Jonathan N. Perkins

Risk of post‐tonsillectomy hemorrhage by clinical diagnosis

Obstructive sleep apnea (OSA) has been associated with upregulation of prothrombotic factors. We hypothesize that diagnosis of OSA may be protective against postoperative hemorrhage. This study investigates the relationships between preoperative clinical diagnosis and postoperative hemorrhage.

Incidence of acute mastoiditis in Colorado children in the pneumococcal conjugate vaccine era.

Background: Acute otitis media is among the most common reasons young children seek medical care, with Streptococcus pneumoniae the most common pathogen. Despite introduction of heptavalent pneumococcal conjugate vaccine (PCV7) in 2000, recent experience suggests an increase in complications of acute otitis media, particularly acute mastoiditis. Methods: We performed a retrospective review of acute mastoiditis in children from 1999 to 2008 using inpatient data from the Colorado Hospital Association and the Children’s Hospital Colorado. The study included patients with documentation of acute mastoiditis or mastoidectomy and excluded those with chronic mastoiditis, chronic otitis media or cholesteatoma. Results: The annual incidence of acute mastoiditis in children <2 years/100,000 population was 11.0 in 2001 before decreasing to 4.6 in 2002 and 4.5 in 2003. The incidence then increased to 12.0 in 2008 (total N = 242). The proportion of S. pneumoniae isolates nonsusceptible to penicillin increased from 0% (0/16) between 1999 and 2004 to 38% (5/13) between 2005 and 2008 (P = 0.03). Conclusions: The incidence of acute mastoiditis in Colorado children <2 years of age exhibited a dynamic pattern from 1999 to 2008: a significant decline early after introduction of PCV7 that paralleled initial vaccine uptake, followed by an increase in subsequent years to pre-PCV7 levels. Replacement with non-PCV7 pneumococcal serotypes and increased pneumococcal antibiotic resistance may be responsible for the increase in incidence to pre-PCV7 rates. Surveillance of mastoiditis incidence, pathogen distribution and resistance patterns following introduction of 13-valent PCV is warranted.

Standardized letter of recommendation for otolaryngology residency selection

Develop a standardized letter of recommendation (SLOR) for otolaryngology residency application that investigates the qualities desired in residents and the letter writers experience. Compare this SLOR to narrative letters of recommendation (NLORs).

Early intervention: distraction osteogenesis of the mandible for severe airway obstruction.

Objective. To determine benefits of early intervention in neonates with symptomatic micrognathia who underwent bilateral mandibular distraction osteogenesis within the first 90 days of life as relates to growth, need for supportive care, and further invasive procedures. Study Design. Case series with chart review. Setting. Tertiary care, academic children’s hospital. Subjects and Methods. Review of neonates with symptomatic micrognathia who underwent bilateral mandibular distraction osteogenesis in the past 5 years. Inclusion criteria included mandibular distraction osteogenesis performed within the first 90 days of life. Outcome measures included hospital course, growth curves, supportive home care needs, and airway at cleft repair. Results. Twenty-four patients met inclusion criteria. The mean age at distraction was 30 days, and the average discharge was postoperative day 14. One patient required home oxygen, 50% were able to feed exclusively by oral diet, and no patients required tracheotomy. In addition, airway results were substantial, with 90% of patients showing objective improvement in airway grade from time of mandibular distraction to time of cleft repair. Conclusion. We present our initial outcomes on mandibular distraction osteogenesis in neonates with symptomatic micrognathia. Early intervention allows discharge to home with minimal supportive care needs by avoiding tracheostomy and facilitating transition to oral feeds. The airway improvement is significant and is sustained and allows for easier intubation at time of cleft repair.

Standardized letter of recommendation for pediatric fellowship selection.

To develop a pediatric otolaryngology fellowship selection standardized letter of recommendation (SLOR).

Clinical Presentation of Cervical Ribs in the Pediatric Population

Cervical ribs may cause thoracic outlet syndrome in adults, but symptoms are poorly described in children. In our series, 88.8% of the 322 children were asymptomatic. The most common symptoms were neck mass and pain. Useful diagnostic tools were cervical spine and chest radiographs. Differential diagnosis of a supraclavicular mass includes cervical ribs.

