International Journal of Pediatric Otorhinolaryngology 2024-06-21

Correlation between neural response telemetry measurements and fitting levels

Mihael Ries, Iva Kelava, Jakov Ajduk, Andro Košec, Roko Žaja, Robert Trotić

Publication date 17-06-2024


The neural response telemetry (NRT) is a standard procedure in cochlear implantation mostly used to determine the functionality of implanted device and to check auditory nerve responds to the stimulus. Correlation between NRT measurements and subjective threshold (T) and maximum comfort (C) levels has been reported but results are inconsistent, and it is still not clear which of the NRT measurements could be the most useful in predicting fitting levels. In our study we aimed to investigate which NRT measurement corresponds better to fitting levels. Impedance (IMP), Evoked Action Potential (ECAP) threshold and amplitude growth function (AGF) slope values were included in the study. Also, we tried to identify cochlear area at which the connection between NRT measurements and fitting levels would be the most pronounced. Thirty-one children implanted with Cochlear device were included in this retrospective study. IMP, ECAP thresholds and AGF were obtained intra-operatively and 12 months after surgery at electrodes 5, 11 and 19 as representative for each part of cochlea. Subjective T and C levels were obtained 12 months after the surgery during cochlear fitting. ECAP thresholds obtained 12 months after surgery showed statistically significant correlation to both T and C levels at all 3 selected electrodes. IMP correlated with C levels while AGF showed tendency to correlate with T levels. However, these correlations were not statistically significant for all electrodes. ECAP threshold measurements correlated to T and C values better than AGF slope and IMP. Measurements obtained twelve months after surgery seems to be more predictive of T and C values compared to intra-operative measurements. The best correlation between ECAP threshold and T and C values was found at electrode 11 suggesting NRT measurements at mid-portion cochlear region to be the most useful in predicting fitting levels.

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Clinical significance of T helper-1/T helper-2 cytokines in peripheral blood of children with otitis media with effusion and allergic rhinitis

Lulu Yu, Jing Bi, Bin Xu, Bo Yu, Yong Fu

Publication date 16-06-2024


Otitis media with effusion (OME) is a prevalent and costly disease, especially in children. This article analyzed the expression patterns and clinical significance of T helper-1 (Th1)/Th2 cytokines in the peripheral blood of children with OME and allergic rhinitis (AR). Subjects were assigned to the OME + AR group and the Control group (children with OME), with their clinical baseline data documented. The correlations between Th1/Th2 cytokines and between the total nasal symptom score (TNSS) and Th1/Th2 cytokines were analyzed. The risk factors and the predictive value of Th1/Th2 cytokines for OME + AR were analyzed using logistics multivariate regression analysis and receiver operating characteristic curve. Significant differences were observed in tympanic pressure/speech frequency/air conduction valve/TNSS score/immunoglobulin E (IgE) level between both groups. The OME + AR children exhibited evidently elevated interleukin-2 (IL-2)/tumor necrosis factor-α (TNF-α)/IL-4/IL-10/IL-6 levels and no significant difference in interferon-γ (IFN-γ) level. Th1/Th2 cytokines were remarkably positively-correlated with the TNSS score. IL-2/TNF-α/IL-4/IL-6 were risk factors for OME with AR. The area under the curves (AUCs) of IL-6/IL-2/IL-4/TNF-α levels in predicting the occurrence of OME + AR were 0.805/0.806/0.775/0.781, with sensitivities of 75.76 %/89.39 %/72.21 %/72.73 % and specificities of 74.29 %/61.34 %/72.86 %/70.00 %, and the cut-off values were 239.600/20.300/29.880/34.800 (pg/mL). The AUC of their combination in predicting OME + AR was 0.955 (93.94 % sensitivity, 85.71 % specificity). Th1/Th2 cytokine levels were imbalanced and obviously positively-correlated with the TNSS score in OME + AR children. IL-2, TNF-α, IL-4, and IL-6 levels had auxiliary predictive value in the occurrence of OME + AR.

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Is there an increased risk of otitis media in children with obstructive sleep apnea?

Chloe Cottone, Eunice Im, Sean Clausen, Michele Carr

Publication date 16-06-2024


The purpose of this study was to investigate the prevalence of otitis media and other otolaryngologic disorders in children with Obstructive Sleep Apnea (OSA) compared to those without OSA in a large cohort. A retrospective cohort study was carried within the US Collaborative Network within Tri NetX. The OSA group was defined by ICD-10 code G47.33 and non-OSA group excluded patients with OSA.
Both groups were required to have a CPT code for an outpatient visit to act as a control: 99202-99215. Propensity score matching for age, sex, and race was performed. Prevalence of otitis media (ICD-10H65, H66), chronic otitis media (ICD-10H66.1, H66.2, H66.3, H65.2, H65.3, and H65.4), tympanostomy (CPT 69433, 69436), adenoidectomy (CPT 42830, 42831), tonsillectomy (CPT 42825, 42826), adenotonsillectomy (CPT 42820, 42821), and allergic rhinitis (ICD-10 J30.9) were compared in this cohort. Propensity score matching yielded 165,665 (M = 95949, F = 69901) patients with a mean age of 10.7 (SD = 4.07) for each cohort. Children with OSA were 1.27x and 3.86x more likely to be diagnosed with otitis media and chronic otitis media, respectively (P<.0001). They were 3.81x more likely to undergo a tympanostomy (P<.0001). Children with OSA were 4.1x, 18.2x, and 24.7x more likely undergo an adenoidectomy, tonsillectomy, and adenotonsillectomy, respectively (P<.0001). Children with OSA were also 2.03x as likely to have a diagnosis of allergic rhinitis (P<.0001). Children with OSA experience otitis media and related surgical intervention more than children without OSA. Since allergic rhinitis and adenoid hypertrophy are contributors to both OSA and AOM, their increased prevalence in children with OSA may explain their increased frequency of AOM.

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Exploration of different electrode types inserted in a 3D model of a patient with incomplete partition type III inner ear malformation

Janez Rebol, Igor Drstvenšek, Petra Povalej Bržan, Tomaž Brajlih

Publication date 16-06-2024


Incomplete partition type III (IP III) represents a rare malformation of the inner ear, posing challenges during cochlear implantation due to inevitable cerebrospinal fluid (CSF) leaks and the potential misplacement of electrodes within the internal auditory canal (IAC). Despite the absence of a consensus on electrode selection, literature suggests both straight and perimodiolar electrodes as viable options for proper insertion. Limited implantation series contribute to the ambiguity in electrode choice. In this study, we evaluated the insertion performance of three electrode types in a 3D model simulating an IP III patient's inner ear. A 3D model replicating the inner ear of a patient with IP III undergoing surgery was created, incorporating a canal wall up mastoidectomy and an enlarged round window approach. Insertions were carried out using a straight electrode, a perimodiolar electrode, and a slim perimodiolar electrode, inserted through a sheath in the basal turn of the cochlea. Electrode positions were assessed after each insertion, with each type being tested 20 times. Successful insertion rates were 95 % for the slim perimodiolar electrode, 85 % for the perimodiolar electrode, and 75 % for the slim straight electrode. Notably, the slim perimodiolar electrode required an adapted insertion technique due to the altered cochlear position in IP III cases. Statistical analysis revealed the slim perimodiolar electrode's superiority over the slim straight electrode in achieving successful insertions. The 3D model of the IP III inner ear proved to be an effective tool for electrode testing and insertion training prior to surgery. Following multiple insertions in the 3D model, the slim perimodiolar electrode demonstrated the highest success rate, emphasizing its potential as the preferred choice for cochlear implantation in IP III cases.

