Search

Objectives/hypothesis: During the current COVID-19 pandemic, the demand for direct-to-home telemedicine services has risen to an unprecedented level. Equal access to specialty care was assessed to identify potential barriers that may negatively impact telemedicine utilization., Study Design: Retrospective case series., Methods: We examined the 6-week period between March and May 2020 when the only access to nonurgent pediatric otolaryngology service was through telemedicine and compared it to in-person visits during the same period in 2019. We compared patient demographics, including age, gender, preferred language, zip code of residence, and primary insurance plan., Results: A total of 1,495 visits were conducted through telemedicine from March 23, 2020 to May 1, 2020, and 1983 in-person visits were completed in 2019. There was no difference in patient age and gender. The proportions of Spanish-speaking families were similar (15.8% in 2019 vs. 14.4% in 2020, P = .96). The percentage of Medi-Cal-insured patients (51.4% in 2019 vs. 49.8% in 2020, P = .73) and the mean poverty level (12.6% in 2019 vs. 12.2% in 2020, P = .38) also remained the same. Spanish-speaking families were statistically more likely to require rescheduling of their telemedicine visits (17.2%) when compared to the overall rescheduling rate of 11.9% (P = .0083)., Conclusions: We were able to successfully provide access to telemedicine services to our vulnerable populations during the current COVID-19 pandemic. Telemedicine is likely to remain an essential mode of delivering patient care going forward. It is important to evaluate and identify potential disparities to telemedicine access and proactively implement changes to address these barriers., Level of Evidence: 4. Laryngoscope, 131:1175-1179, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objective: Although subject recruitment is one of the most critical aspects of human subject research, there is a lack of studies prospectively examining the recruitment preferences of adults for research involving children., Methods: This was a cross-sectional study of adults accompanying patients at an otolaryngology clinic in a pediatric medical center. Anonymous questionnaires were distributed in English and Spanish to one adult for every patient. Questions assessed the respondent's preferences for research recruitment including contact method preferences, contact preferences for medical profession type, and whether they would expect a child to receive a small gift for participating in a research study. Fisher's exact tests were used to assess the association between the primary predictor, language, and each outcome., Results: 566 surveys were collected. 505 (89.1%) were completed in English and 61 (10.7%) were completed in Spanish. Spanish-speaking respondents were more likely to prefer talking to a doctor (76.7%) than English-speaking respondents (40.1%, p < 0.05). Spanish-speaking respondents were more likely to prefer talking over the phone (48.3%) than English-speaking respondents (17.3%, p < 0.05). Spanish-speaking respondents were more likely to prefer communicating via text messaging (41.7%) than English-speaking respondents (16.3%, p < 0.05). English-speaking respondents were more likely to prefer communicating through the patient portal of an electronic health record (EHR) (19%) than Spanish-speaking respondents(3.3%, p < 0.05). Mothers were more likely to prefer talking to a nurse/physician's assistant (20%) than fathers (10%, p < 0.05). Mothers were more likely to prefer talking to research staff (20%) than fathers (9%, p < 0.05). Mothers were more likely to prefer communication via text-message (22%) than fathers (6%, p < 0.05). Spanish-speaking respondents were more likely to prefer pediatric patients receiving a small monetary gift for participating in clinical research (70%) than English-speaking respondents (30%, p < 0.05)., Conclusion: There was a significant association between preference for recruitment method and primary language spoken by the respondent. Further inquiry is required to understand these differences between English and Spanish speakers., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

This plain language summary serves as an overview in explaining earwax (cerumen). The summary applies to patients older than 6 months with a clinical diagnosis of earwax impaction and is based on the 2017 update of the Clinical Practice Guideline: Earwax (Cerumen Impaction). The evidence-based guideline includes research that supports diagnosis and treatment of earwax impaction. The guideline was developed to improve care by health care providers for managing earwax impaction by creating clear recommendations to use in medical practice.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the updated Clinical Practice Guideline: Earwax (Cerumen Impaction). To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations emphasize proper ear hygiene, diagnosis of cerumen impaction, factors that modify management, evaluating the need for intervention, and proper treatment. An updated guideline is needed due to new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials) and the need to add statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.

