Pediatric Frontal Bone and Sinus Fractures: Cause, Characteristics, and a Treatment Algorithm.

BACKGROUND: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures. METHODS: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay. RESULTS: A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11). CONCLUSIONS: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Diagnostic yield of MRI for pediatric hearing loss: a systematic review.

OBJECTIVE: To perform a systematic review to analyze the diagnostic yield of magnetic resonance imaging (MRI) for pediatric hearing loss, including comparison to computed tomography (CT) and subgroup evaluation according to impairment severity and specific diagnostic findings (cochlear anomalies, enlarged vestibular aqueduct, cochlear nerve abnormalities, and brain findings). DATA SOURCES: Pubmed, EMBASE, and the Cochrane library were assessed from their inception through December 2013. Manual searches were also performed, and topic experts were contacted. REVIEW METHODS: Data from studies describing the use of MRI with or without comparison to CT in the diagnostic evaluation of pediatric patients with hearing loss were evaluated, according to a priori inclusion/exclusion criteria. Two independent evaluators corroborated the extracted data. Heterogeneity was evaluated according to the I(2) statistic. RESULTS: There were 29 studies that evaluated 2434 patients with MRIs and 1451 patients with CTs that met inclusion/exclusion criteria. There was a wide range of diagnostic yield from MRI. Heterogeneity among studies was substantial but improved with subgroup analysis. Meta-analysis of yield differences demonstrated that CT had a greater yield than MRI for enlarged vestibular aqueduct (yield difference 16.7% [95% CI, 9.1%-24.4%]) and a borderline advantage for cochlear anomalies (4.7% [95% CI, 0.1%-9.5%]). Studies were more likely to report brain findings with MRI. CONCLUSIONS: These data may be utilized in concert with that from studies of risks of MRI and risk/yield of CT to inform the choice of diagnostic testing.

Seasonal variation in family member perceptions of physician competence in the intensive care unit: findings from one academic medical center.

PURPOSE: Researchers have found mixed results about the risk to patient safety in July, when newly minted physicians enter U.S. hospitals to begin their clinical training, the so-called "July effect." However, patient and family satisfaction and perception of physician competence during summer months remain unknown. METHOD: The authors conducted a retrospective observational cohort study of 815 family members of adult intensive care unit (ICU) patients who completed the Family Satisfaction with Care in the Intensive Care Unit instrument from eight ICUs at Beth Israel Deaconess Medical Center, Boston, Massachusetts, between April 2008 and June 2011. The association of ICU care in the summer months (July-September) versus other seasons and family perception of physician competence was examined in univariable and multivariable analyses. RESULTS: A greater proportion of family members described physicians as competent in summer months as compared with winter months (odds ratio [OR] 1.9; 95% confidence interval [CI] 1.2-3.0; P = .003). After adjustment for patient and proxy demographics, severity of illness, comorbidities, and features of the admission in a multivariable model, seasonal variation of family perception of physician competence persisted (summer versus winter, OR of judging physicians competent 2.4; 95% CI 1.3-4.4; P = .004). CONCLUSIONS: Seasonal variation exists in family perception of physician competence in the ICU, but opposite to the "July effect." The reasons for this variation are not well understood. Further research is necessary to explore the role of senior provider involvement, trainee factors, system factors such as handoffs, or other possible contributors.

Diagnostic yield of computed tomography scan for pediatric hearing loss: a systematic review.

