective case series with chart review using the Epic® Electronic Medical Record system from 2013 to 2021. SETTING: Dedicated tertiary referral children's hospital. METHODS: Pneumococcal antibody titer results were assessed for children ages 0 to 21 years and: (1) at least 1 of 7 otolaryngologic disease diagnoses and (2) having received the 4-dose schedule of pneumococcal conjugate vaccine (PCV 7 or 13). RESULTS: A total of 241 subjects met inclusion criteria with 356 laboratory tests. Recurrent acute otitis media, chronic rhinitis, and chronic otitis media with effusion were the 3 most frequent diagnoses. At presentation, only 27.0% of subjects had titers conferring immunity from their prior vaccinations with PCV. About 85 subjects had been subsequently revaccinated with Pneumococcal Polysaccharide Vaccine (PPSV), and antibody responses conferring immunity reached 91.8%. Seven subjects never developed adequate responses; 5 of these had recurrent acute otitis media as the primary otolaryngologic diagnosis. Secondary "revealed" diagnoses included Juvenile Rheumatoid Arthritis (n = 1), unresolved specific antibody deficiency (n = 2), and Hypogammaglobulinemia (n = 1). CONCLUSION: In pediatric patients with recurrent infectious otolaryngologic disease refractory to traditional medical and surgical therapy, inadequate responses to pneumococcal vaccination may be revealed. This correlation represents a potential pathway for diagnosis and therapy.

Telehealth Adoption and Perspectives Among Pediatric Otolaryngologists Following the COVID-19 Pandemic.

OBJECTIVES: To assess use of and physician experiences with pediatric otolaryngology telehealth visits as impacted by the COVID-19 pandemic. STUDY DESIGN/SETTING: Cross sectional survey. METHODS: A 15-question survey was electronically distributed to 656 members of the American Society of Pediatric Otolaryngology in August 2021, addressing member demographics, experiential practice elements, and use pre-pandemic, during the initial shutdown period of March-May 2020, and current use at the time of survey inquiry. RESULTS: There were 124 respondents (response rate = 18.9%). Incident use pre-pandemic and during the shutdown were 21.0% (n = 26), and 92.7% (n = 115), respectively. Current use was 83.9% (n = 104) and the percentage of new current users (79.5%, n = 78) was significant (P < .0001,95% CI = 70.6%-86.4%). Estimated median telehealth visit rates pre-pandemic, during shutdown, and currently were 0 to 1, 4 to 5, and 2 to 3 per week, respectively (P < .0001). A difference in post-covid adoption rates was noted only for location (P = .008), with no differences for years out of training or practice type. Compared to in-person visits, physician satisfaction with telehealth visits was rated equivalent (49.0%) or worse/much worse (48.1%). The most common telehealth uses were follow-up visits (83.7%), pre-operative counseling (76.9%), and post-operative evaluation (69.2%). The need for a detailed exam (89.4%) and initial visits (32.7%) were reasons a telehealth visit was not offered. CONCLUSIONS: The COVID-19 pandemic appears to have precipitated a rapid increase in telehealth adoption among surveyed pediatric otolaryngologists, regardless of age or practice type. The most significant limitations remain the need for a detailed exam, perceived low patient technological literacy, and limitations to interpretive services. Technology-based optimization of these barriers could lead to increased use and physician satisfaction.

Racial identification represents significant risk factor for healthcare disparity among patients with severe bronchopulmonary dysplasia treated with tracheostomy.

