Perioperative factors influencing hospitalization duration for pediatric neck abscesses.

PURPOSE: Pediatric neck abscesses are a common pathology seen in an ambulatory setting. Although some pediatric neck abscesses are managed medically with antibiotics, surgical intervention is often required. Given the often non-emergent presentation of many abscesses, a variety of logistical and perioperative factors may delay time to care and subsequently prolong hospital stay. The objective of this study was to examine factors that influence the overall time to surgery (TTS) and hospital length of stay (LOS) in a pediatric population with neck abscesses who ultimately require surgical drainage. MATERIALS AND METHODS: 161 pediatric patients who underwent incision and drainage of a neck abscess over a ten-year period at a tertiary referral children's center were reviewed. Demographic information, radiographic studies, and surgical information were extracted from patient charts. Descriptive statistics, Mann-Whitney U tests, and multivariate analyses were performed. RESULTS: The most common subcategory location was deep neck abscesses (33.1 %). Computed tomography (CT) was the most common pre-operative imaging modality (54.1 %) followed by ultrasound (US) (49.1 %) and magnetic resonance imaging (2.6 %). US and a combination of multiple preoperative imaging modalities were associated with increased LOS and TTS. Repeat surgery was associated with increased LOS. Pre-admission antibiotic use was associated with increased LOS and TTS. Younger patients were more likely to have a longer LOS. CONCLUSIONS: A variety of factors can influence TTS, LOS, and time from surgery to discharge including patient age, abscess location, a non-optimized utilization of imaging modalities, the utilization of pre-admission antibiotics, and the need for repeat operations.

Hemorrhage Rates in Pediatric Patients Receiving Postoperative Steroids After Tonsillectomy.

Importance. Developing a safe postoperative pain regimen after tonsillectomy is important. While postoperative steroids may provide an analgesic benefit, it is not known whether steroids increase the bleeding risk after tonsillectomy. Objective. To determine whether postoperative steroids increase the risk of hemorrhage after tonsillectomy in children. Design. Retrospective cohort study. Setting. Tertiary referral academic medical center. Participants. An age- and indication-matched cohort was randomly selected from tonsillectomy patients ≤12 years old from 2012 to 2017. Intervention. Prednisolone, 0.5 mg/kg (maximum dose 20 mg/day) qAM × 3 days postoperatively. Main Outcome. Postoperative hemorrhage requiring operative intervention. Results. A total of 1358 patients were included in this study, 679 of which received postoperative steroids. The steroid group had a similar of operative intervention for post-tonsillectomy hemorrhage of 1.8% versus 2.2% in the nonsteroid group (P = .560). Conclusion and Relevance. Post-tonsillectomy steroid use is not associated with an increase in operative intervention for postoperative hemorrhage.

Systematic review of endoscopic-assisted surgical management for congenital nasolacrimal duct obstruction.

OBJECTIVES: Epiphora is a common presenting complaint in infants affecting up to 6% of infants in the United States. It is most frequently due to congenital anomalies of the nasolacrimal duct system, termed congenital nasolacrimal duct obstruction (CNLDO). Nasolacrimal duct probing is widely accepted as the primary surgical intervention in cases that fail conservative management. Recently, nasal endoscopy has been combined with traditional probing to improve success rates and outcomes. Several studies have been conducted, but the results have been inconclusive overall. The goal of this systematic review is to examine the existing literature on the role of nasal endoscopy during nasolacrimal duct probing and evaluate patient outcomes. METHODS: A systematic search was performed in PubMed, MEDLINE, The Cochrane Library, ClinicalTrials.gov, LILAC, and EMBASE to identify peer-reviewed research. Eligible studies were those containing original peer-reviewed research in English addressing nasolacrimal duct probing for congenital nasolacrimal duct obstruction in conjunction with nasal endoscopy. Two investigators independently reviewed all articles and extracted data. Bias was assessed using the Cochrane Collaboration's tool, the Newcastle-Ottawa Assessment scale, and the NIH Quality Assessment scale. RESULTS: A literature review ultimately yielded 11 articles that were selected and included in our analysis. Of the seven case series, the success rate was 92.5% for a total of 492 eyes. Of the four cohort/case-control studies, the success rate in conventional probings was 75.3% for a total of 293 eyes. In probings with nasal endoscopy, the success rate was 95.3% for 162 eyes. Overall, there was a high risk of bias and variation in data reporting amongst studies. CONCLUSION: Infants with congenital nasolacrimal duct obstruction that does not resolve with conservative treatment often require surgical intervention. Based on this systematic review of the current literature, nasal endoscopy is a useful adjunct for nasolacrimal duct probing.

Thyroidectomy-related malpractice claims.

OBJECTIVE: Little information is available regarding the frequency of thyroidectomy-related malpractice claims. Previous studies have not assessed claims that were settled or dropped before trial, providing only a limited view of the medical-legal environment. We sought to determine the frequency of thyroid surgery-related malpractice claims, their causes, and outcomes. STUDY DESIGN: Database assessment. SETTING: Academic medical center. SUBJECTS AND METHODS: The database of the Physician Insurers Association of America was reviewed. These data are estimated to represent 25% of medical malpractice claims in the United States. Claims from 1985 to 2008 with thyroid-related procedure codes were evaluated for claimant information, insured's specialty, loss description, causation, and claim outcomes. RESULTS: During the 24-year period reviewed, 380 claims related to thyroid surgery were reported. 128 claims (33.7% of total claims) resulted in an indemnity payment either due to settlement or a finding against the defendant. The average indemnity payment was $185,366 (range, $363 to $2,000,000). Among cases in which a specific outcome was reported, 55 were related to laryngeal nerve injury or voice disturbance. No substantial change occurred in the incidence of claims across the study period. During this time, approximately 2,585,000 thyroidectomies were performed. Extrapolating from the Physician Insurers Association of America data, this represents an estimated 5.9 claims per 10,000 cases. CONCLUSION: Malpractice claims related to thyroid surgery are surprisingly infrequent. While the rates of thyroid surgery have risen steadily, there has not been a corresponding increase in the rate of related malpractice claims.