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Sustainable improvement in upstream and downstream outcomes for intubated patients three years after an airway-based educational intervention in a low-resource pediatric intensive care unit

Phoebe H. Yager, Aubrey Samost-Williams, Jose A. Bonilla, Luis Guzman, Susana C.A. Hasbun, Angel E.A. Rodríguez, Alejandra Cárdena, Alexia M.L. Núñez, Asitha D.L. Jayawardena, Evelyn J. Zablah, Kevin Mary Callans, Christopher J. Hartnick

Publication date 13-06-2024


To determine whether implementation of an education-based intervention can sustainably improve upstream and downstream outcomes in intubated patients in a pediatric intensive care unit (PICU) in a low-resource country. Quality improvement study comparing airway-related morbidity in two previously studied patient cohorts pre-intervention (Epoch 1) and immediately post-intervention (Epoch 2) with a third cohort thirty-six months post-intervention (Epoch 3). PICU of the largest public children's hospital in El Salvador. 147 patients under 18 years requiring intubation and mechanical ventilation (MV) met inclusion criteria in the long-term follow-up period and were consecutively sampled without exclusion (Epoch 3) (compared to 98 previously studied patients in the short-term follow-up period (Epoch 2)). A low-cost, education-based intervention to close knowledge gaps, improve communication among PICU doctors, nurses, and respiratory therapists, and optimize patient outcomes. The primary outcome measure was change in unplanned extubation (UE) between Epochs 2 and 3. Other outcomes included use of cuffed endotracheal tubes (ETT), rate of elective ETT change and days of MV. The 17 % decrease in UE previously reported for Epoch 2 was sustained in Epoch 3. There was a statistically significant increase in use of cuffed ETT from 35.7 % in Epoch 2-55.1 % in Epoch 3 (p = 0.003, z-score -2.99). There was also a statistically significant mean difference in rate of elective ETT change per 100 MV days from Epoch 2 to Epoch 3 of 1.7 (p = 0.007; 95 % CI 0.15-0.84). There was no change in MV days from Epoch 2 to Epoch 3 (p-value 0.764; 95 % CI -1.48-2.02). Beyond these quantifiable results, many unanticipated practice changes were observed three years after the initial intervention. Sustained improvement in upstream and downstream outcomes (UE, cuffed ETT use, elective ETT change) for intubated patients in a low-resource PICU were observed three years after a low-cost, low-touch, education-based intervention.

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Neuropathological features of pediatric laryngomalacia

Inbal Hazkani, Matthew Schniederjan, Ching Siong Tey, Anthony N. Botros, Kristan P. Alfonso

Publication date 12-06-2024


Laryngomalacia is the most common pediatric laryngeal anomaly. The pathophysiology of laryngomalacia is not well defined; the leading hypothesis suggests weak laryngeal tone and neuromuscular discoordination. Only a few studies explored the histopathology of the laryngeal submucosal nerves, with reported nerve hypertrophy. Our study aims to describe the histopathology of submucosal nerves in specimens obtained from children with severe laryngomalacia compared to pediatric cadaveric controls. Prospective study. Tertiary care children's hospital. Histologic and immunohistochemical sections of supraglottic tissue from 26 children with severe laryngomalacia and six pediatric autopsies were digitally scanned and assessed with image analysis software (Qu Path), resulting in the identification and measurement of 4561 peripheral nerves and over 100,000 foci of neurofilaments. Chronic inflammation was noted in all patients. Eosinophils were rare. The mean nerve area and perimeter were significantly smaller for patients with laryngomalacia compared to the control group (1594.0 ± 593.2 μm^2 vs. 2612.1 ± 2824.0 μm^2, p < 0.0001, and 158.8 ± 30.3 μm vs. 217.6 ± 165.0 μm, p < 0.0001). Nerve-per-area unit was significantly greater for patients with laryngomalacia compared to controls (1.39E-05 vs. 6.19 E-06, p = 0.009). The mean area and the number of neurofilaments per total nerve area were similar. Immunohistochemistry for calretinin, a marker for intestinal ganglion cells in Hirschsprung disease, was absent from all specimens. This series includes a comparison of all identifiable nerve fibers obtained from children with severe laryngomalacia and shows that the mucosal nerves are smaller on average than controls. These findings fail to provide support for significant morphologic peripheral nerve pathology in laryngomalacia.

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Characteristics and management of pediatric medial subperiosteal orbital abscesses

Nathan E. Lu, Lauren A. Gardiner, Jennifer L. McCoy, Joseph E. Dohar, Allison B.J. Tobey

Publication date 10-06-2024


Subperiosteal orbital abscesses (SPOA) are the most common suppurative complications of acute bacterial sinusitis. Medial SPOAs arise from infection of the ipsilateral ethmoid sinus and favor initial conservative management reserving surgical drainage for patients who do not demonstrate clinical improvement. No standard algorithm defining medical versus surgical treatment of medial SPOAs exist in the pediatric population. To identify a size cutoff for medial SPOAs to predict the likelihood for surgical drainage. This is a retrospective review of patients with medial SPOAs at a tertiary care center from 2003 to 2017. Diagnosis of SPOA was based on radiographic findings. Variables included are patient demographics, antibiotic therapy, surgical intervention, and length of stay. 82 patients with a medial SPOA were included with an average age at presentation of 6.27 (range 0-15) years were included in this study. 62 patients were male (75.6 %), and 20 were female (24.4 %). The average abscess length was 16.1 mm, range 4.5-30.7 mm. The average abscess width was 4.17 mm, range 1.5-14.6 mm. The odds ratio for surgical treatment with every 1 mm increase in abscess width was 1.89 (95CI:1.33-2.69, p < 0.001). Abscesses over 3.6 mm width were 6.65 times more likely to undergo surgical drainage than those less than 3.6 mm (OR:6.65, 95CI:2.52-17.54, p < 0.001). The average(SD) length of stay was 5.4(3.0) days for patients who underwent surgery and 4.0(0.9) days for patients treated with conservative measures, p < 0.001. Medial SPOAs greater than 3.6 mm were more likely to undergo surgical drainage; however there was no difference in the likelihood of drainage between anteriorly and posteriorly based medial abscesses. These findings help further characterize the landscape of pediatric subperiosteal abscesses that are managed with surgical drainage.

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Pediatric cerebrospinal fluid rhinorrhea caused by low flow vascular anomaly of the temporal bone: A case series

Victoria W. Huang, Melisa Ruiz-Gutierrez, Erin Spera, Eelam Adil, Dennis S. Poe, Caroline D. Robson, A. Eliot Shearer

Publication date 09-06-2024


Atraumatic cerebrospinal fluid (CSF) rhinorrhea is uncommon in children and necessitates a multi-disciplinary evaluation for an etiology. Underlying osseous abnormality due to extensive or multifocal low flow vascular anomaly should be considered as a potential cause of spontaneous CSF leak. Treatment of multifocal low flow vascular anomalies may include medical and surgical approaches. In this series, we seek to determine the presenting signs and symptoms and medical and surgical treatment options for multifocal or extensive low flow vascular anomalies. A retrospective case series at a quaternary care children's hospital was compiled. All children with CSF rhinorrhea diagnosed and treated for multifocal low flow vascular anomalies at our institution were included. A total of four patients were identified. All four patients had delay in initial diagnosis of underlying cause of meningitis and CSF rhinorrhea. Average age at diagnosis of multifocal low flow vascular anomaly was 7 years. This was on average 4 years after initial presentation for medical attention. Treatment approach was multidisciplinary and included medical management with sirolimus and bisphosphonates as well as surgical approaches to the skull base (lateral and anterior) to prevent CSF egress. Consideration of multifocal low flow vascular anomaly should be included in any pediatric patient presenting with CSF rhinorrhea.

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Exploring the effects of a repair strategies training program among children with auditory processing disorder: A pilot study

Sandra Fortin, Susan Plante, Paméla McMahon-Morin, Stefano Rezzonico, Eve Julie Rioux, Marianne Paquet, Tony Leroux, Benoît Jutras

Publication date 09-06-2024


Children with hearing loss, as well as those with auditory processing disorder (APD), experience more communication difficulties than their normal-hearing peers. Receiving training on communication strategies has been shown to be beneficial for children with hearing loss, but little is known on the effect of such training on children with APD. The main purpose of this pilot study was to assess the effects of a repair strategies training program among children with APD. Ten school-aged children with APD participated in a ten 60-min weekly repair strategies training program (experimental group) and ten did not receive any training (control group). In pre- and post-intervention, children were filmed while taking part in short scripted conversation situations in which communication breakdowns were introduced. Additionally, questionnaires on communication difficulties and repair skills, on life habits related to communication and education as well as on emotional well-being were filled by the children and their parents. In post-compared to in pre-intervention, children in the experimental group used significantly more of the repair strategies taught right after a communication breakdown occurred, used a greater variety of repair strategies, and overcame more communication breakdowns. The number of strategies needed to overcome a breakdown was not significantly different after the training compared to before. The level of difficulty to accomplish education-related life habits was generally lower, although not significantly, after entering the program than before. The individualized data showed that the studied training was more suited for children aged 9 years and older. The results of the children in the control group were not significantly different between the two measured times on all outcomes. Learning how to recognize and overcome communication breakdowns through a training program was beneficial for children with APD. The program enabled them to use a wider variety of repair strategies and to be more proactive in situations where communication is difficult. Studies are needed to further examine these findings in a larger sample of children with APD and in real-life settings.