OBJECTIVES: To characterize the patient population with severe bronchopulmonary dysplasia (BPD) requiring tracheostomy in a large tertiary level 4 neonatal intensive care unit (NICU) and to identify potential targets for improvement in the delivery of high-quality healthcare. METHODS: An IRB-exempt but IRB-registered retrospective review of medical records. Study inclusion criteria: patients treated for severe BPD with tracheostomy under 2 years of age in our tertiary referral center NICU. Control group criteria: 4-year aggregate NICU patient demographics. Basic demographics, maternal history, clinical data points, and outcomes variables were collected. RESULTS: There was a statistically significant difference between the two groups in only one variable: racial identification (p-value = 0.036). All data points were then analyzed against racial identification, and statistically significant differences appeared in 4 categories: 1) illicit drug use, 2) birth head circumference and length, 3) days to readmission, and 4) child opportunity index scores. There was not a statistically significant difference in any other maternal characteristics or medical comorbidities, NICU length of stay, age at tracheostomy, or decannulation status. CONCLUSION: The incidence of our tracheostomy in infants with severe BPD was significantly higher (p = 0.036) in the subjects whose families identified as racially African American or Black, a marked contrast to our general NICU population and our overall tracheostomy population. The timing of the first readmission to the hospital was shorter for Caucasian or White infants compared to African American or Black infants. COI demonstrated statistically significantly poorer resources for African American or Black infants compared to White infants with tracheostomy. All other perinatal and outcome measurements did not differ significantly between the two racial groups. This suggests that this racial disparity is present and needs further investigation to better assess its impact on risk and outcomes as we develop pathways for high-quality healthcare delivery.

Health literacy rates among pediatric tracheostomy caregivers.

INTRODUCTION: As health outcomes and disparities become more important in national healthcare, physicians must be aware of every patient's health literacy in order to deliver effective care. Our goal was to measure the health literacy rates in the caregivers of our pediatric tracheostomy population. These caregivers specifically have an immense responsibility that requires a certain capacity for understanding and learning complex skills. Thus far there have been no studies or surveys investigating the rates of health literacy in this population or tracheostomy patients in general. Caregivers' literacy rates were measured by administering a Test of Functional Health Literacy in Adults (TOFHLA). This test uses actual materials that patients might encounter in a typical clinic and consists of a reading comprehension and numeracy section. To assess impact of the complex care on caregiver quality of life, we simultaneously administered the Pediatric Tracheostomy Health Status Instrument (PTHSI), a validated caregiver quality of life measurement. METHODS: Caregivers of children with tracheostomies were recruited and surveyed during the Pediatric Tracheostomy Clinic between July 2019-October 2019. Twenty - six caregivers completed the TOFHLA; 24 completed all three parts - the TOFHLA, the demographic survey, and the PTHSI. RESULTS: Health literacy rates among patient families in the out-patient setting with experience with tracheostomy were deemed "adequate" in 85% of caregivers; the remaining 15% of caregivers scored "inadequate". Overall adult literacy rates in the general population in this state are 26% "inadequate." Approximately 80% of our caregivers rely solely on Medicaid for healthcare insurance and nearly half of participants reported an annual household income less than $5000. Ages of caregivers ranged from 20 to 61 years, with no significant correlation to health literacy. The average PTHSI score was 36 (SD 8.6), denoting a moderate level of caregiver burden but no correlation to the caregiver health literacy score was found. When comparing caregiver health literacy scores in relation to education level, caregivers with college and post-graduate education had higher literacy scores than those with a high school education, p = .0086. In addition, when comparing African American to white caregivers, white caregivers were found to have higher health literacy scores, p = .036. Notably, caregiver burden as measured by the PTHSI score did not differ significantly between caregivers in lower income and higher income levels, p = .91. CONCLUSION: Health literacy measurements for caregivers of children with complex medical conditions exceed the health literacy rates of the general population in our state, potentially biased by the intensive training provided to families during their prolonged hospitalization. Healthcare disparities may impact the medically complex child differently from the healthy child. Assumptions about health, wealth and caregiver burden may be inaccurate and warrant further evaluation. Assessing health literacy before institutionalization has occurred may enable us to more accurately design caregiver training programs to further augment literacy and health literacy.

Bronchopulmonary dysplasia requiring tracheostomy: A review of management and outcomes.