Importance: The optimal treatment for head and neck lymphatic malformations (LMs) is unknown. To our knowledge, this is the first head-to-head comparison of primary surgery and sclerotherapy for this condition., Objective: To compare surgery and sclerotherapy as initial treatment for head and neck LMs., Design, Setting, and Participants: Retrospective cohort study including patients in 2 pediatric vascular anomaly programs receiving treatment for head and neck LMs., Interventions: Primary surgery or primary sclerotherapy and any subsequent therapy within 1 year., Main Outcomes and Measures: Treatment effectiveness was measured by (1) need for further therapy after first treatment and within 1 year and (2) change in Cologne Disease Score (CDS). Resource utilization was reflected by total intervention number, hospital and intensive care unit (ICU) days, and tracheostomy placement., Results: A total of 174 patients were studied. Their mean (SD) age at presentation was 4.2 (4.7) years; 45.1% were female. The initial treatment was surgery in 55.8%, sclerotherapy in 35.1%, and other interventions in 9.1%. The LM stage ranged from 1 to 5, with similar distributions (P = .15) across initial treatment types; 31.2% of LMs were macrocystic, 34.8% were microcystic, and 33.9% were mixed, with similar distributions across treatment types. Patients receiving sclerotherapy had worse pretreatment CDS subscores for respiration, nutrition, and speech (all P ≤ .02). In univariate analysis, initial surgery and initial sclerotherapy had similar effectiveness after the first intervention (P = .21) and at 1 year (P = .30). In multivariate analysis controlling for lesion stage and type, initial surgery and sclerotherapy did not differ in effectiveness after the first intervention (P = .28) or at 1 year (P = .97). Total CDS and subscale changes were similar between treatment types except for the nutrition subscale. Treatment type did not predict total number of interventions (P = .64), total hospital days (P = .34), total ICU days (P = .59), or higher likelihood of subsequent tracheostomy (P = .36). Higher LM stage predicted more hospital and ICU days and higher likelihood of tracheostomy (all P ≤ .02)., Conclusions and Relevance: In this multisite comparison, initial surgery and sclerotherapy for head and neck LMs were similar in effectiveness and resource utilization. Higher stage predicted greater resource utilization.

Background: Upper airway obstruction in children with Pierre Robin sequence (PRS) may be severe enough to require surgical intervention. Although many studies have demonstrated the effectiveness of mandibular distraction osteogenesis (MDO) in relieving airway obstruction, no study has reported health-related quality of life (QOL) outcomes. The objective of the present study was to conduct the first health-related QOL assessment post-MDO., Methods: The Glasgow Children's Benefit Inventory (GCBI) questionnaire was distributed in a retrospective manner to the caregivers of all children who had undergone MDO at the authors' institutions between January 2007 and December 2010. Patients who had other major surgical procedures were excluded., Results: The response rate was 84% (21 of 25 questionnaires completed). The total mean GCBI score was +54 (SD, 19.5), which demonstrated a subjective overall benefit in health-related QOL post-MDO. All of the domains within the GCBI also scored in the positive range, indicating domain specific improvements in health-related QOL. There were no significant differences in the GCBI scores between syndromic-PRS patients and isolated PRS patients; similar results were observed between tracheostomy patients and no tracheostomy patients., Summary: In treating children with PRS and severe upper airway obstruction, MDO resulted in a subjective overall benefit in health-related QOL in our study population., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Introduction: In addition to upper airway obstruction, many patients with micrognathia and Pierre Robin sequence also have swallowing abnormalities and reflux. Many studies have demonstrated the effectiveness in alleviating the airway symptoms with mandibular distraction osteogenesis, but very few studies have focused on feeding and reflux outcomes., Methods: A retrospective chart review was performed to identify patients with Pierre Robin sequence who underwent mandibular distraction osteogenesis with completed pre- and post-operative upper gastroesophageal series and videofluoroscopic swallow assessments., Results: All six children in our series demonstrated significant improvements in both airway obstructive symptoms and feeding abnormalities. More specifically, all patients showed clinical and objective improvements in reflux and swallowing function after distraction surgery., Conclusion: Objective and symptomatic improvements in swallowing function and reflux disease can be seen after mandibular distraction osteogenesis in children with Pierre Robin sequence., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Ankyloglossia is a congenital condition in which tongue mobility is limited due to an abnormality of the lingual frenulum. The impact of ankyloglossia on breastfeeding is poorly understood but there is a recent trend toward more recognition of this condition and early intervention when needed. Currently, there lacks clear definition of ankyloglossia and different subtypes have been proposed with no clinical correlation., Objective: To determine the prevalence of anterior versus posterior ankyloglossia in a large series of consecutive patients and to assess clinical outcomes after frenotomy., Methods: Retrospective chart review of patients from July 2007 to July 2009 who were diagnosed with ankyloglossia and underwent office frenotomy. Baseline characteristics, specific feeding issues, type of ankyloglossia, and clinical outcomes after frenotomy were reviewed., Results: Of the 341 total patients, 322 (94%) had anterior ankyloglossia and 19 (6%) had posterior ankyloglossia. Median age at presentation was 2.7 weeks (range 1 day of life to 24 weeks); 227 were males and 114 were females. Revision frenotomy rates were significantly higher for the posterior ankyloglossia group (3.7% anterior and 21.1% posterior, p=0.008)., Conclusion: Anterior ankyloglossia is much more common and readily managed when compared to posterior ankyloglossia. Posterior ankyloglossia is a poorly recognized condition that may contribute to breastfeeding difficulties. The diagnosis is difficult due to the subtle clinical findings but relevant health care providers should be aware of this condition. Frenotomy is a simple, safe, and effective intervention for ankyloglossia which improves breastfeeding., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

