Ellen S. Deutsch

Clinical practice guideline: Hoarseness (Dysphonia)

Objective: This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness. Purpose: The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology–head and neck surgery, pediatrics, and consumers. Results The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patients larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures. Disclaimer: This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Increased incidence of head and neck abscesses in children

Objective To describe increasing incidence and changing microbiology of head and neck abscesses in children admitted to the hospital during the first quarters of 2000 through 2003. Study Design and Setting Retrospective data warehouse review identified 89 children less than 19 years of age admitted to a tertiary care pediatric hospital during the first quarters of 2000 through 2003 for suspicion of head and neck abscess involving the neck, face, and peritonsillar, retropharyngeal, and parapharyngeal spaces; and for orbital and intracranial complications of acute sinusitis. Outcome Measures Outcome measures included the incidence of infection admissions and description of infection location and microbiology, calculated by χ2 technique. Results The incidence of infections increased in 2003. The greatest increase was in neck abscesses and complications of acute sinusitis. Conclusions The increase in group A strep infections may be related to its biologic properties. Significance Group A strep remains a significant cause of head and neck infections in children.

The Role of Extraesophageal Reflux in Otitis Media in Infants and Children

Objectives/Hypothesis: Gastroesophageal reflux disease (GERD) is common in children, and extraesophageal reflux disease (EORD) has been implicated in the pathophysiology of otitis media (OM). We sought to 1) determine the incidence of pepsin/pepsinogen presence in the middle ear cleft of a large sample of pediatric patients undergoing myringotomy with tube placement for OM; 2) compare this with a control population of pediatric patients undergoing middle ear surgery (cochlear implantation) with no documented history of OM; 3) analyze potential risk factors for OM in children with EORD demonstrated by the presence of pepsin in the middle ear cleft; and 4) determine if pepsin positivity at the time of myringotomy with tube placement predisposes to posttympanostomy tube otorrhea.

Office-based insertion of pressure equalization tubes : The role of laser-assisted tympanic membrane fenestration

Objective: To describe the role of the hand‐held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting.

A Pilot Survey of Vocal Health in Young Singers

The objective of this study was to determine the incidence of vocal problems in young choir singers and to correlate vocal problems with demographic and behavioral information. A questionnaire addressing vocal habits and hygiene was offered to 571 young choir singers, up to 25 years of age, who sing at least weekly; 129 (22.6%) responded. More than one-half of the respondents had experienced vocal difficulty, particularly older adolescents. Detrimental behaviors and circumstances surveyed were not reflective of the incidence of vocal difficulty, except for morning hoarseness, chronic fatigue, insomnia, and female gender after puberty. Voice care professionals should be aware that self-reported voice difficulties are common among young choral singers, especially postpubescent girls, and children with symptoms consistent with reflux (morning hoarseness) and emotional stress (insomnia). Laryngologists should communicate with choral conductors and singing teachers to enhance early identification and treatment of children with voice complaints, and to develop choral educational strategies that help decrease their incidence.

Multimodality Education for Airway Endoscopy Skill Development

Objectives: Airway endoscopy is a difficult skill to master. A unique practicum was designed to help otolaryngology residents develop endoscopy skills. The learning modalities included lectures, an animal laboratory, high-fidelity manikins, virtual bronchoscopy simulation, and standardized patients. This study compares the relative subjective value of these learning modalities for skill development and realism. Methods: Participants used a Likert scale (1 = disagree to 5 = agree) and open responses to anonymously rate the efficacy of 5 learning modalities for teaching airway management, endoscopy skills, and clinical leadership and for providing a realistic experience. Results: The results in 2007 were uniformly positive, with mean scores for every category and modality greater than 4 for developing cognitive, psychomotor, and affective skills; managing normal and abnormal conditions; preventing and managing complications; improving endoscopy skills; understanding team process; and experiencing overall and manual “feel” realism. In 2008, the participants were encouraged to more critically evaluate the course. The ratings demonstrated statistically significant differences between the mean scores for 4 of the 9 evaluation categories in 2007 and all 9 categories in 2008. Conclusions: Specific learning modalities (eg, lecture, animal laboratory, high-fidelity manikin, virtual bronchoscopy, standardized patient) were perceived to have different values for teaching airway management, developing endoscopy skills, teaching clinical leadership, and providing a realistic experience. We propose that these learning modalities can be used in a complementary manner.

Transition to surgical residency: a multi-institutional study of perceived intern preparedness and the effect of a formal residency preparatory course in the fourth year of medical school.

