Ellis M. Arjmand

Pediatric Sinusitis and Subperiosteal Orbital Abscess Formation: Diagnosis and Treatment

Twenty-two children with subperiosteal orbital abscesses were treated at St. Louis Childrens Hospital between 1983 and 1992. Eighteen patients were otherwise in good health; four patients had cystic fibrosis, mucoceles, or were immunocompromised. All patients were treated with intravenous antibiotics and abscess drainage. CT scans were obtained preoperatively in each case. Ten patients were treated with endoscopic ethmoidectomy and abscess drainage, and 11 were treated with external ethmoidectomy and abscess drainage. One child was initially treated with abscess drainage and an elective endoscopic ethmoidectomy was performed later. There were no cases of permanent visual loss or neurologic sequelae. Culture results were positive in 14 cases and mixed infections were common. Complications included recurrent abscess, cerebritis, and empyema. We recommend combined medical and surgical treatment for all children with subperiosteal orbital abscess. We feel that endoscopic ethmoidectomy and abscess drainage offers some advantages over external ethmoidectomy and abscess drainage.

The large vestibular aqueduct: A new definition based on audiologic and computed tomography correlation:

Objective The study goal was to determine the prevalence and clinical significance of a large vestibular aqueduct (LVA) in children with sensorineural hearing loss (SNHL). Study Design and Setting We conducted a retrospective review of a pediatric SNHL database. One hundred seven children with SNHL were selected and their radiographic and audiometric studies were evaluated. Radiographic comparisons were made to a group of children without SNHL. Results A vestibular aqueduct (VA) larger than the 95th percentile of controls was present in 32% of children with SNHL. Progressive SNHL was more likely to occur in ears with an LVA and the rate of progressive hearing loss was greater than in ears without an LVA. The risk of progressive SNHL increased with increasing VA size as determined by logistic regression analysis. Conclusions An LVA is defined as one that is ≥2mm at the operculum and/or ≥1 mm at the midpoint in children with nonsyndromic SNHL. An LVA appears to be more common than previously reported in children with SNHL. A linear relationship is observed between VA width and progressive SNHL. Significance The finding of an LVA in children with SNHL provides diagnostic as well as prognostic information.

Developmental changes in frequency mapping of the gerbil cochlea: Comparison of two cochlear locations

The cochlear microphonic measured in scala tympani referenced to that at the round window is used to determine characteristic frequency (CF) at two locations in an age-graded series of Mongolian gerbils. No significant ontogenic shift in CF is seen at a second turn location, while an approximately 1.5 octave shift is seen in the mid-basal turn.

Laryngomalacia induced by exercise in a pediatric patient.

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.

Cortical reorganization in children with unilateral sensorineural hearing loss.

Previous studies have shown evidence of cortical reorganization following unilateral sensorineural hearing loss (USNHL). In addition, study participants with right USNHL have shown greater deficits in academic and language performance compared with those with left USNHL. A preliminary functional magnetic resonance imaging investigation was performed on a small cohort of participants, four with left USNHL and four with right USNHL, using the paradigm of listening to random tones. While the participants with left USNHL displayed greater activation in the right superior temporal gyrus, those with right USNHL displayed greater activation in the left inferior frontal area immediately anterior to the superior temporal gyrus. The results provide preliminary evidence of disparate neural circuitry supporting auditory processing in participants with left and right USNHL.

The age of diagnosis of sensorineural hearing impairment in children

OBJECTIVE To identify factors responsible for delays in diagnosis and treatment of pediatric sensorineural hearing impairment (SNHI), and to assess the thoroughness of medical evaluation in these children. DESIGN Retrospective analysis. SETTING State-supported school for the deaf. PATIENTS AND OTHER PARTICIPANTS 291 children with SNHI, the bast majority of whom are profoundly hearing impaired. Data were collected from the schools database, individual student records, and a parental questionnaire. MAIN OUTCOME MEASURES (1) The age of diagnosis and treatment of SNHI; (2) actors leading to a delay in diagnosis; (3) current medical evaluations used to determine the etiology of SNHI; and (4) the level of parental satisfaction with the evaluation process. RESULTS Many children with SNHI experience delays in diagnosis from the time of first suspicion of hearing loss. Children with a risk factor for SNHI are diagnosed no earlier than children without a risk factor. Caucasian children are diagnosed significantly earlier than either Black or Hispanic children, regardless of socioeconomic status. Inconsistent medical evaluation ensues following the diagnosis of SNHI, and parental satisfaction with this process is low. CONCLUSIONS The average age of diagnosis of SNHI remains unacceptably high. There exists a need to enhance physician awareness of childhood deafness and to develop guidelines for the medical evaluation in cases of pediatric SNHI. Lastly, the importance of parental concern regarding a childs hearing or language development must be re-emphasized.