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Temporal trends in BAHA softband wear time among pediatric patients

Samantha B. Fabian, Erin W. Adkins, Brian N. White, Daniel J. Kirse, Eleanor P. Kiell

Publication date 09-06-2024


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Socioeconomic determinants of moderate and severe obstructive sleep apnea in children: A pre and post COVID analysis

Erin Mulry, Nancy Grover

Publication date 09-06-2024


COVID-19 has disproportionately affected healthcare access of certain minority groups, and thus could contribute to delay in timely evaluation and management of pediatric obstructive sleep apnea (OSA). Socioeconomic status (SES) is known to affect healthcare access in pediatric otolaryngology and may also be a risk factor for OSA and its associated co-morbidities. Our primary objective is to determine the impact of COVID-19 on time to diagnosis (TTD) and time to treatment (TTT) of polysomnography (PSG)-proven moderate to severe pediatric OSA in different socioeconomic classes. Secondary objectives include determining the impact of racial and demographic factors on TTD and TTT. This is a retrospective chart review of 120 children; 60 children pre-COVID (February 2018 to February 2020), and 60 children post-COVID onset (March 2020 to March 2022). This study was performed at a pediatric teaching hospital and tertiary referral center, and involved children aged 3-17 years old with outpatient PSG-proven moderate to severe OSA. Approval was obtained from our hospital's institutional review board (IRB). There were a total of 120 children, 60 in each group. The average age was 9.5 years old; females constituted 41.6 % of the sample. TTD increased from 53.7 days pre-covid to 103 days post-COVID onset in all children (p = 0.00), 42.5 days-151.9 days in white children (p = 0.00), 38 days-142.7 days in children with high SES (p = 0.00), 32.1 days-146.5 days in children with private insurance (p = 0.00), and 65.7 days-105.8 days in children with public insurance (p = 0.04). TTT did not change significantly. Our results show that TTD of OSA and obesity in advantaged groups were affected to a greater degree than disadvantaged groups. This suggests children of all socioeconomic groups are susceptible to healthcare disparities and the COVID-19 pandemic has uncovered the vulnerability of such populations. Policymakers should consider providing more funding and support for all children, including continued funding for those with lower SES.

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Slide tracheoplasty for congenital tracheal stenosis: A systematic review

Alix Maltezeanu, Bshair Aldriweesh, Ching Yee Chan, Pierre Fayoux, Pierre-Luc Bernier, Sabrina Daniela da Silva, Sam J. Daniel

Publication date 17-06-2024


Slide tracheoplasty has become the gold standard surgery for congenital tracheal stenosis (CTS). This condition is rare and the surgery can be challenging and is performed by experienced surgeons in tertiary centers. A few reports involving relatively small cohorts have been published. The aim of this review is to evaluate the post-operative mortality and morbidity of pediatric slide tracheoplasty for CTS. A systematic literature review was performed according to PRISMA guidelines. The Medline and EMBASE databases were screened using a search strategy defined in collaboration with a librarian. We included articles reporting the post-operative mortality rate of slide tracheoplasties for treatment of CTS in children, when at least 10 patients were included. A total of 932 articles were reviewed, and 15 studies were eligible with a total of 845 patients. The overall post-operative mortality rate was 9.3 %, and most deaths were airway related. The open revision surgery rate after surgery was 2.8 % and the endoscopic revision rate was 27.6 %. This study highlights key factors to consider before the surgery and helps anticipate post-operative follow-up considerations for children with CTS. Several factors were identified as predictors of mortality including young age, weight at the time of surgery and association with lung hypoplasia or aplasia. Although slide tracheoplasty has gained popularity in recent years due to better outcomes, it remains a major surgery with mortality risk and the need for multidisciplinary management.

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Endoscopic posterior cricoid split with costal cartilage graft placement in patients under one year of age

Jeffrey C. Mecham, Dana N. Eitan, Austin DeHart, Mark E. Gerber, Patrick Scheffler

Publication date 23-05-2024


Endoscopic posterior cricoid split and costal rib graft placement (EPCSCG) is an important tool in enlarging the glottic and subglottic airway, both of which can be disproportionally affected in the small airways of neonates and early infants. We present a series of 8 patients under the age of one who successfully underwent EPCSCG, with 7/8 patients avoiding tracheostomy entirely. Of these patients, the indication for EPCSCG was isolated bilateral vocal fold immobility (6/8), bilateral vocal fold immobility with subglottic stenosis (1/8), and isolated subglottic stenosis (1/8). EPCSCG can be safely applied to select patients less than one year of age.

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The impact of adenotonsillectomy on healthcare utilization in children with obstructive sleep apnea: Experience of an integrated medical model

Elias S. Saba, Deanna Fink, Luke Schloegel, Mustafa Bseikri

Publication date 06-06-2024


Studies suggest that children with obstructive sleep apnea (OSA) have increased healthcare utilization patterns in comparison to matched controls. However, the effect of adenotonsillectomy (AT) on utilization patterns in these children is poorly understood. Additionally, no previous studies have compared the effect of AT on healthcare utilization patterns across different OSA severity groups. The aim of this retrospective cohort study is to assess the effects of surgical treatment on the level of healthcare utilization among children with OSA at a large integrated multicenter healthcare system. Retrospective analysis was performed of children aged 3-12 diagnosed with OSA via an attended polysomnogram (PSG) between December 2016 and February 2019. Demographic variables including age (at time of PSG), body mass index (BMI), race, and ethnicity were obtained. Variables for healthcare utilization were assessed for 12 months prior to PSG, and for 12 months after PSG (or after AT, delayed for the first 30 days after surgery to account for surgery-related visits). Healthcare utilization variables assessed included the total number of outpatient visits, inpatient, and emergency department (ED) visits, visits involving diagnostic codes associated with upper respiratory infection (URI), otitis media (OM), and allergic rhinitis (AR), prescription data involving intranasal steroids or leukotriene receptor antagonists (LTRA), and communication data such as secure message load and specialty referrals. Repeated measure linear difference-in-difference (D-I-D) models were used to assess the causal impact of AT on healthcare utilization outcomes. Sensitivity analyses were performed using modeling with a Poisson distribution and as an unadjusted model, with statistical significance set to p < 0.05. Analysis elicited 577 children identified with OSA. Of these, 336 (58.2 %) underwent observation while 241 (41.8 %) underwent AT. The mean age was 6.4 years, with a slight male predominance (60.5 %). Analysis of baseline healthcare utilization patterns revealed that the treatment group had a significantly higher number of baseline inpatient/ED visits and OM visits in comparison to the observation group, but no differences in regards to baseline outpatient visits, or in visits involving URI or AR. Analysis of the entire OSA cohort via D-I-D modelling showed a significantly larger reduction in outpatient visits, secure messages, specialty referrals, and the use of intranasal steroid and LTRA in the treatment group compared to the observation group. Stratification of children based on OSA severity showed that the significant differences in healthcare utilization attributed to surgical treatment were primarily driven by the severe OSA group. Children with severe OSA who underwent AT showed significant reductions in most variables including outpatient visits, inpatient/ED visits, and OM visits. Alternatively, the only significant reductions in healthcare utilization among children with mild OSA treated with AT were in AR visits, intranasal steroid use, and LTRA use. Pattern changes among children with moderate OSA compared similarly to those with mild OSA. To the authors' knowledge this study represents the largest available study assessing the impact of AT on healthcare utilization in children with OSA that also considers the effect of OSA severity on utilization patterns. AT appears to decrease healthcare utilization patterns, particularly in children with severe OSA. Alternatively, children with mild or moderate OSA treated with AT had only modest reductions in healthcare utilization patterns.