Bronchopulmonary Dysplasia (BPD) is a pulmonary disease affecting newborns, commonly those with prematurity or low birth weight. Its pathogenesis involves underdevelopment of lung tissue with subsequent limitations in ventilation and oxygenation, resulting in impaired postnatal alveolarization. Despite advances in care with improved survival, BPD remains a prevalent comorbidity of prematurity. In severe cases, management may involve mechanical ventilation via tracheostomy. BPD's demand for multidisciplinary care compounds the challenges in management of this condition. Here, we review existing literature: the history of disease, criteria for diagnosis, pathogenesis, and modes of treatment with a focus on the severe subtype: that which is associated with pulmonary hypertension (PAH) for which tracheostomy is often required to facilitate long-term mechanical ventilation. We review the current recommendations for tracheostomy and decannulation.

A Surgical Simulator for Tympanostomy Tube Insertion Incorporating Capacitive Sensing Technology to Track Instrument Placement.

We describe a device engineered for realistic simulation of myringotomy and tympanostomy tube insertion that tracks instrument placement and objectively measures operator proficiency. A 3-dimensional computer model of the external ear and cartilaginous external auditory canal was created from a normal maxillofacial computed tomography scan, and models for the bony external auditory canal and tympanic cavity were created with computer-aided design software. Physical models were 3-dimensionally printed from the computer reconstructions. The external auditory canal and tympanic cavity surfaces were coated with conductive material and wired to a capacitive sensor interface. A programmable microcontroller with custom embedded software completed the system. Construct validation was completed by comparing the run times and total sensor contact times of otolaryngology faculty and residents.

Extracellular matrix for repair of type IV laryngotracheo-esophageal cleft.

Type IV laryngotracheo-esophageal cleft (LTEC) extending to the level of the carina presents unique challenges to operative repair, particularly with respect to soft tissue durability. This is the first report of CorMatrix(®) extra-cellular matrix (ECM) material use as an interposition graft in a four-layered LTEC repair. At day seven post-operatively, there was epithelialization along the surface of the trachea. At 3 months, she was stable for tracheotomy. At 6 months, the posterior wall resembled completely native tissue. CorMatrix(®) ECM(®) use intra-operatively and post-operative outcome were both highly satisfactory. No adverse reaction was seen in this case through 12-month follow up.

Otopathogens Detected in Middle Ear Fluid Obtained during Tympanostomy Tube Insertion: Contrasting Purulent and Non-Purulent Effusions.

Otitis media is a prominent disease among children. Previous literature indicates that otitis media is a polymicrobial disease, with Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis and Moraxella catarrhalis being the most commonly associated bacterial pathogens. Recent literature suggests that introduction of pneumococcal conjugate vaccines has had an effect on the etiology of otitis media. Using a multiplex PCR procedure, we sought to investigate the presence of the aforementioned bacterial pathogens in middle ear fluid collected from children undergoing routine tympanostomy tube placement at Wake Forest Baptist Medical Center during the period between January 2011 and March 2014. In purulent effusions, one or more bacterial organisms were detected in ~90% of samples. Most often the presence of H. influenzae alone was detected in purulent effusions (32%; 10 of 31). In non-purulent effusions, the most prevalent organism detected was A. otitidis (26%; 63 of 245). Half of the non-purulent effusions had none of these otopathogens detected. In purulent and non-purulent effusions, the overall presence of S. pneumoniae was lower (19%; 6 of 31, and 4%; 9 of 245, respectively) than that of the other pathogens being identified. The ratio of the percentage of each otopathogen identified in purulent vs. non-purulent effusions was >1 for the classic otopathogens but not for A. otitidis.

Suppurative cervical lymphadenitis in infancy: microbiology and sociology.