A systematic review is a transparent and unbiased review of available information. The published systematic review must report the details of the conduct of the review as one might report the details of a primary research project. A meta-analysis is a powerful and rigorous statistical approach to synthesize data from multiple studies, preferably obtained from a systematic review, in order to enlarge the sample size from smaller studies to test the original hypothesis and/or to generate new ones. The objective of this article is to serve as an easy to read practical guide to understand systematic reviews and meta-analyses for those reading them and for those who might plan to prepare them.

Objective: To determine the evidence for efficacy of tonsillectomy in reducing the incidence of recurrent pharyngitis., Data Sources: Literature databases consisting of PUBMED, SCOPUS, CINHAL AND OVID EMBASE including all languages., Review Methods: Literature search of database by 2 authors with structured criteria using an online database. Selected studies evaluated with meta-analysis., Results: In four randomized, controlled trials tonsillectomy was favored over medical therapy in reducing pharyngitis. The difference was statistically significant in only one study. Overall meta-analysis results were significant, indicating that tonsillectomy results in a reduction of about 43% in the incidence of pharyngitis. The number needed to treat with tonsillectomy to prevent one sore throat per month for the first year after surgery was 11 (95% CI; 7-23)., Conclusion: Tonsillectomy reduces the incidence of recurrent pharyngitis to a modest degree.

Objective: To evaluate olfactory function in children with blunt head trauma., Methods: Eligible subjects were consecutive children presenting at San Diego Children's Hospital Emergency Department or Trauma Service with blunt head trauma. Thirty-seven head injured children mean age 10.11+/-2.74 were evaluated; 36 healthy age and gender matched community children, mean age 10.08+/-2.99, served as controls. The medical record was reviewed for clinical measures related to head injury (HI). All children underwent olfactory assessment with the San Diego Children's Odor Identification Test (SDOIT). Olfactory event-related potentials were recorded on a subset of head injured and control children., Results: Three of 37 head injured children had olfactory dysfunction. The head injured hyposmics had signs of more severe head injury represented by lower Glasgow Coma Scores (GCS), 10.33+/-5.51, when compared to their normosmic counterparts with mean GCS of 14.06+/-2.82. When stratifying the head injured children by clinical measures, lower Glasgow Coma Score, and abnormalities on head CT scan were associated with poorer olfactory performance., Conclusion: Children with blunt head injury may suffer post-traumatic olfactory impairment. More severe head injuries are more likely to produce olfactory deficits. In cases of significant head injury, cranial nerve I evaluation is imperative.