Purpose To evaluate interns’ perceived preparedness for defined surgical residency responsibilities and to determine whether fourth-year medical school (M4) preparatory courses (“bootcamps”) facilitate transition to internship. Method The authors conducted a multi-institutional, mixed-methods study (June 2009) evaluating interns from 11 U.S. and Canadian surgery residency programs. Interns completed structured surveys and answered open-ended reflective questions about their preparedness for their surgery internship. Analyses include t tests comparing ratings of interns who had and had not participated in formal internship preparation programs. The authors calculated Cohen d for effect size and used grounded theory to identify themes in the interns’ reflections. Results Of 221 eligible interns, 158 (71.5%) participated. Interns self-reported only moderate preparation for most defined care responsibilities in the medical knowledge and patient care domains but, overall, felt well prepared in the professionalism, interpersonal communication, practice-based learning, and systems-based practice domains. Interns who participated in M4 preparatory curricula had higher self-assessed ratings of surgical technical skills, professionalism, interpersonal communication skills, and overall preparation, at statistically significant levels (P < .05) with medium effect sizes. Themes identified in interns’ characterizations of their greatest internship challenges included anxiety or lack of preparation related to performance of technical skills or procedures, managing simultaneous demands, being first responders for critically ill patients, clinical management of predictable postoperative conditions, and difficult communications. Conclusions Entering surgical residency, interns report not feeling prepared to fulfill common clinical and professional responsibilities. As M4 curricula may enhance preparation, programs facilitating transition to residency should be developed and evaluated.

Adenotonsillectomy in the morbidly obese child

OBJECTIVE The prevalence of obesity in the pediatric population has risen more than 20% in 25 years. Accordingly, surgical procedures on obese children have become more common. Adenotonsillectomy (AT) remains among the most frequently performed pediatric surgical procedures in the United States. Our objective was to determine if there is an increased complication rate in morbidly obese (MO) children undergoing AT and if elective pediatric intensive care unit (PICU) admission for observation is warranted. METHODS This retrospective study includes postoperative admissions to the PICU over a 4-year period at one hospital. Out of 957 adenotonsillectomies performed by one surgeon, 543 were admitted to the hospital. Fourteen MO children were identified. Using body mass index (BMI; weight in kg/m(2)), as calculated for age appropriate categories, postoperative outcomes of AT in MO children (>95th percentile BMI) were determined. These 14 were electively admitted to the PICU for airway observation. The indication for surgery in these 14 children was obstructive sleep apnea. Ages ranged from 4 to 15 years. There were 11 males and 3 females. RESULTS Two patients required overnight bi-level positive airway pressure (BiPAP) for oxygen desaturation. One patient remained intubated for 10 days. Three patients required supplemental oxygen. Four of these admissions had preoperative polysomnograms (PSGs). CONCLUSIONS Our study concluded that routine PICU admission was not warranted for most MO patients although several required supplemental oxygen, BiPAP, and one required intubation. These interventions can easily be administered in a surgical floor bed. In fact, these results imply that performing this surgical procedure in obese children is not as risky as many believe. Trends were noted for an increased need of airway interventions in children requiring preoperative BiPAP and in those with comorbidities. In this small population, sample AT was performed on the basis of history. This is to serve as a pilot review for a prospective study in which preoperative PSGs would be used to determine potential indicators for elective PICU admission.

Powered Intracapsular Tonsillectomy in the Management of Recurrent Tonsillitis

OBJECTIVE: To compare intracapsular tonsillectomy (IT) and traditional tonsillectomy (TT) in treating recurrent adenotonsillitis or streptococcal pharyngitis. DESIGN: Retrospective chart review. SETTING: Tertiary care pediatric referral center. RESULTS: Of 166 patients who met all inclusion criteria, 117 received TT and 49 received IT. Seventeen TT patients and 8 IT patients were treated at least once postoperatively for streptococcal pharyngitis or tonsillitis. The mean number of infections after surgery in each group did not reach statistical significance (P = 0.295). CONCLUSION: There was no difference between the IT and TT groups in postoperative infection rates.

Simulation in Otolaryngology Smart Dummies and More

Simulation is revolutionizing medical education, certification, and ongoing professional development. Simulation encompasses a variety of technologies as well as nontechnical approaches to improve individual psychomotor skills, group effectiveness, and systems processes, all without direct risk to patients. Simulation-enhanced learning experiences, addressing learning objectives based on the needs of the individual or the group and following the principles of adult education, can be used to ensure consistent and comprehensive learning opportunities, thereby creatively complementing didactic and clinical learning experiences. Pockets of simulation expertise are already present in the field of otolaryngology; more will develop as these exciting and important innovations blossom.