OBJECTIVE: To investigate the associations between patient age, sociological factors, and the microbiology of pediatric neck infections. METHODS: Retrospective chart review of children up to 5 years old who underwent surgical management of suppurative cervical lymphadenitis. RESULTS: A total of 76 individuals met inclusion criteria; 93% of culture-positive infections were caused by Staphylococcus aureus in infants, compared with 59% in children between 13 months and 5 years of age (P = .002). Of the S aureus isolates, 51% were methicillin-resistant S aureus (MRSA) and 49% were methicillin-sensitive S aureus. Methicillin resistance was associated with African American race (P = .004); 67% of participants received empirical antibiotics prior to admission. Of these, 73% received antibiotics in the ß-lactam class, and 25% received treatment with clindamycin. CONCLUSIONS: Incidence of MRSA is high in infants with cervical lymphadenitis who fail empirical antibiotic therapy and require surgical management. Empirical coverage for cervical lymphadenitis with ß-lactam antibiotics may provide inadequate coverage for early infection in this population.

Compliance with recommendations for tympanostomy tube follow-up: patient characteristics.

OBJECTIVES: (1) To determine the percentage of otherwise healthy patients achieving "graduation," or postoperative compliance achieving complete problem resolution and discharge from the otolaryngologist's care, after tympanostomy tube placement. (2) To analyze follow-up behaviors and patient characteristics influencing the likelihood of graduation. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Analysis of details of tympanostomy tube placements performed from 2004 to 2011 by 2 pediatric otolaryngologists for children aged 0 to 18 years. Exclusion criteria were clearly defined craniofacial anomalies, cleft palates, and other ongoing postoperative care. The remaining study subjects were categorized into 3 groups. Graduation (GRAD) subjects achieved discharge from care with "follow-up pro re nata" status. LOST<2Y subjects had not attended scheduled follow-up in <2 years. LOST≥2Y subjects had no follow-up in ≥2 years. RESULTS: A total of 1454 pediatric subjects were included. GRADs constituted only 25.6% of the subject pool; 22.1% were LOST<2Y, and 52.3% were LOST≥2Y. Statistically significant factors in achieving graduation were total number of follow-up visits, total duration of follow-up, compliance with first postoperative visit, patient age, insurance type, and distance between home and practice. CONCLUSION: Rate of graduation, or postoperative compliance achieving complete problem resolution, of otherwise healthy tympanostomy tube patients is low despite perioperative discussions of the importance of proper follow-up. Higher graduation rates are associated with increasing number of follow-up visits and duration, younger patient age, private insurance, and proximity to the practice. Compliance with attending the first postoperative visit may be an early marker for increased likelihood of graduation.

Simulation model for tracheotomy education for primary health-care providers.

OBJECTIVES: We performed this study to evaluate the competency of health-care providers managing patients with tracheotomies, and assess the need for, and efficacy of, a multidisciplinary educational program incorporating patient simulation. METHODS: The prospective observational study included 87 subjects who manage patients with tracheotomies within a tertiary-care hospital. The subjects completed self-assessment questionnaires and objective multiple-choice tests before and after attending a comprehensive educational course using patient simulation. The outcome measurements included pre-course and post-course questionnaire and test scores, as well as observational data collected during recorded patient simulation sessions. RESULTS: Before the education and simulation, the subjects reported an average comfort level of 3.3 on a 5-point Likert scale across 10 categories in the questionnaire, which improved to 4.4 after the training (p < 0.0001). The subjects' mean scores improved from 56% on the pre-course test to 91% on the post-course test (p < 0.0001). The specific deficiencies observed during patient simulation scenarios included unfamiliarity with different tracheotomy tube types, misunderstanding of speaking valve physiology, and delayed recognition and treatment of a plugged or dislodged tracheotomy tube. CONCLUSIONS: There is a significant need for improved tracheotomy education among primary health-care providers. Incorporating patient simulation into a comprehensive tracheotomy educational program was effective in improving provider confidence, increasing provider knowledge, and teaching the skills necessary for managing patients with a tracheotomy.

Computed tomography demonstrates abnormalities of contralateral ear in subjects with unilateral sensorineural hearing loss.