Characteristics of children under 2 years of age undergoing tonsillectomy for upper airway obstruction

INTRODUCTION To study characteristics of children less than 2 years who underwent a tonsillectomy for sleep disordered breathing (SDB) or obstructive sleep apnea (OSA) to assess for factors associated with requesting a preoperative polysomnogram (PSG) and to identify predictors of upper airway obstruction in this group. MATERIALS AND METHODS A retrospective chart review of children under 2 years who underwent a tonsillectomy over a 7-year period at a tertiary care pediatric hospital was undertaken. Patient demographics, characteristics and polysomnography results, when applicable, were collected. In order to determine if the gathered demographics of our cohort differed from the non-surgical population, we compared our data with available Colorado data for each variable. Children were stratified by OSA severity using their obstructive apnea-hypopnea index (OAHI). RESULTS 197 (2.2%) of 9038 patients who underwent tonsillectomy for SDB or OSA were ≤ 24 months. The proportions of male, African-American, Hispanic, obese, underweight, premature, syndromic and daycare patients in our cohort were significantly different than in the general population. In a multivariate model, the odds of African-Americans having severe OSA were 12.5 times greater than the odds of Caucasians. The odds of patients with syndromes or craniofacial anomalies were 11 times greater (p < 0.0001), and the odds of patients in daycare were 2.2 times lower (p = 0.04) of undergoing a PSG before tonsillectomy. Weight did not influence polysomnogram requests. CONCLUSIONS In children under 2 years, ethnicity seems to be a predictor of OSA severity. African-American, prematurity, daycare and Down syndrome patients were significantly more represented in our study population. PSG is more likely to be requested for syndromic children.

Auditing of operating room times: A quality improvement project

OBJECTIVE A quality improvement project to evaluate operating room efficiency and utilization and to identify areas for improvement. METHODS A retrospective assessment of a single surgeons surgical cases over a 6-month period at a tertiary childrens hospital. Primary outcomes included case timing defined as T1, T2, T3 and T4. (T1)-Patient enters OR-to-procedure start. (T2)-Procedure start-to-procedure end. (T3)-Procedure end-to-patient exits OR. (T4)-Patient exits OR-to-next patient enters OR (turnover). Comparison to existing literature was performed and results were presented to stakeholders. RESULTS A total of 180 surgical cases were reviewed, 92 adenotonsillectomies (T&A), 33 Bilateral Pressure Equalization Tube Placement (PET) and 55 microlaryngoscopies and bronchoscopies (MLB). All outcomes were calculated by case type, except T4, and compared to available published data. T2 was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A and PET. However, T4 was considerably longer at our institution (average 31.09). Overall OR efficiency was 20.58%. CONCLUSIONS The operating room represents one of a hospitals most costly resources. Ensuring that this resource is designed, staffed and utilized efficiently is of major importance to both the quality of patient care and financial productivity. Surgeons are key components of operating room efficiency, utilization and other measurements of institutional performance. How surgeons schedule and perform cases directly impacts, and is impacted by, these measurements of performance. For fields dominated by high volume, short duration procedures such as pediatric otolaryngology, T4 may be the most important variable in determining OR efficiency. By utilizing modern electronic medical records, surgeons can easily track OR time points thereby determining the potential causes of and solutions for OR inefficiency.

Pediatric facial fractures: demographic determinants influencing clinical outcomes

There is limited data linking demographic determinants to clinical outcomes in facial trauma, particularly when comparing regional to national datasets; these are the aims of the present study.

Parent, dentist, and orthodontist satisfaction following alveolar cleft repair using recombinant human bone morphogenic protein.

Objective Our aim was to evaluate dental/orthodontic outcomes for patients who underwent recombinant human bone morphogenic protein (rhBMP-2) alveolar cleft repair and to examine parental satisfaction following the procedure. Design Retrospective review. Setting Tertiary childrens hospital. Participants Parents, dentists, and orthodontists completed satisfaction questionnaires. Main Outcome Measures Parent, dentist, and orthodontist satisfaction with the use of rhBMP-2 in alveolar cleft repair. Results Parent response rate was 71.4% (30/42). The dentist response rate was 60% (18/30). The orthodontist response rate was 53.3% (16/30). Parent and patient satisfaction was 93.3% and 83.3%, respectively. Of dentist respondents, 55.6% reported that the bone quality and alveolar ridge mucosal repair allowed for dental treatment. Of orthodontist respondents, 87.5% reported the graft enabled treatment, and 73.3% felt the graft prevented tooth root exposure and resorption. Conclusions Parents, dentists, and orthodontists are satisfied with outcomes when rhBMP-2 is used for alveolar cleft repair. The bone formed was reported as adequate to support dental and orthodontic treatment in most cases with few complications. Because of safety concerns over the use of this product in an off-label manner, further controlled studies are warranted.