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Evaluating the accuracy and readability of ChatGPT in providing parental guidance for adenoidectomy, tonsillectomy, and ventilation tube insertion surgery

Emre Polat, Yagmur Basak Polat, Erol Senturk, Remzi Dogan, Alper Yenigun, Selahattin Tugrul, Sabri Baki Eren, Fadlullah Aksoy, Orhan Ozturan

Publication date 03-06-2024


This study examined the potential of ChatGPT as an accurate and readable source of information for parents seeking guidance on adenoidectomy, tonsillectomy, and ventilation tube insertion surgeries (ATVtis). ChatGPT was tasked with identifying the top 15 most frequently asked questions by parents on internet search engines for each of the three specific surgical procedures. We removed repeated questions from the initial set of 45. Subsequently, we asked ChatGPT to generate answers to the remaining 33 questions. Seven highly experienced otolaryngologists individually assessed the accuracy of the responses using a four-level grading scale, from completely incorrect to comprehensive. The readability of responses was determined using the Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) scores.
The questions were categorized into four groups: Diagnosis and Preparation Process, Surgical Information, Risks and Complications, and Postoperative Process. Responses were then compared based on accuracy grade, FRE, and FKGL scores. Seven evaluators each assessed 33 AI-generated responses, providing a total of 231 evaluations. Among the evaluated responses, 167 (72.3 %) were classified as 'comprehensive.' Sixty-two responses (26.8 %) were categorized as 'correct but inadequate,' and two responses (0.9 %) were assessed as 'some correct, some incorrect.' None of the responses were adjudged 'completely incorrect' by any assessors. The average FRE and FGKL scores were 57.15(±10.73) and 9.95(±1.91), respectively. Upon analyzing the responses from ChatGPT, 3 (9.1 %) were at or below the sixth-grade reading level recommended by the American Medical Association (AMA). No significant differences were found between the groups regarding readability and accuracy scores (p > 0.05). ChatGPT can provide accurate answers to questions on various topics related to ATVtis. However, ChatGPT's answers may be too complex for some readers, as they are generally written at a high school level. This is above the sixth-grade reading level recommended for patient information by the AMA. According to our study, more than three-quarters of the AI-generated responses were at or above the 10th-grade reading level, raising concerns about the ChatGPT text's readability.

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Degrees of Inflammation in the Treatment of Subglottic Stenosis in a Rabbit Model: Histopathological Assessment of a Novel Bioabsorbable Ultra-high Ductility Magnesium Alloy Stent

E. Berryhill McCarty, Dylan Bertoni, Terral Patel, Couger Jaramillo, Allison B.J. Tobey, Prashant N. Kumta, David Chi, Leila J. Mady

Publication date 02-06-2024


Utilizing a novel histopathological scoring system and subglottic stenosis (SGS) rabbit model, we aimed to compare degrees of inflammation and severity of narrowing in the subglottis between two minimally invasive therapeutic modalities: endoscopic balloon dilation (EBD) alone versus EBD with placement of a bioabsorbable ultra-high ductility magnesium (UHD-Mg) alloy stent. SGS was induced endoscopically via microsuspension laryngoscopy in 23 New Zealand white rabbits. The control group (n = 11) underwent EBD alone, the study arm (n = 12) underwent EBD with implantation of bioabsorbable UHD-Mg alloy stents. Rabbits were euthanized at 2-, 3-, and 6-weeks after SGS induction, coinciding with wound healing stages. Using Optical Coherence Tomography (OCT), cross-sectional areas of airways were compared to calculate the mean percentage of intraluminal area at sequential time points. A novel histopathological scoring system was used to analyze frozen sections of laryngotracheal complexes. The degree of inflammation was quantified by scoring changes in inflammatory cell infiltration, epithelial ulceration/metaplasia, subepithelial edema/fibrosis, and capillary number/dilation. Univariate analysis was utilized to analyze these markers. We found rabbits implanted with the bioabsorbable UHD-Mg alloy stent had statistically significantly higher scores in categories of hyperplastic change (stents vs controls: 1.48 vs 0.46 p < 0.001), squamous metaplasia (22 vs 5 p < 0.001), and neutrophils/fibrin in lumen (31 vs 8, p < 0.001). Rabbits who received EBD alone had higher scores of subepithelial edema and fibrosis (2.70 vs 3.49, p < 0.0256). The stented rabbits demonstrated significantly increased mean percent stenosis by intraluminal mean area compared to controls at 2 weeks (88.56 vs 58.98, p = 0.032), however at all other time points there was no significant difference between intraluminal subglottic stenosis by mean percent stenosis area. Rabbits with SGS treated with UHD-Mg alloy stents demonstrated histopathologic findings suggestive of lower levels of tracheal fibrosis. This could indicate a reduced tendency towards the development of stenosis when compared to EBD alone. There was not a difference in luminal size between stent and non-stented rabbits at the six-week end point. Histologically, however, overall the use of bioabsorbable UHD-Mg alloy stenting elicited a greater tissue response at the level of the superficial mucosa rather than fibrosis of the lamina propria seen in the stented rabbits. This suggests more favorable healing and less of a tendency towards fibrosis and stenosis even though there may not be a benefit from a luminal size standpoint during this early healing period. Compared to known complications of currently available non-bioabsorbable metal or silicone-based stents, this proof-of-concept investigation highlights the potential use of a novel biodegradable UHD-Mg stent as a therapeutic modality for pediatric SGS.

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Utilizing child-centered nursing care approaches for pediatric ENT patients undergoing nasal endoscopy

Ting-ting Zhang, Xiu-feng Liu, Su-qing Chen, Yue Wang

Publication date 31-05-2024


To investigate whether the child-centered treatment significantly increased satisfaction as revealed by CBCL scores and decreased duration of nasal endoscopy. A total of 206 pediatric patients were selected as study participants. Using a random number table, the participants were divided into the control group and the treatment group, with 103 cases in each group. The control group received routine nursing care, whereas the treatment group received child-centered health education nursing intervention.
The differences between the two groups were observed in four aspects: examination compliance, child behavior checklist (CBCL) scores, the satisfaction level of the patient's family with the nurses in the endoscopy room, and the average duration of the nasal endoscopy. Subsequent to the implementation of the intervention, it was observed that within the treatment group, the level of compliance among pediatric patients undergoing nasal endoscopy exhibited a statistically significant increase when compared to the control group; the CBCL scores of both groups were lower than those before nursing care, and those of the treatment group were statistically significantly lower than those of the control group; the satisfaction rate of the patient's family in two groups was 74 % and 90 %, respectively. The average duration of nasal endoscopy was statistically significantly lower in the treatment group than that in the control group. The implementation of a child-centered health education nursing intervention for pediatric patients undergoing nasal endoscopy has been shown to effectively mitigate instances of crying and screaming, enhance patient compliance, reduce examination duration, and elevate the overall satisfaction levels among their respective families.

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Development and validation of the caregiver Burden from infant home NGT care instrument

Cheryl Hersh, Mollie Warren, Nora Horick, Jessica Sorbo, Kevin Callans, Shannon Fracchia, Marcela Radano, Christopher Hartnick

Publication date 29-05-2024


To design and validate an age and condition-specific health status instrument to best reflect the parental experience caring for these children with complex needs and home Nasogastric Tube (NGT) placement. Combined Qualitative and Quantitative design, testing and implementation for item production and reduction, followed by formal validation by evaluating validity, reliability, and establishing a clinically meaningful change score. Tertiary care, multi-disciplinary aerodigestive center. All caregivers whose infant met criteria for eligibility for discharge home from the NICU or Special Care Nursery (SCN) with NGT in place were offered inclusion in this group. Intervention/Exposure: Structured qualitative interviews of these caregivers to explore and define these concepts and domains, to item generate and then reduce, and then psychometric analyses. Structured, moderated qualitative interviews with parents/caregivers of children who have undergone home NGT care of their children for item creation, design, and then reduction. Reliability was assessed by Cronbach alpha analysis. Construct validity and clinically meaningful change score was assessed using various query methods. Cronbach's alpha to assess reliability, a priori hypotheses validity analyses, and minimally important clinical difference calculation. Scaled scores of this condition specific instrument ranged from 14 to 74 where higher scores indicate better QOL related to managing the NGT. Cronbach's alpha with all 14 items was 0.93. Validity was assessed by a self-assessment question to discriminate between change (95% CI: 8.5-14.1; p < 0.0001) as well as by other comparators to identify the instrument's ability to discriminate among populations where parents felt a difference in experience. The minimally important difference was calculated at 18 points. This represents the initial validation of the first condition and age-specific health status instrument to assess parent experience of caring for infants requiring a home NGT for dysphagia.