PURPOSE: Prior studies have associated gross inner ear abnormalities with pediatric sensorineural hearing loss (SNHL) using computed tomography (CT). No studies to date have specifically investigated morphologic inner ear abnormalities involving the contralateral unaffected ear in patients with unilateral SNHL. The purpose of this study is to evaluate contralateral inner ear structures of subjects with unilateral SNHL but no grossly abnormal findings on CT. MATERIALS AND METHODS: IRB-approved retrospective analysis of pediatric temporal bone CT scans. 97 temporal bone CT scans, previously interpreted as "normal" based upon previously accepted guidelines by board certified neuroradiologists, were assessed using 12 measurements of the semicircular canals, cochlea and vestibule. The control-group consisted of 72 "normal" temporal bone CTs with underlying SNHL in the subject excluded. The study-group consisted of 25 normal-hearing contralateral temporal bones in subjects with unilateral SNHL. Multivariate analysis of covariance (MANCOVA) was then conducted to evaluate for differences between the study and control group. RESULTS: Cochlea basal turn lumen width was significantly greater in magnitude and central lucency of the lateral semicircular canal bony island was significantly lower in density for audiometrically normal ears of subjects with unilateral SNHL compared to controls. CONCLUSION: Abnormalities of the inner ear were present in the contralateral audiometrically normal ears of subjects with unilateral SNHL. These data suggest that patients with unilateral SNHL may have a more pervasive disease process that results in abnormalities of both ears. The findings of a cochlea basal turn lumen width disparity >5% from "normal" and/or a lateral semicircular canal bony island central lucency disparity of >5% from "normal" may indicate inherent risk to the contralateral unaffected ear in pediatric patients with unilateral sensorineural hearing loss.

Computed tomography supports histopathologic evidence of vestibulocochlear sexual dimorphism.

OBJECTIVE: To investigate whether the effects of sex (male/female) that have been demonstrated in the pathology literature using 0.1 mm histopathologic slices are measurable and statistically significant using high-resolution (0.625 mm slice) computed tomography (CT). METHODS: IRB-approved retrospective analysis of high-resolution "normal" CT temporal bone images in pediatric subjects (0-18 years) using comparative anatomic measurements between males and females obtained from the semicircular canals, cochlea and vestibule as follows: (1) lateral semicircular canal (LSCC) bony island width, (2) superior semicircular canal (SSCC) bony island width, (3) central lucency of the LSCC bony island, (4) coronal cochlear height, (5) axial cochlear height, (6) cochlear length, (7) cochlea basal turn lumen width, (8) cochlear aperture width, (9) cochlear aperture height, (10) vestibular length, (11) vestibular width, and (12) coronal vestibule oblique diameter. RESULTS: Eighteen females (36 ears) and twenty males (36 ears) were included in the study. Independent-samples t-tests revealed statistically significant differences in measurements for females and males as follows (differences reported as a percentage and as an absolute difference (AD) in mm): (1) vestibular width was 4.2% (0.13 mm AD) smaller in females (mean ± SD; 3.0 ± 0.27) compared to males (mean ± SD; 3.2 ± 0.25) [t(70) = 2.083, p = 0.041]; (2) cochlear length was 3.9% (.23 mm AD) smaller in females (mean ± SD; 5.8 ± 0.32) compared to males (mean ± SD; 6.0 ± 0.40) [t(70)=2.660, p = 0.010]; (3) cochlear aperture height was 11.6% (0.13 mm AD) smaller in females (mean ± SD; 1.0 ± 0.18) compared to males (mean ± SD; 1.2 ± 0.22) [t(70)=2.549, p = 0.013]; and (4) coronal cochlear height was 11.4% (0.55 mm AD) smaller in females (mean ± SD; 4.8 ± 0.58) compared to males (mean ± SD; 5.4 ± 0.48) [t(68) = 4.270, p < 0.005]. CONCLUSION: Sexual dimorphism of inner ear structures may contribute to variability in reported normative and pathologic measurements of inner ear structures. This variability must be taken into consideration when designing future research studies to investigate inner ear structures and for drawing accurate conclusions about possible inner ear morphologic abnormalities associated with SNHL compared to controls.