Objectives: To continue assessment of the benefits and risks of intralesional administration of cidofovir, an acyclic nucleoside phosphonate, for treating severe recurrent respiratory papillomatosis (RRP) in pediatric patients, and to discuss guidelines for larger prospective multi-institutional studies of the use of cidofovir., Design: Prospective case series., Setting: Tertiary care children's hospital., Patients: A total of 10 patients with severe RRP (defined as requiring debulking procedures to maintain airway patency at least once a month) underwent intralesional cidofovir therapy. The original 5 patients have received more than 1 year of follow-up since their last cidofovir injection, and 5 subsequent patients have been treated with a revised injection protocol., Intervention: Microsuspension laryngoscopy with intralesional injection of cidofovir after repetitive carbon dioxide laser treatments and mechanical debulking of papillomas., Main Outcome Measures: Papilloma stage at the time of serial laryngoscopies. Histologic examination of biopsy specimens of laryngeal tissue obtained 1 year or more after last cidofovir injection., Results: There was evidence of marked improvement in the 4 of the 5 new patients enrolled under the revised injection protocol, continuation of a disease-free state in 1 of the original 5 patients, and sustained improvement in 4 of the 5 original patients, resulting in a significantly reduced interval of intervention., Conclusions: Intralesional cidofovir therapy continues to show benefit in the treatment of severe RRP in pediatric patients. Safety profiles have not been fully established, but current histologic data are reassuring.

Objective: To assess the potential benefit of intralesional administration of cidofovir, an acyclic nucleoside phosphonate with activity against several DNA viruses, for treating severe respiratory papillomas in pediatric patients., Design: Prospective case series., Setting: Tertiary care children's hospitals., Patients: Five pediatric patients with severe recurrent respiratory papillomatosis requiring laryngoscopy with carbon dioxide laser therapy more frequently than once a month to maintain airway patency. Each patient underwent between 12 and 33 laryngoscopies with laser treatment prior to being injected with cidofovir., Intervention: Microsuspension laryngoscopy with intralesional injection of cidofovir (Vistide) in conjunction with mechanical debulking and carbon dioxide laser of papillomas., Main Outcome Measure: Papilloma stage at time of serial laryngoscopies., Results: One patient was disease free and 3 patients demonstrated a dramatic response to adjuvant therapy with cidofovir at the 9-month follow-up visit after the last injection of cidofovir. One patient showed an improvement in papilloma stage that was possibly related to concurrent therapy with interferon., Conclusions: Intralesional injection of cidofovir seems to be of benefit in the treatment of severe respiratory papillomatosis in pediatric patients. Larger prospective studies with longer follow-up will be required before cidofovir can be considered an accepted means of managing this difficult disease.

Postoperative management of the patient younger than 36 months undergoing adenotonsillectomy has been the subject of many debates. Concerns for early postoperative complications such as airway obstruction, emesis, dehydration, and hemorrhage have led many physicians to consider overnight hospitalization following adenotonsillectomy in very young children. Trends in health care management have had increasing focus on cost effective means of treating patients to limit unnecessary expenditure on the part of the patient, physician, and hospital facility. The purpose of this retrospective review was to analyze two methods of early postoperative management in children less than 36 months old undergoing adenotonsillectomy at the Children's Hospital, San Diego from 1992 to 1997. Three hundred and seven cases were reviewed. Same-day discharge was compared with overnight inpatient observation based on the cost analysis of these two methods of postoperative care. Postoperative care was based on length of stay in the recovery room and as an inpatient. Expense of postoperative care was based on cost calculation for the recovery room and overnight hospitalization. Of the 307 patients, 194 went home the day of surgery and 113 were observed overnight in the hospital. Average hospital cost was higher in the outpatient group than in the inpatient group (P < 0.001). This difference reflects longer recovery room stay (350 min) in the outpatient group compared to the inpatient group (108 min) (P < 0.001). Outpatient adenotonsillectomy in the patient under 36 months may be safe; however, prolonged recovery room stays may actually make outpatient surgery less cost-effective than overnight admission. Recovery room costs are significantly higher per unit time than costs of inpatient hospitalization. Further investigation of cost-effective outpatient observation units may improve cost containment in the outpatient surgical setting.