Findings from multidisciplinary evaluation of children with permanent hearing loss

OBJECTIVES To describe clinical findings from a multidisciplinary program for children with permanent hearing loss (PHL). METHODS Retrospective chart review at a tertiary care childrens hospital. PATIENTS Two hundred patients charts were selected from the population of 260 children with permanent hearing loss presenting between July 2005 and December 2006. MAIN OUTCOME MEASURES PHL etiology; radiographic findings; clinical findings by genetics, ophthalmology, developmental pediatrics, speech pathology, and aural rehabilitation. RESULTS Etiology of hearing loss was determined in 60% of subjects. Genetic causes of hearing loss were identified or presumed (positive history of first degree relative with hearing loss) in 27% of the children. Structural ear anomalies were found in 20% of children. Among the 36% of children with CNS imaging, abnormal findings were noted in 32%. There were a high rate of ophthalmological findings (53%) among children seen by ophthalmology (n = 105). Neurodevelopmental evaluations were completed in 58% of subjects and clinically significant findings were noted in 68%. Of the 61% of children who receiving received speech/language evaluations, 77% required intervention. Over half of the 40% of subjects who had an aural rehabilitation evaluation needed therapy. There were not significant differences in rates of findings for children with mild or unilateral hearing loss as compared to children with more severe degrees of hearing loss. CONCLUSIONS Interdisciplinary medical evaluation of children with PHL allows for the identification and treatment of clinically significant ophthalmologic, neurodevelopmental, genetic, and speech/language disorders. A high rate of CNS and temporal bone abnormalities were identified. These findings provide an understanding of the importance of considering thorough medical and developmental evaluations among children who are deaf/hard of hearing.

Comparing quality at an ambulatory surgery center and a hospital-based facility: preliminary findings.

OBJECTIVE: To measure the quality of outpatient surgery in an ambulatory surgery center (ASC) compared to a hospital-based facility (HBF) in a multidimensional manner. STUDY DESIGN: Cross-sectional survey based on chart review. SETTING: Pediatric academic health center. SUBJECTS AND METHODS: A total of 486 cases were reviewed. Procedures were performed at either an ASC (n = 275) or an HBF (n = 211). Cases comprised four procedure types: ventilation tube insertion (ASC, n = 126; HBF, n = 108), dental rehabilitation (ASC, n = 89; HBF, n = 58), adenotonsillectomy (ASC, n = 37; HBF, n = 34), and ventilation tube insertion/adenoidectomy (ASC, n = 23; HBF, n = 11). Measures were developed for five categories: safety, patient-centeredness, timeliness, efficiency, and equitability. Performance was compared between facilities. RESULTS: The ASC had no unexpected safety events (0/275) compared to nine events (9/211) at the HBF. Tonsil bleed rates were 0 percent (0/37) at the ASC compared to 5.9 percent (2/34) at the HBF. Patient satisfaction was similar between facilities (ASC, n = 64; HBF, n = 35). Differences in timeliness approached 30 percent. A total of 77 percent of ASC cases finished within the scheduled time compared to 38 percent at the HBF. Total charges were 12 to 23 percent less at the ASC. Patients treated at the ASC generally lived in wealthier neighborhoods. CONCLUSION: Performance at the ASC generally exceeded that at the HBF. Future research should investigate how perioperative processes result in these quality differences. Health policy implications are discussed.

Growth of the 2f1-f2 distortion product otoacoustic emission for low-level stimuli in human neonates.

Distortion product otoacoustic emissions (DPOAEs) for low stimulus levels (<60 dB SPL) have been reported in adult humans under ideal conditions. In neonates, DPOAEs have been reported only for high-level stimuli. The purpose of this paper was to determine characteristics of the 2f,−f, DPOAE for low-level stimuli in neonates and to assess the feasibility of obtaining such measures in a noisy environment. Subjects were 19 premature neonates presumed to have normal hearing based on systematic pneumatic otoscopy measures and evoked auditory brainstem responses. For stimuli centered at 2000 and 6000 Hz and presented over a range of 30 to 75 dB SPL, DPOAEs were measured employing linear time averaging for up to 128 time frames at each level. In quiescent subjects, the level of the noise floor was as low as that reported in cooperative adults under ideal conditions (–30 dB SPL), and the functions were identical. That is, valid measures were obtained for very low stimulus levels (30 dB SPL), the rate of growth approached 1 dB/dB, and identical nonmonotonicities (saturation, plateaus, and notches) were observed as those reported for adults. When the noise floor was elevated due to subject activity, no valid data could be obtained for low-level stimuli even though the DPOAEs were at expected levels for high-level stimuli. These results have important implications for the use of such measures in this population because the DPOAEs associated with the metabolically active nonlinear cochlear processes at low stimulus levels may be contaminated with DPOAEs associated with other processes at high stimulus levels.

Applying Cost Accounting to Operating Room Staffing in Otolaryngology Time-Driven Activity-Based Costing and Outpatient Adenotonsillectomy

Objectives (1) To describe the application of a detailed cost-accounting method (time-driven activity-cased costing) to operating room personnel costs, avoiding the proxy use of hospital and provider charges. (2) To model potential cost efficiencies using different staffing models with the case study of outpatient adenotonsillectomy. Study Design Prospective cost analysis case study. Setting Tertiary pediatric hospital. Subject and Methods All otolaryngology providers and otolaryngology operating room staff at our institution. Results Time-driven activity-based costing demonstrated precise per-case and per-minute calculation of personnel costs. We identified several areas of unused personnel capacity in a basic staffing model. Per-case personnel costs decreased by 23.2% by allowing a surgeon to run 2 operating rooms, despite doubling all other staff. Further cost reductions up to a total of 26.4% were predicted with additional staffing rearrangements. Conclusion Time-driven activity-based costing allows detailed understanding of not only personnel costs but also how personnel time is used. This in turn allows testing of alternative staffing models to decrease unused personnel capacity and increase efficiency.