BACKGROUND: Computed tomography (CT) has been used in the assessment of pediatric hearing loss, but concern regarding radiation risk and increased utilization of magnetic resonance imaging (MRI) have prompted us toward a more quantitative and sophisticated understanding of CT's potential diagnostic yield. OBJECTIVE: To perform a systematic review to analyze the diagnostic yield of CT for pediatric hearing loss, including subgroup evaluation according to impairment severity and laterality, as well as the specific findings of enlarged vestibular aqueduct and narrow cochlear nerve canal. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library were assessed from the date of their inception to December 2013. In addition, manual searches of bibliographies were performed and topic experts were contacted. REVIEW METHODS: Data from studies describing the use of CT in the diagnostic evaluation of pediatric patients with hearing loss of unknown etiology were evaluated, according to a priori inclusion/exclusion criteria. Two independent evaluators corroborated the extracted data. Heterogeneity was evaluated according to the I(2) statistic. RESULTS: In 50 criteria-meeting studies, the overall diagnostic yield of CT ranged from 7% to 74%, with the strongest and aggregate data demonstrating a point estimate of 30%. This estimate corresponded to a number needed to image of 4 (range, 2-15). The most commonly identified findings were enlarged vestibular aqueduct and cochlear anomalies. The largest studies showed a 4% to 7% yield for narrow cochlear nerve canal. CONCLUSION: These data, along with similar analyses of radiation risk and risks/benefits of sedated MRI, may be used to help guide the choice of diagnostic imaging.

Risk of malignancy associated with head and neck CT in children: a systematic review.

OBJECTIVE: To perform a systematic review to evaluate the risk of malignancy associated with computed tomography (CT) of the head and/or neck in infants, children, and adolescents. DATA SOURCES: Pubmed, EMBASE, and the Cochrane Library were assessed from the date of their inception to January 2014. Additionally, manual searches of bibliographies were performed and topic experts were contacted. REVIEW METHODS: Data were obtained from studies measuring or estimating the risks of malignancy associated with radiation from head and/or neck CT in pediatric populations according to an a priori protocol. Two independent evaluators corroborated the extracted data. RESULTS: There were 16 criterion-meeting studies that included data from n = 858,815 patients. The radiation-related risk of malignancy was estimated using primary patient data for both the exposure and outcome in a minority of studies, with most analyses utilizing mathematical modeling techniques. The data regarding otolaryngology-specific studies were limited and suggested a borderline significant increase in the risk of all combined cancers after facial CT (incidence rate ratio [IRR] = 1.14; 95% CI, 1.01-1.28) and neck/spine CT (IRR = 1.13; 95% CI, 1.00-1.28). Cohort data suggest that 1 excess brain malignancy occurred after 4000 brain CTs (40 mSv per scan) and that the estimated risk in the 10 years following CT exposure was 1 brain tumor per 10,000 patients exposed to a 10 mGy scan at less than 10 years of age. CONCLUSION: Detailed understanding of any potential malignancy risk associated with pediatric imaging of the head and neck furthers our ability to engage in rational, shared, informed decision making with families considering CT scan.

Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative pain control is essential for optimal patient outcomes. Ketorolac is an attractive alternative for achieving pain control postoperatively, but concerns over postoperative bleeding have limited its use. METHODS: Computer searches of the MEDLINE, EMBASE, and Cochrane Library databases were performed. Twenty-seven double-blind, randomized, controlled studies were reviewed by two independent investigators for the incidence of adverse events, including postoperative bleeding. Comprehensive meta-analysis software was used to evaluate the differences between ketorolac and control groups. RESULTS: Twenty-seven studies with 2314 patients were analyzed. Postoperative bleeding occurred in 33 of 1304 patients (2.5 percent) in the ketorolac group compared with 21 of 1010 (2.1 percent) in the control group (OR, 1.1; 95 percent CI, 0.61 to 2.06; p = 0.72). Adverse events were similar in the groups, 31.7 percent in the control group and 27.9 percent in the ketorolac group (OR, 0.64; 95 percent CI, 0.41 to 1.01; p = 0.06). There was a lower incidence of adverse effects with low-dose ketorolac (OR, 0.49; 95 percent CI, 0.27 to 0.91; p = 0.02). Pain control with ketorolac was superior to controls and equivalent to opioids. CONCLUSIONS: This is the first meta-analysis of randomized controlled trials examining whether there is increased postoperative bleeding with ketorolac. Postoperative bleeding was not significantly increased with ketorolac compared with controls, and adverse effects were not statistically different between the groups. Pain control was found to be superior with ketorolac compared with controls. Ketorolac should be considered for postoperative pain control, especially to limit the use of opioid pain medications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.