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Recurrence of sleep apnea in children after intracapsular coblation tonsillectomy: A comprehensive exploration of tonsil regrowth

Georgina Ahmarani, Patrick El Khoury, Maroun Aoun, Maria Clara Ahmarani, Simon Rassi

Publication date 29-05-2024


Sleep apnea is a prevalent issue in children, associated with significant morbidities such as cardiovascular and neurocognitive disorders. There is increasing interest in intra-capsular tonsillectomy by coblation (ICTC) as a method to address obstructive sleep apnea (OSA) in children. However, the literature remains controversial regarding the most effective intra-capsular tonsillectomy (ICT) technique with the least morbidity. Our current research extends a previous study that established the effectiveness and safety of ICTC, demonstrating rapid post-surgical recovery with minimal analgesic needs. This new investigation specifically focuses on long-term follow-up. Our aim is to assess tonsil regrowth and the risk of recurrence of OSA symptoms at a mean follow-up of 6.1 years post-surgery. By presenting the results of this extended study, our goal is to gain a better understanding of the long-term effectiveness of this surgical intervention in treating OSA in children. Thus, considering the initial benefits, we will also explore potential long-term implications. This research follows up on children from our previous study who underwent ICTC, with or without adenoidectomy, for OSA resulting from tonsillar hypertrophy at a tertiary-level university hospital between March 2016 and March 2018. They were followed up for an average of 6.1 years postoperatively. Symptom recurrence is assessed by comparing preoperative OSA-18 questionnaire results with those obtained at the 6.1-year mark. Tonsil regrowth is evaluated by comparing preoperative Brodsky scores with those obtained at 6.1 years. The mean total score of OSA-18 significantly decreased from 79.41 (SD = 14.95) before ICTC to 25.47 (SD = 8.92) at 6.1 years postoperatively (p < 0.001, mean difference = 53.94, 95 % CI [50.32, 57.56]). Similarly, the mean Brodsky score dropped from 2.95 (SD = 0.51) before ICTC to 1.04 (SD = 0.24) 6.1 years postoperatively (p < 0.001, mean difference = 1.92, 95 % CI [1.80, 2.04]). The overall regrowth rate was 2.35 % (n = 2), with a revision surgery rate of 1.18 % (n = 1). ICTC exhibits minimal risk of tonsil regrowth and maintains long-term efficacy in preventing the recurrence of OSA symptoms. Therefore, it justifies broader utilization in addressing OSA symptoms arising from tonsillar hypertrophy in children.

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“A lonely time for deaf and hard of hearing kids”: A qualitative study of the impact of pandemic precautions on classroom communication for adolescents with hearing loss

Lindsay Booth, Julie Pauwels, Neil K. Chadha, Mark Felton

Publication date 29-05-2024


Pandemic public health measures, such as masks and social distancing, present unique challenges for people who are hard-of-hearing. This study sought to understand how adolescents with varying levels of hearing loss would describe their experiences communicating in a classroom environment during a pandemic and its associated public health measures. Qualitative study utilizing one-on-one semi-structured interviews conducted from July 2021 to April 2022. Interviews were transcribed and analyzed using a reflexive thematic analysis to conceptualize the main themes from the data. Adolescents ages 12-17 who attended school in person during the COVID-19 pandemic with either normal hearing or; bilateral cochlear implants or; bone-anchored hearing aids or; unilateral moderate to severe (40-70 dB) conductive hearing loss secondary to mastoidectomy, were interviewed. Participants were recruited from BC Children's Hospital Otolaryngology clinic via a convenience sample. Fourteen adolescents were interviewed with a median age of 15, 9 with hearing loss and 5 with normal hearing. Pandemic associated challenges such as masks muffling speech, protocol fatigue, and missing pre-pandemic life were present in both the hearing loss and normal hearing groups. Classroom communication for adolescents with hearing loss was disproportionately affected by pandemic measures, leading to challenges making friends, feeling behind their peers in learning, and listening fatigue. Resilience was noted among adolescents with hearing loss in their ability to adapt to pandemic measures and changing classroom dynamics. For adolescents with unilateral hearing loss, the pandemic provided an improved listening environment via a reduction in background noise. Pre-existing classroom communication challenges for adolescents with hearing loss were amplified under pandemic public health measures and shared, in part, by those with normal hearing. These findings can be used to further inform classroom design to the optimize learning environment for deaf and hard of hearing students.

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Cochlear implantation in pediatrics: Impact of newborn hearing screening on intervention time

Noura Alothman, Yassin Abdelsamad, Fida Almuhawas, Hussain Allami, Abdulrahman Hagr

Publication date 27-05-2024


The newborn hearing screening (NHS) program was globally established for early hearing loss (HL) identification and intervention. Early intervention is essential to minimize or prevent the negative consequences of HL. In Saudi Arabia, the NHS was officially implemented in 2016. Currently, its impact on the timing of cochlear implantations (CIs) in Saudi Arabia remains unclear, and information on potential hospital-related delays affecting early implantation is lacking. Thus, this study aimed to evaluate the effect of implementing the NHS on age at CI in children with prelingual deafness in a CI center in Saudi Arabia, and to evaluate the hospital timing in the CI process. All pediatric CI users who presented for the first time to the CI committee (CIC) at a tertiary center and received their implants between 2015 and 2022 were enrolled in this study. Date of birth (DOB), date of presentation to the CI committee (DOCIC), and date of CI surgery (DOCIS) were retrospectively reviewed. In total, 304 CI children were included in the analysis. Approximately 55 % of the children (n = 167) were screened for HL through the NHS, whereas 45 % of the children (n = 137) were born before the launch of the NHS. Both age at the presentation to the CIC (i.e. difference between DOCIC and DOB) and age at implantation (i.e. difference between DOCIS and DOB) were significantly earlier in children who were screened for HL through the NHS than those who were not screened (P < 0.0001). The time difference between the DOCIC and DOCIS was not significantly different between the screened and unscreened children (P > 0.05). The implementation of the NHS in the tertiary center has a significant positive effect on age at presentation to the CIC and age at implantation, but not on the actual CI surgery. Further research is needed to reduce the hospital delays before the actual surgery in order to increase the likelihood of children receiving implantation early in their life.

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Association of autoimmune and autoinflammatory disorders with chronic rhinosinusitis in children

Sairisheel Gabbireddy, Sameer Shetty, Dominic Coutinho, Hassan Ramadan, Chadi Makary

Publication date 26-05-2024


Increasing evidence suggests that autoimmune disorders and their immunomodulating medications may increase the risk of rhinosinusitis. The goal of this study is to determine if autoimmune and autoinflammatory diseases are associated with increased risk of chronic rhinosinusitis (CRS) in children. A retrospective case-control study of pediatric patients (age 2-18 years) seen in the West Virginia University Hospitals System in the past 10 years was performed. Cases were children with autoimmune or autoinflammatory diseases. Controls were children without any autoimmune or autoinflammatory disorders. Query of our electronic medical record (Epic) was performed using ICD-10 codes. Univariate (unadjusted) and multivariate (adjusted) logistic regression were used to calculate the strength of association of autoimmune or autoinflammatory disorders with CRS and the other airway disorders while adjusting for age, sex, and race. 420582 pediatric patients were queried with mean age of 10.8 years (SD of 4.8, range of 2-18 years), and 47.9% being female. 1956 (0.5%) had autoimmune disorders and 293 (0.07%) had autoinflammatory disorders. Both autoimmune and autoinflammatory disorders increase the odds of having CRS in the unadjusted [OR = 3.36, p < 0.001 and 5.69, p < 0.001 for the respectively] and the adjusted [OR = 2.90, p < 0.001 and OR = 5.07, p < 0.001 respectively after adjusting for age, sex, and race] models. Autoimmune and autoinflammatory disorders increase the risk of CRS and chronic rhinitis in children.