Cochlear implantation after renal transplantation.

OBJECTIVE: Cochlear implantation after renal transplantation is uncommon and poses unique challenges that have only recently been described in the medical literature. This work reports our experience with cochlear implantation in patients who have undergone renal transplantation. STUDY DESIGN: A retrospective review was performed. SETTING: This study was performed in a tertiary academic medical center. PATIENTS: Two patients were identified as having undergone cochlear implantation after renal transplantation. INTERVENTIONS: Uneventful unilateral cochlear implantations were performed. MAIN OUTCOME MEASURES: Postoperative complications to include wound infection or dehiscence were reported as well as audiometric data. RESULTS: Cochlear implantation was completed uneventfully in both patients without postoperative complications. One patient expired two years after the procedure as a result of multiple comorbidities. Both patients achieved successful use of their device. CONCLUSIONS: This study adds to the growing evidence that successful cochlear implantation can be achieved in appropriately selected renal transplant patients. Decision making should rely on surgical candidacy as well as assessment of surgical risk in collaboration with the transplant service.

Cochlear implantation using thin-film array electrodes.

OBJECTIVE: Current limitations in language perception may stem from an inability to provide high-resolution sound input. Thin-film array technology allows for a greater density of stimulating sites within the limited diameter of the scala tympani. This study examines the use of a flexible carrier to achieve adequate depth of insertion. STUDY DESIGN: A prospective human cadaveric temporal bone insertion analysis. SETTING: Academic otolaryngology department and school of electrical and computer engineering collaboration. METHODS: A prototype thin-film array electrode coupled with an insertion test device (ITD) was manufactured and inserted into 10 human cadaveric temporal bones. As controls, 2 additional temporal bones were implanted with the ITD only and 2 were unimplanted. Radiologic and histologic data were collected. RESULTS: Ten thin-film array electrodes were successfully implanted into 10 individual temporal bones via round window (5) and cochleostomy (5) approaches. Seventeen millimeters of insertion was noted for each device, with an average angular insertion depth of 292° by radiographic measurements and 392° by histologic sectioning. Electrode distance to the modiolus averaged 0.88 mm by computed tomography and 0.67 mm by histologic measurements. Average percentage trauma was 26% for the ITD-backed arrays compared with 15% and 29% for ITD only and unimplanted temporal bones, respectively. CONCLUSION: Thin-film array electrodes coupled with an ITD were successfully inserted into the human cochlea with limited trauma. With continued development and testing of this electrode design, the thin-film array may improve the language perception achieved through cochlear implantation.

Incision and drainage followed by mattress suture repair of auricular hematoma.

OBJECTIVE: Auricular hematoma is a condition requiring early and effective management to prevent pathogenesis of the unsightly cauliflower ear. The objective of this study is to review cases of auricular hematoma and present incision and drainage followed by through-and-through whip-type absorbable mattress sutures without bolsters as an effective treatment. STUDY DESIGN: Retrospective chart review of auricular hematoma cases. METHODS: A 5-year retrospective evaluation of auricular hematomas presenting to an otolaryngology group was performed. Patients' charts were reviewed and data regarding the treatment and follow-up of auricular hematomas were assembled and analyzed. RESULTS: Twenty-two patients were found to present with auricular hematoma. One patient was lost to follow-up. Twenty-eight treatments were performed on 23 ears. Seven hematomas were treated with needle aspiration, two were treated with incision and drainage with iodoform wick placement, and 19 were treated with incision and drainage followed by absorbable mattress sutures. There were five hematoma reaccumulations requiring an additional procedure after treatment by an otolaryngologist. Three followed needle drainage; one followed incision and drainage with wick placement, and one followed incision and drainage with absorbable mattress sutures. CONCLUSION: Incision and drainage followed by through-and-through absorbable mattress sutures appears to be a superior method of treatment with rare reaccumulation of hematoma. This method of treatment was shown to be simple and well tolerated, and it had few complications.

Ciprofloxacin/dexamethasone drops decrease the incidence of physician and patient outcomes of otorrhea after tube placement.

OBJECTIVE: To evaluate ciprofloxacin 0.3%/dexamethasone 0.1% (CIPRODEX, Alcon, Ft. Worth, TX) for the prevention of early post-operative otorrhea following TT placement. METHODS: This was a single-center, randomized, evaluator-blinded, parallel-group study. Two hundred children undergoing bilateral TT placement were categorized as having unilateral ("wet/dry"), bilateral ("wet/wet"), or no ("dry/dry") effusion at the time of surgery. All patients received Ciprodex or no treatment for 5 days post-operatively and returned at 2 weeks. RESULTS: Physician-observed otorrhea was reported in 5 (4.95%) patients receiving Ciprodex and 39 (39.39%) patients receiving no treatment (p<0.0001). Treatment decreased otorrhea in all groups, while the greatest benefit was observed in patients with bilateral effusion (93% reduction). Ciprodex treatment also decreased the rate of clinically diagnosed otitis media (OM) and effusion following TT placement (p< or =0.0006). CONCLUSION: Ciprodex reduced early post-operative otorrhea, clinically diagnosed OM and effusion following TT insertion. The greatest reduction in otorrhea was observed in patients with bilateral effusion at the time of surgery.