A review of unilateral hearing loss and academic performance: is it time to reassess traditional dogmata?

OBJECTIVE: The aim of this paper was to review traditional approaches to habilitation of unilateral hearing losses as well as new research concerning management of unilateral hearing loss. DATA SOURCES: Literature review/systematic review. REVIEW METHODS: A PubMed search was performed for articles pertaining to unilateral hearing loss and academic loss and academic performance. Articles ranged in date from 1986 to 2012. Five resources were reviewed for content to determine the pertinence of the materials to the understanding of the history of diagnosis of unilateral hearing loss, the traditional treatment methods and their advantages and disadvantages, and more recent publications concerning academic outcomes for patients with unilateral hearing loss with and without treatment. RESULTS: Unilateral hearing loss scan be detrimental to the academic success of children. Effects encompass not only auditory effects such as difficulty hearing in noise, but also self esteem and exhaustion. Although assistive devices were traditionally not offered as options, more recent literature suggests that devices such as BAHA, hearing aids, or FM systems may provide aids in the classroom and that early intervention may provide more favorable outcomes. CONCLUSION: Since the 1980s, the approach to management of unilateral hearing losses has evolved. In order to maximize academic potential, treatment options should be discussed and implemented.

Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease.

BACKGROUND: Commonly, foreign objects are incidentally ingested and pass harmlessly through the gastrointestinal tract; however, disk batteries present exceptional risk. In 2009, the American Association of Poison Control Centers listed disk batteries as the number 1 cause of fatal ingestions in children younger than 5 years. Lithium batteries are the most dangerous, and they are rapidly rising in use by manufacturers. Paralleling that rise, there has been a 6.7-fold increase in major or fatal outcomes between 1985 and 2009. This study describes the variability in patient presentations, the courses of patients' evaluations, and the clinical and financial consequences of disk battery ingestion. METHODS: In this retrospective study, cases from 2001 to 2011 were reviewed for details of care for disk battery ingestions including presentation and management details. Cost of care information from our patients' records was compared with that of national averages on esophageal foreign bodies using the Healthcare Cost and Utilization Project's Kids' Inpatient Database. RESULTS: Six cases are presented. The patients' age averaged 1.85 years. Presentations varied with respect to symptoms, time course, and steps in treatment. Mean length of stay was 9.0 days, and mean cost was $14,994. CONCLUSIONS: Emergency medicine physicians, otolaryngologists, radiologists, gastroenterologists, and pediatric surgeons may be able to mitigate, albeit not entirely prevent, potential serious complications in patients with disk battery ingestions by proper diagnosis and timely treatment. Recommendations for management are presented, which highlight the need for emergent removal of any battery that is lodged and close follow-up of these patients once they are out of the hospital.

One third of middle ear effusions from children undergoing tympanostomy tube placement had multiple bacterial pathogens.