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Clinical efficacy of Dermatophagoides farina drops on allergic rhinitis in children sensitized by dust mites combined with different allergens

Lifen Chen, Yang Liu, Yuanshi Jiang, Yufei Jiang

Publication date 26-05-2024


This study aimed to investigate the clinical efficacy and safety of sublingual immunotherapy (SLIT) using standardized dermatophagoides farina drops for the treatment of allergic rhinitis (AR) in children sensitized to dust mites combined with different allergens. The findings contribute to establishing a preliminary foundation for future in-depth studies on AR treatment.
A total of 152 AR children undergoing SLIT were categorized into two groups based on serological test results: the inhalation group (dust mite combined with inhalation allergy) and the ingestion group (dust mite combined with ingestion allergy). The clinical efficacy and safety were evaluated by assessing the total nasal symptoms score (TNSS), total medication scores (TMS), visual analog scale scores (VAS scores), and the incidence of adverse reactions before treatment and after two years of treatment. After two years of treatment, TNSS, TMS, and VAS scores significantly improved compared to pre-treatment values in both the inhalation and ingestion groups (p < 0.05). However, there were no significant differences in efficacy between the two groups after two years of treatment (p > 0.05). During the treatment period, only 15 cases (10.9 %, 9 cases in the inhalation group and 6 cases in the ingestion group) experienced mild adverse reactions. There was no significant difference in the incidence of adverse reactions between the two groups (p > 0.05). SLIT using standardized dermatophagoides farina drops demonstrates long-term efficacy in children with AR, regardless of whether they belong to the inhalation or ingestion group, without significant differences in treatment outcomes.

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Cholesteatoma in the pediatric aerodigestive population

Connie C. Ma, John J. Ceremsak, Christopher T. Wootten

Publication date 24-05-2024


To report the prevalence of cholesteatoma and related comorbidities in pediatric aerodigestive patients requiring tracheostomy or airway reconstruction procedures. To use study findings to inform clinical management of these complex patients. A repository of clinical data drawn from our institution's electronic medical records was queried to identify airway reconstruction (airway) and complex hospital control (control) patient cohorts. Retrospective chart review was then performed to investigate the occurrence of cholesteatoma and related pathologies in these patients, as well as clinical management. The prevalence of cholesteatoma in airway and control patients was 6/374 (1.60 %) and 35/30,565 (0.11 %), respectively. The relative risk of cholesteatoma diagnosis in airway patients was 14.01 (95 % CI 6.06-32.14). Airway patients were more likely than control patients to have pressure equalization tube history (relative risk 3.25, 95 % CI 2.73-3.82). Age at cholesteatoma diagnosis and first surgical intervention was younger in airway compared to control patients (5.43 vs. 8.33, p = 0.0182, and 6.07 vs. 8.82, p = 0.0236). However, time from diagnosis to intervention and extent of surgery were similar between the groups. This is the first study to investigate the prevalence of cholesteatoma in the pediatric aerodigestive population. The relative risk of cholesteatoma diagnosis was found to be 14 times higher in patients with tracheostomy or airway reconstruction history. Underlying eustachian tube and palatal dysfunction are likely contributing factors to the elevated risk. Additionally, cholesteatoma in this population was diagnosed and required surgical intervention at a younger age, which may suggest a more aggressive disease course. Providers should maintain a high degree of suspicion for cholesteatoma in this complex population.

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White noise use among children undergoing sound field audiometry: A preliminary study

Alison C. Ma, Mattie Rosi-Schumacher, Alexandra F. Corbin, Helana Geisen, Michele M. Carr

Publication date 23-05-2024


To describe the prevalence of routine white noise exposure in children who undergo sound field audiometry. A retrospective cohort study was conducted at a pediatric otolaryngology clinic affiliated with an academic tertiary care hospital. The medical records of children who underwent sound field audiometry were reviewed and data was collected regarding demographics and audiogram results. The group was divided into two cohorts based on routine exposure to white noise. Children exposed to white noise were tested with warble tones, while those not exposed were tested with narrow-band noise. 127 patients underwent sound field audiometry testing, of which 96 (75.6%) were reported by their parents to use white noise for sleep. The mean age at time of testing was 1.6 years (95% Confidence Interval [CI] 1.5-1.7). 104 (81.9%) children were able to respond to at least four of the sound field thresholds, and there was no significant difference between the children exposed to white noise and those who were not (P = 0.459). Mean pure tone average (PTA) was 26.2 dB (95% CI 25.2-27.2) and mean speech reception threshold (SRT) was 19.2 dB (95% CI 18.2-20.2). The sound field response rate, PTA, and SRT were similar between these two groups. The routine use of white noise therapy was extremely common in this pediatric population. The use of warble tones as the audiometric stimuli for children exposed to white noise resulted in similar testing success compared to the use of narrow-band noise in children not exposed to white noise.

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Socioeconomic and racial disparities in revisits, indication, and readmission or reoperation in pediatric tonsillectomy

Sophie E. Yu, Robert S. Semco, Gillian R. Diercks, Regan W. Bergmark

Publication date 20-05-2024


Pediatric tonsillectomy is a frequent otolaryngologic procedure. This study aimed to characterize disparities in post-tonsillectomy revisits, including emergency department evaluation, readmission, or reoperation as well as indication for revisit. Cases of inpatient and ambulatory pediatric tonsillectomy in New York and Florida in 2016 constituted the analytic sample. Patients were extracted from the State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID) and linked to the SID and State Emergency Department Database (SEDD) and SASD.
Outcomes include 3 types of revisits within 30 days: ED visits, hospital readmissions, and reoperation. Indication for revisit was also analyzed. Multivariable analysis determined the association of each outcome with gender, age, race/ethnicity, primary payer, urbanicity, and zip code median household income quartile. The Holm Bonferroni test was used to correct for multiple hypothesis testing. 15,264 pediatric tonsillectomies were included. The revisit rate was 6.77% (N = 1,034, 49.1% female; 6 years median age [interquartile range: 5]). The 30-day ED revisit rate was 4.85%, readmission rate was 1.27%, and reoperation rate was 0.65%. On multivariate analysis, Latinx patients (OR = 3.042, 95% CI = 1.393-6.803) and those who identify as other race/ethnicity (OR = 6.116, 95% CI = 1.989-19.245) have greater odds of requiring inpatient care for indications including pain, dehydration, nausea, and vomiting compared to white patients. No significant differences in tier of care for the management of post-tonsillectomy hemorrhage were identified. Disparities in pediatric post-tonsillectomy ED presentation, readmission and reoperation demonstrate opportunities to improve patient safety and equity.

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Risk factors and the severity of defect in patients with cleft lip and palate

Dominika Matyskova, Jitka Vokurkova, Tomas Jimramovsky, Marek Joukal, Lumir Trencansky, Eva Sloukova, Vaclav Baslik, Michaela Richtrova, Olga Koskova

Publication date 19-05-2024


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The A2ml1-Knockout mouse as an animal model for non-syndromic otitis media

Christina L. Elling, Helen Z. Gomez, Nam K. Lee, Scott D. Hirsch, Regie Lyn P. Santos-Cortez

Publication date 18-05-2024


Inflammation and infection of the middle ear, known as otitis media (OM), is a leading cause of hearing loss and the most frequently diagnosed disease in children worldwide. Traditionally, mouse models for OM rely on inducing acute infection through inoculation of the middle ear, e.g. with the human otopathogen non-typeable Haemophilus influenzae (NTHi), and with very few genetic models with spontaneous or chronic OM. A2ML1 variants, including loss-of-function variants, were associated with susceptibility to OM in humans, but no animal model has been reported for A2ml1-related OM. Here, we report our middle ear findings in a mouse line with a CRISPR-induced knockout (KO) of A2ml1. Mice were X-rayed prior to harvest to determine if there are craniofacial or skeletal abnormalities. Tissue from mouse middle ears, as well as other upper respiratory mucosal tissues, were harvested. The harvested middle ear bullae were examined under microscope and submitted for histologic preparation to study phenotypic indications of OM. RNA samples isolated from middle ear tissue were assayed for expression of genes correlated with A2ML1 expression in humans. Data from a total of 119 mice (35 wildtype, 40 heterozygous, 44 homozygous) are presented here, with each analyses being performed on subsets of these mice. There were no significant craniofacial differences by genotype (n = 22). Findings in mice with the A2ml1-KO indicated an increased incidence of OM (n=29; odds ratio = 11; CI: 1.1, 573.6; Fisher exact two-sided p = 0.02) with tympanic membrane perforations or thickening, as well as cases of middle ear effusion, inflammatory cells, or fluid from histologic sections. Dsp was upregulated in the middle ear tissues of homozygous mice (Wilcoxon test p = 0.001). Thus far, our results in this A2ml1-KO mouse line indicate spontaneous occurrence of OM and dysregulation of Dsp in the middle ear as a potential disease mechanism for A2ml1-related OM.

