Michele M. Carr

Complications in Pediatric Tracheostomies

Objective To examine complications of pediatric tracheostomy.

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease.

Objective To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD).

Clinical presentation as a guide to the identification of GERD in children.

OBJECTIVE to determine if there is a correlation between common otolaryngologic symptoms and presence of gastroesophageal reflux disease (GERD) in children. METHODS charts of 295 children presenting with suspicion of GERD were reviewed for presenting symptoms including: (1) airway symptoms: stertor, stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, blue spells, hoarseness, throat clearing; (2) feeding symptoms: wet burps, globus sensation, frequent emesis, dysphagia, choking/gagging, sore throat, halitosis, food refusal, stomach aches, arching, drooling, chest pain, irritability, and failure to thrive. At least one positive test of barium esophagram, gastric scintiscan, pH probe or esophageal biopsy resulted in inclusion in the GERD positive group. RESULTS 214 children had GERD diagnosed while 81 had no positive tests for GERD. Between the GERD positive and GERD negative groups, the significantly different symptoms were stertor (P=0.040), cyanotic spells (P=0.043), frequent emesis (P=0.007), failure to thrive (P=0.006), and choking/gagging (P=0.044). Three pooled variables were created: airway flow (stertor, stridor, cyanotic spells), airway irritation (frequent cough, recurrent croup, throat clearing), and feeding (dysphagia, failure to thrive, frequent emesis). GERD patients who were 2 years or less were compared to those older than 2 years and all three of these pooled variables were significantly different between these groups (P<0. 001). CONCLUSION children who present with a certain constellation of airway or feeding symptoms are more likely to have a positive GERD test. Children 2 years old or less are more likely to present with airway symptoms or feeding difficulties while children older than 2 years are more likely to present with airway irritation.

Program Directors' Opinions about Surgical Competency in Otolaryngology Residents

Objectives: The purpose of this study was to determine whether certain surgical procedures could be used as benchmark skills to monitor resident progress in developing surgical competency.

COMPARISON OF COMPUTER-ASSISTED INSTRUCTION AND SEMINAR INSTRUCTION TO ACQUIRE PSYCHOMOTOR AND COGNITIVE KNOWLEDGE OF EPISTAXIS MANAGEMENT

Epistaxis is a common problem faced by primary care physicians. Typically, first-hand experience with this problem is not obtained in medical school. A computer learning module was developed to address practical management of epistaxis. It was evaluated by use of third-year clerks and compared with an interactive seminar based on the same material. Fifty-eight students doing their required otolaryngology rotations were randomly separated into 3 groups: (1) doing a preinstruction test, (2) using the computer module, and (3) participating in a small-group seminar. All participants were tested with a short written test and a practical test that involved performing anterior nasal pack placement in a model patient. Percentage scores for the 2 groups were compared by use of t tests, and there was no significant difference between the written, practical, or combined scores at a level where P = 0.05. This study shows that basic patient management and a simple procedure can be taught as effectively with a computer module as with a small-group interactive seminar.

Success rates in paediatric tympanoplasty

OBJECTIVE To determine if the success of paediatric tympanoplasty is dependent on certain criteria, which are determinable prior to surgery. DESIGN Retrospective chart review. SETTING An academic paediatric otolaryngology department. PATIENTS Seventy-seven patients who had undergone tympanoplasty with or without ossicular reconstruction, but without mastoidectomy, between April 1997 and May 1999. MAIN OUTCOME MEASURES Status of the repaired tympanic membrane at last follow-up visit measured by otoscopic examination and with tympanometry. RESULTS Eighty-nine tympanoplasties were performed during this period. The age range was 2.9 to 22 years. The success rate was 75% overall. For patients younger than 11 years (n = 43), the success rate was 82%, and for those 11 to 18 years (n = 44), it was 74%, which was not significantly different. In 18 patients 7.5 years or younger, the success rate was 79%. Perforation location, size, presence of myringosclerosis, status of the other ear or nose, history of the perforation, surgical approach, middle ear findings, canal packing, and gender were not shown to be significantly different between successful and unsuccessful tympanoplasty groups. CONCLUSION These young patients had a good success rate post-tympanoplasty, which we believe reflects less severe disease. These results mitigate against delaying tympanoplasty in young children.

Needs assessment for an undergraduate otolaryngology curriculum.