BACKGROUND: Because previous studies have indicated that otitis media may be a polymicrobial disease, we prospectively analyzed middle ear effusions of children undergoing tympanostomy tube placement with multiplex polymerase chain reaction for four otopathogens. METHODS: Middle ear effusions from 207 children undergoing routine tympanostomy tube placement were collected and were classified by the surgeon as acute otitis media (AOM) for purulent effusions and as otitis media with effusion (OME) for non-purulent effusions. DNA was isolated from these samples and analyzed with multiplex polymerase chain reaction for Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis, and Moraxella catarrhalis. RESULTS: 119 (57%) of 207 patients were PCR positive for at least one of these four organisms. 36 (30%) of the positive samples indicated the presence of more than one bacterial species. Patient samples were further separated into 2 groups based on clinical presentation at the time of surgery. Samples were categorized as acute otitis media (AOM) if pus was observed behind the tympanic membrane. If no pus was present, samples were categorized as otitis media with effusion (OME). Bacteria were identified in most of the children with AOM (87%) and half the children with OME (51%, p < 0.001). A single bacterial organism was detected in middle ear effusions from children with AOM more often than those with OME (74% versus 33%, p < 0.001). Haemophilus influenzae was the predominant single organism and caused 58% of all AOM in this study. Alloiococcus otitidis and Moraxella catarrhalis were more frequently identified in middle ear effusions than Streptococcus pneumoniae. CONCLUSIONS: Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis, and Moraxella catarrhalis were identified in the middle ear effusions of some patients with otitis media. Overall, we found AOM is predominantly a single organism infection and most commonly from Haemophilus influenzae. In contrast, OME infections had a more equal distribution of single organisms, polymicrobial entities, and non-bacterial agents.

Detection of group A Streptococcus in tonsils from pediatric patients reveals high rate of asymptomatic streptococcal carriage.

BACKGROUND: Group A Streptococcus (GAS) causes acute tonsillopharyngitis in children, and approximately 20% of this population are chronic carriers of GAS. Antibacterial therapy has previously been shown to be insufficient at clearing GAS carriage. Bacterial biofilms are a surface-attached bacterial community that is encased in a matrix of extracellular polymeric substances. Biofilms have been shown to provide a protective niche against the immune response and antibiotic treatments, and are often associated with recurrent or chronic bacterial infections. The objective of this study was to test the hypothesis that GAS is present within tonsil tissue at the time of tonsillectomy. METHODS: Blinded immunofluorescent and histological methods were employed to evaluate palatine tonsils from children undergoing routine tonsillectomy for adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis. RESULTS: Immunofluorescence analysis using anti-GAS antibody was positive in 11/30 (37%) children who had tonsillectomy for adenotonsillar hypertrophy and in 10/30 (33%) children who had tonsillectomy for recurrent GAS pharyngitis. Fluorescent microscopy with anti-GAS and anti-cytokeratin 8 & 18 antibodies revealed GAS was localized to the tonsillar reticulated crypts. Scanning electron microscopy identified 3-dimensional communities of cocci similar in size and morphology to GAS. The characteristics of these communities are similar to GAS biofilms from in vivo animal models. CONCLUSION: Our study revealed the presence of GAS within the tonsillar reticulated crypts of approximately one-third of children who underwent tonsillectomy for either adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis at the Wake Forest School of Medicine. TRIAL REGISTRATION: The tissue collected was normally discarded tissue and no patient identifiers were collected. Thus, no subjects were formally enrolled.

Retrieval of a penny from the pediatric esophagus: a cost analysis.

OBJECTIVE: As part of the oral phase of development, children commonly ingest foreign bodies. The most common lodged foreign body, requiring operative removal, in the United States is the penny. Valued at 1 cent, comprised of materials valued at less than 1 cent, costing 1.62 cents to manufacture, and being never removed from circulation, pennies are aplenty. But ingestion can lead to mucosal damage, the consequences of which can be esophageal perforation or stricture formation. We hypothesize that the monetary value of the penny is far less than the cost of its ingestion and removal. This quality assurance study examines the effect of the penny on the purse. PATIENTS AND METHODS: This retrospective review identified 180 foreign bodies in children under the age of 18 over a five year period. Eighty-two were pennies. Operative notes revealed degree of injury. Hospital charge assessments revealed the "cost" of each visit. RESULTS: There were no esophageal perforations, and cases were divided evenly among injury grades 0-III. The average total charge for all penny-related injuries was $7164.78. CONCLUSIONS: The purpose was to examine the actual cost of a penny (more than its value in production) and the potential cost of its damage (thousands of dollars in measurable costs, untold immeasurable costs). The goal of this study is to draw healthcare professional and public attention to a potentially serious and yet highly preventable injury in young children.