There is some evidence to suggest that the incidence and complications of ACM may be increasing. However, in the current era of widespread access to health care and broad-spectrum antibiotics, an intratemporal or intracranial complication from acute otitis media may not initially be suspected. The reported case is significant in that the patient was very young, had no underlying disease or immunocompromise, and did not have a known antecedent acute otitis media. With the emergence of resistant streptococcal species and prolonged survival in immunocompromised patients, the relative incidence of complications caused by acute otitis media will probably continue to rise, making it imperative that we raise our index of suspicion for previously rare infectious complications of relatively common diseases.

Objective: To determine if the polymerase chain reaction (PCR) can detect bacterial DNA in pediatric middle ear effusions that are sterile by standard cultural methods., Design: Single-center, blinded, comparative study of diagnostic assays. The PCR-based detection systems for Moraxella catarrhalis, Haemophilus influenzae, and Streptococcus pneumoniae were designed and validated using a battery of DNAs obtained from cultured bacteria. Chronic middle ear effusion specimens were collected and comparatively analyzed by culture and the PCR., Setting: Tertiary care pediatric hospital., Patients: A total of 97 middle ear effusions were collected from pediatric outpatients at Children's Hospital of Pittsburgh (Pa) during myringotomy and tube placement for chronic otitis media with effusion (duration > 3 months). All patients had failed multiple courses of antimicrobial therapy and were diagnosed by a combination of validated otoscopy and tympanograms., Main Outcome Measure: Differences in the percentage of positive test results between PCR-based assays and culture for M catarrhalis, H influenzae, and S pneumoniae., Results: Of the 97 specimens of otitis media with effusion, 28 (28.9%) tested positive by both culture and PCR for M catarrhalis, H influenzae, or S pneumoniae. An additional 47 specimens (48%) were PCR positive/culture negative for these three bacterial species. Thus, 75 (77.3%) of the 97 specimens tested PCR positive for one or more of the three test organisms. The minimum number of bacterial genomic equivalents present in the average culture-negative ear was estimated to be greater than 10(4) based on dilutional experiments., Conclusions: The PCR-based assay systems can detect the presence of bacterial DNA in a significant percentage of culturally sterile middle ear effusions. While this finding is not proof of an active bacterial infectious process, the large number of bacterial genomic equivalents present in the ears is suggestive of an active process.

Preview A crabby infant or a toddler pulling at his or her ears is a fairly common sight in a primary care office, and a 10-day course of antibiotics often does the trick. But what should you do when this doesn't work? And what if symptoms seem to resolve but effusion continues? The authors describe acute and chronic otitis media, explain how to diagnose and treat patients to avoid lifelong problems, and suggest when to call in an otolaryngologist.

Previous studies using the chinchilla animal model demonstrated that the third generation cephalosporin cefixime (Suprax) with split dosing was as effective as ampicillin in sterilizing the middle ear cleft when infected with S. pneumoniae. In this investigator-blinded, randomized trial, a single daily dose of cefixime (8 mg/kg per day) performed as well as split dosing of cefixime (8 mg/kg every 8 h) and ampicillin (150 mg/kg every 8 h) in the time to sterilization of the middle ear cleft. No statistically significant differences were noted between groups in otoscopy or tympanometry. All antibiotic regimens performed better than saline control (P < 0.0001) with regard to time to sterilization of the middle ear cleft. The results of this study support the daily administration of cefixime as an effective agent for the treatment of otitis media due to its extended half-life and broad antibiotic spectrum.

Clinical guideline development is a major emphasis of recent health policy efforts. Interest in clinical guidelines is the result of multiple factors, including economic pressures and the desire to achieve a baseline level of practice in clinical settings. Guidelines have always been of fundamental importance in medicine. This article will discuss the place clinical guidelines have in contemporary practice and the difficulties encountered in the process of developing a meaningful guideline for managing otitis media with effusion.