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Intranasal dexmedetomidine for sedation in ABR testing in children: No pain, big gain!

Ana Giordano, Brigitte Lehner, Anca Voicu, Dominique Donzeau, Aline Joulie, Luc Froissant, Eric Fontas, Sonanda Bailleux

Publication date 16-05-2024


Obtaining perfect immobility or sleep in children undergoing ABR auditory brainstem response) testing can be challenging. We examined the effectiveness and safety of intranasal dexmedetomidine for sedation of children undergoing ABR testing. We included prospectively all patients aged from 1 to 15 years for whom sedation for ABR testing was required, between July 2018 and November 2021. We administered an initial dose of 2.5 μg/kg intranasal dexmedetomidine with a repeat dose of 1 μg/kg if needed 30 min later. Collected data included success rate of sedation, sedation onset and recovery times and incidence of side effects. ABR testing was undertaken successfully in 57 of the 59 patients, giving a total success rate of 96,6 %. (95 % confidence interval 88.5 %-99.1 %). The median time to onset of sleep was 32 ± 18.3 min. The median duration of sedation recovery time was 48 ± 24.7 min. We recorded the adverse effects. Thirty-one patients experienced bradycardia and 28 patients experienced hypotension, all of which resolved without intervention. Intranasal dexmedetomidine is an effective, safe, simple of use and noninvasive method for sedation in children. It could have a major role in auditory brainstem response testing, specially in the case of non-cooperative children. NCT03530371.

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"‘It is difficult for us to assess the severity!’ A qualitative analysis of parents expectations to postoperative care after ventilation tube surgery"

Ann Helen Nilsen, Anne-Sofie Helvik, Wenche Moe Thorstensen, Bjarne Austad

Publication date 15-05-2024


Surgery with ventilation tubes (VT) in children suffering from otitis media with effusion is quite common. However, the knowledge surrounding parents' expectations to the treatment and postoperative care is sparse. The aim of this study was to describe the parents' expectations to VT surgery and postoperative care shortly after surgery. A qualitative study was conducted based on semi-structured individual interviews with parents recruited from a study where postoperative care was randomized to either an otolaryngologist or the patient's general practitioner (GP). The interviews were conducted within the first weeks after surgery and analyzed by reflexive thematic analysis. In total, 13 parents aged 29-42 years participated in the study. We identified three main themes elucidating parents' expectations to VT surgery and postoperative care: 1) Preconceptions about VT surgery and hearing - most parents expected surgery to restore the child's normal hearing, and some were uncertain about their knowledge of normal hearing and VT treatment; 2) A safety net to ensure hearing and function - it was reassuring if the child received structured postoperative care that secured and notified appointments and had quick access to a specialist if needed; 3) High-quality care - most parents expected the otolaryngologist to provide the highest level of quality of care due to their specialist competence, special equipment and sufficient understanding of the problem to communicate well with parents. Postoperative care by the GP was perceived as incomplete among most parents due to a lack of both specialist competence and access to audiometry. Parents expect postoperative care to safeguard their child as long as needed after VT surgery, and they expect access to high-quality care. Low health literacy among some parents challenges the current method of postoperative care and requires that more emphasis be set on both informing and educating parents regarding hearing and VT treatment.

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Impact of national health insurance and socioeconomic disparities on newborn hearing screening performance in South Korea: A nationwide population-based evaluation

Sojeong Kim, Sun Choi, Jiwon Chang, Ho Yun Lee, Su-Kyoung Park, Kyu Young Choi

Publication date 15-05-2024


This study aimed to assess the impact of national health insurance coverage on newborn hearing screening (NHS) outcomes by analyzing hearing questionnaires from the National Infant Health Check-up Program (NIHCP) in South Korea. This study evaluated the performance and referral rates of NHS using nationwide data from 814,875 infants enrolled in the 4-month NIHCP from January 2017 to December 2019. This period encompasses the periods before and after the National Health Insurance in South Korea began covering NHS expenses in October 2018. The study also investigated household income levels to determine their relationship with participation in the NIHCP and NHS outcomes. The performance of NIHCP increased year-on-year, with NHS performance rates increasing from 88.5 % in 2017 to 91.5 % in 2019. Analysis by household income level revealed that the medical benefit recipients' group had the lowest NHS performance rate of 81.9 % in 2019, whereas that of the higher income level group exceeded 90 %. The NHS referral rate remained consistent at 0.9 % nationally during the study period. The inclusion of NHS in national insurance coverage positively influenced its performance rates across South Korea. Nevertheless, the data indicate the need for more focused and customized support for low-income families to enhance early hearing detection and interventions in newborns and infants.

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Distribution of mitochondrial MT-RNR1, MT-TL1, MT-TS1, MT-TK and MT-TE genes variants associated with hearing loss in Southwestern China

Shiyu Zhou, Menglan Chen, Jiahong Pei, Chen Zhang, Xiaofei Ren, Jingyu Li, Yaliang Sa, Baosheng Zhu, Yunlong Li

Publication date 14-05-2024


Maternally inherited hearing loss has been associated with mitochondrial genes, including MT-RNR1, MT-TL1, MT-TS1, MT-TK and MT-TE. Among these genes, MT-RNR1 is known to be a hotspot for pathogenic variants related to aminoglycoside ototoxicity and nonsyndromic hearing loss. However, the frequency and spectrum of variants in these genes, particularly in multi-ethnic hearing loss patients from Southwestern China, are still not fully understood. In this study, we enrolled 460 hearing loss patients from various ethnic backgrounds (Han, Yi, Dai, Hani, etc.) in Southwestern China. Next-generation sequencing was used to analyze the mitochondrial MT-RNR1, MT-TL1, MT-TS1, MT-TK and MT-TE genes. Subsequently, bioinformatical methods were employed to evaluate the identified variants. Among the patients with hearing loss, we identified 70 variants in MT-RNR1 (78.6 %, 55/70), MT-TL1 (4.3 %, 3/70), MT-TS1 (4.3 %, 3/70), MT-TK (7.1 %, 5/70) and MT-TE (5.7 %, 4/70) genes. We found that 15 variants were associated with hearing loss, including m.1555 A > G and m.1095 T > C. Additionally, we discovered three reported mitochondrial variants (m.676 G > A, m.7465 insC, and m.7474 A > G) newly correlated with hearing loss. Notably, certain pathogenic variants, such as m.1555 A > G, displayed non-consistent distributions among the multi-ethnic patients with hearing loss. Furthermore, the number of variants associated with hearing loss was higher in the Sinitic group (n = 181) and Tibeto-Burman group (n = 215) compared to the Kra-Dai group (n = 38) and Hmong-Mien group (n = 26). This present study revealed the distribution of mitochondrial variants linked to hearing loss across various ethnic groups in Southwestern China. These data suggest a potential correlation between the distribution of mitochondrial variants associated with hearing loss and ethnic genetic backgrounds.

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Otolaryngology outcomes of infants with conductive hearing loss identified through universal newborn hearing screening

Alison Collins, Rachael Beswick, Carlie Driscoll, Joseph Kei, Lia Traves

Publication date 12-05-2024


Infants and children diagnosed with a conductive hearing loss (CHL) are often referred for otolaryngology assessment. Although this is also a regular occurrence for infants diagnosed with a CHL through Universal Newborn Hearing Screening (UNHS), less is known about these infants and their outcomes. Using a cohort of infants diagnosed with CHL through UNHS and referred to otolaryngology, this study aimed to investigate the relationship between specific demographic or clinical characteristics and 1) triage category 2) middle ear diagnosis and intervention and, 3) service-related factors at otolaryngology. Retrospective analysis through clinical chart review was performed on all infants born between January 2014 and December 2017 who referred on UNHS, diagnosed with a CHL and referred to the Queensland Children's Hospital. Descriptive analysis and Chi squared analysis was conducted on data from 95 records. Analysis between all infants referred from UNHS and those who referred, diagnosed with CHL and then referred to otolaryngology suggest that bilateral referrals/medical exclusion, preterm and infants with ≥1 risk factors are more readily associated with referral to otolaryngology for CHL. Nearly all (92.86 %) infants who were referred to otolaryngology had a primary diagnosis of OM and most infants (89.66 %) received grommets as an intervention. The average age of first appointment at otolaryngology was 427 days, the average age of intervention was 579 days and the average occasions of service at otolaryngology was 6.72. This paper provides a snapshot into the journey and outcomes of infants referred from UNHS, diagnosed with CHL, and referred to otolaryngology. Further investigation in both general and UNHS populations is needed to better understand and apply these findings.