A needs assessment was conducted to determine what family doctors need to know about otolaryngology. A survey was mailed to a group of community otolaryngologists and family doctors. They were asked to rate the importance of 46 otolaryngologic topics. A true needs assessment was carried out with a small group of family practice residents to examine which needs were perceived to be significantly different in importance between these 2 survey groups. A list of important topics was generated from the survey. There were many statistically significant differences between the survey groups, but only 2, vertigo and epistaxis, appeared to be potentially important. The family practice residents (n = 8) were asked to complete a short-answer test about epistaxis management and then to demonstrate placement of an anterior nasal pack. Despite having already faced this problem in 50% of cases, the residents had average scores of less than 30%, indicating a lack of knowledge in this area.

Extraesophageal reflux in children.

Purpose of reviewTo summarize and contextualize current concepts in the incidence, diagnosis, management and long-term sequelae of extraesophageal reflux disease in children. Recent findingsExtraesophageal reflux disease is a different disease entity from gastroesophageal reflux disease. The two diseases have a common etiology, refluxate causing mucosal damage, but the extent and location of the damage varies considerably depending on the underlying mucosal characteristics. Extraesophageal reflux disease in children is characterized by a broad set of symptoms and signs that vary according to age at presentation and severity of disease. Serious long-term effects begin in childhood. The role of pepsin, bile acids, pancreatic enzymes, motility disorders, and food allergies have only recently been recognized. Newer diagnostic modalities include multichannel intraluminal pH/impedance, the 48 h Bravo implantable probe, and hypopharyngeal pH monitoring. While proton pump inhibitors provide superior acid suppression compared with histamine-2 blockers, variability in response and lack of efficacy for alkaline refluxate often require other therapeutic interventions. SummaryPediatric extraesophageal reflux disease has variable presentation and a gold standard test is still lacking. Primary treatment includes lifestyle and feeding changes and medical therapy. Ongoing monitoring for recurrence and agreement as to duration of therapy present significant challenges not yet standardized amongst practitioners.

Emerging Trends in Tonsillectomy

Objective. To describe the tonsillectomy techniques and management used by practicing otolaryngologists in the United States. Study Design. Anonymous 18-question postal survey of pediatric and general otolaryngologists on their current tonsillectomy practices. Setting. Tertiary academic medical center. Subjects and Methods. Current preoperative, perioperative, and postoperative practices in tonsillectomy were queried with multiple-choice and open-ended questions. Pediatric otolaryngologists and general otolaryngologists were compared. Results. Eighty percent of respondents perform subcapsular (total tonsillectomy) dissection. Most otolaryngologists trained with either monopolar cautery (52%) or cold steel (42%). The Coblator (ArthroCare ENT, Austin, Texas) is the most common single instrument used for tonsillectomy (27.5%), followed by monopolar cautery (26%), but in combination with other instruments, monopolar cautery was still more common (33.5%) than coblation (28.9%). Coblation was more common among private practice and general otolaryngologists. The majority of those surveyed do not use intraoperative local anesthesia, but most do use intraoperative steroids (67%). Compared with generalists, pediatric otolaryngologists were less likely to use coblation, were less likely to use local anesthetic, managed postoperative pain slightly differently, and were more likely to recommend diet ad libitum after surgery. Otolaryngologists were more likely to admit medically compromised patients postoperatively. Conclusions. Coblation is becoming a more commonly used instrument for tonsillectomy. Pediatric otolaryngologists perform more tonsillectomies than do general otolaryngologists and manage their patients differently.

Ceruminolytic efficacy in adults versus children.

OBJECTIVES An inexpensive, nontoxic ceruminolytic with reasonable efficacy that can be used by the patient or their caregivers at home could represent significant financial saving for patients and health care systems. The purpose of this study was to compare two simple ceruminolytics for in vitro efficacy. STUDY DESIGN Randomized controlled trial. METHODS Thirty-six children and 33 adults presenting to a community family practice clinic who had cerumen occluding at least one external auditory canal were randomly assigned to compare use of 10% aqueous sodium bicarbonate and 2.5% aqueous acetic acid as ceruminolytics in occlusive cerumen. RESULTS We were unable to demonstrate a difference between in vivo efficacy of these two ceruminolytic solutions, but both solutions were significantly more efficacious in children than adults. CONCLUSIONS There is a role for these ceruminolytics in children with occlusive cerumen, but adults would be better treated in another way.