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Endoscopic repair of tracheoesophageal fistulas: A contemporary multi-institutional case series and literature review

Catherine F. Roy, Alix Maltezeanu, Jean-Martin Laberge, Kimberley Kaspy, Ana Sant’Anna, Hélène Broucqsault, Pierre Fayoux, Sam J. Daniel

Publication date 11-05-2024


Recurrent and primary tracheoesophageal fistulas (TEFs) are a challenging surgical pathology to treat, as standard open surgical approaches are associated with high morbidity and mortality. As such, endoscopic modalities have gained interest as an alluring alternative, yet variable success rates have been reported in the literature. The aim of this study was to provide a contemporary update of the literature and describe our institutional experience with the bronchoscopic obliteration of recurrent and primary TEFs. Retrospective chart review of all pediatric patients having undergone endoscopic TEF repair at two pediatric academic centers in Montreal, Canada and Lille, France between January 1, 2008 to December 31, 2020. 28 patients with TEFs (20 recurrent, 8 primary) underwent a total of 48 endoscopic procedures. TEF repair was performed under endoscopic guidance using various combinations of techniques, including fistula de-epithelialization (endoscopic brush, thulium laser, trichloroacetic acid-soaked pledgets or electrocautery), tissue adhesives, submucosal augmentation, esophageal clip and stenting. Successful closure was achieved in 16 patients (57 %), while 12 (43 %) required eventual open or thoracoscopic repair. The mean number of endoscopic procedures was 1.7. There were no major treatment-related complications such as pneumothorax, mediastinitis or death (mean follow-up 50.8 months). Endoscopic repair of recurrent or primary TEFs is a valuable component of our therapeutic armamentarium and may contribute to decreased surgical morbidity in this complex patient population. Families should be counselled that endoscopic results may be more modest than with open or thoracoscopic approaches, and multiple procedures may be required.

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"Early assessment of communicative competence in children with hearing loss using the Child-Caregiver Communication Assessment through Rebescos Evaluation (CC-CARE) method"

Roberta Rebesco, Arianna Colombani, Giacomo Handjaras, Davide Bottari, Eva Orzan

Publication date 10-05-2024


This work presents a new frame-by-frame video analysis method called Child-Caregiver Communication Assessment through Rebesco's Evaluation (CC-CARE), developed in the context of pediatric hearing loss as a rehabilitation tool for assessing children's early communication skills. CC-CARE stems from the commonly used Tait video analysis and extends it by including a new set of parameters aimed at disentangling between hearing-dependent and hearing-independent aspects of communication. In this paper, we collected video samples of child-caregiver interactions in a group of 65 normal-hearing children and a group of 165 hearing-impaired children. For each group, we present the CC-CARE method and describe the parameters, their score distributions, correlations and we estimate the adherence of the CC-CARE scores with children's developmental trajectory. Moreover, we compare the results of CC-CARE scores between the two groups having had different development of the auditory system. Finally, a fully-data driven approach was employed to assess the consistency of the communicative efficacy index (CEI), a score aiming to capture a global result of the CC-CARE procedure. Correlations among parameter scores were found in each within-group analysis, revealing CC-CARE's internal consistency in measuring associated but nonoverlapping communication dimensions. For both groups, CC-CARE scores were associated with participants' age. Differences between scores emerged for a between-group analysis, indicating CC-CARE sensitivity to extract communication differences as a function of the hearing status. For both groups, the data analysis revealed that the CEI captures large variance portions across all parameter scores of the CC-CARE method. Results provide the first evidence that the CC-CARE video analysis method could be a reliable tool capable of highlighting the cascading effects of hearing impairment on children's preverbal communicative efficacy. The CC-CARE method aims to support early rehabilitation of hearing loss by describing a child's communicative efficacy.

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Coblation intracapsular tonsillectomy in a paediatric tertiary centre: Revision surgery rates over a nine-year period

Rujuta Cameron, Adam Haymes, Christopher Pepper, Victoria Possamai, Sean Blaney, Gavin Morrison, Nicolaas Jonas, Liliana Jablenska, Louisa Ferguson, Ian Lilly, Shradha Sharma, Nikul Amin, Daniel J. Tweedie

Publication date 10-05-2024


Coblation intracapsular tonsillectomy (ICT) is increasingly being used in the paediatric population because of the rapid recovery and low rates of complications associated with it. There is, however, a risk of symptomatic regrowth with this technique. The objective of our study is to establish the rate of, and risks for, revision surgery over time in a major tertiary referral centre with a large cohort of paediatric Coblation ICT cases. A retrospective review of all children (0-19 years) undergoing Coblation ICT from April 2013 to June 2022 was undertaken, using electronic databases and clinical records. Post-operative follow up was reviewed and revision cases were subsequently identified and examined. Statistical analysis was performed using a Chi-Squared test. 4111 patients underwent Coblation ICT during the studied period, with or without concomitant adenoidectomy. Of these, 135 (3.3 %) required revision tonsil surgery, primarily for recurrence of initial symptoms; two patients required two consecutive revision procedures (137 revision procedures in total). Eight-eight (n = 88) (64 %) of these were revised with a repeat Coblation ICT procedure and 49 (36 %) with bipolar diathermy extracapsular tonsillectomy (ECT) of remnant tonsil tissue. The revision rates after Coblation ICT declined steeply on a year-on-year basis since the commencement of this technique (from 10.6 % early on, to 0.3 % at the end of the study period P<0.001). A significantly higher revision rate was noted in children below the age of two at the time of primary surgery, compared to those older than two years of age (P<0.001). This study demonstrates real-world departmental revision rates over a nine-year period from the technique's commencement of use. With Coblation ICT, symptomatic re-growth occurs rarely, but may be clinically significant, with higher rates of recurrent symptoms seen in children under two years of age at the time of primary surgery. The revision rate apparently drops over time in parallel with overall experience of surgeons and formalised training.

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Fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics: A systematic review

Nicole Pizzorni, Sara Rocca, Angelo Eplite, Marta Monticelli, Sibora Rama, Francesco Mozzanica, Letizia Scarponi, Antonio Schindler

Publication date 27-05-2024


The systematic review aimed to provide an overview of the state-of-art regarding the use of fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics, specifically investigating FEES feasibility, safety, diagnostic accuracy, and protocols. Four electronic databases were searched for original studies on the pediatric population that instrumentally assessed swallowing function using FEES. A hand-search of the references of included studies was performed. Data on the population, feasibility of endoscope insertion and bolus trials, adverse events, sensitivity and specificity, and FEES equipment and protocol were extracted. The quality of the studies was assessed using the checklists of the Johanna Briggs Institute. Selection of the studies, data extraction, and quality appraisal were conducted by two independent researchers. Eighty-two reports from 81 studies were included. The mean overall quality of the studies was 80 % (17-100 %). The feasibility of endoscope insertion was high (89%-100 %), while the feasibility of bolus trials varied from 40 % to 100 %. Adverse events were excessive crying (8 studies), irritability or agitation (4 studies), transitory oxygen desaturations (3 studies, 1.2-6.7 % of the patients), epistaxis (3 studies, 0.8-3.3 % of the patients), increased heart rate (1 study, 1 patient), vomiting (1 study, 1 patient), hypertonia (1 study), and hypersalivation (1 study). No major complications were reported. Using VFSS as the reference standard, FEES was generally found to be less sensitive (25-94 %) but more specific (75-100 %) for aspiration, whereas the reverse was true for penetration (sensitivity 76-100 %, specificity 44-83 %). FEES protocols were highly heterogeneous with poor reporting. FEES is a safe, accurate, and generally feasible examination in the pediatric population with suspected dysphagia. However, a consensus on the best FEES protocol for clinical practice and research is currently lacking.

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Retraction notice to “Outcomes and considerations in children with developmental delay undergoing tonsillectomy” Int. J. Pediatr. Otorhinolaryngol. 164 (January 2023) 111393

Jordan B. Luttrell, Chad A. Nieri, Madhu Mamidala, Anthony Sheyn

Publication date 21-02-2024


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