Nikhila Raol

Inpatient Pediatric Tonsillectomy Does Hospital Type Affect Cost and Outcomes of Care

Objective To ascertain whether hospital type is associated with differences in total cost and outcomes for inpatient tonsillectomy. Study Design Cross-sectional analysis of the 2006, 2009, and 2012 Kids’ Inpatient Database (KID). Subjects and Methods Children ≤18 years of age undergoing tonsillectomy with/without adenoidectomy were included. Risk-adjusted generalized linear models assessed for differences in hospital cost and length of stay (LOS) among children managed by (1) non–children’s teaching hospitals (NCTHs), (2) children’s teaching hospitals (CTHs), and (3) nonteaching hospitals (NTHs). Risk-adjusted logistic regression compared the odds of major perioperative complications (hemorrhage, respiratory failure, death). Models accounted for clustering of patients within hospitals, were weighted to provide national estimates, and controlled for comorbidities. Results The 25,685 tonsillectomies recorded in the KID yielded a national estimate of 40,591 inpatient tonsillectomies performed in 2006, 2009, and 2012. The CTHs had significantly higher risk-adjusted total cost and LOS per tonsillectomy compared with NCTHs and NTHs (

Validation of the Dyspnea Index in Adolescents With Exercise-Induced Paradoxical Vocal Fold Motion

9423.34/2.8 days,

A novel technique to repair moderate-sized nasoseptal perforations.

6250.78/2.11 days, and

Evaluation of True Vocal Fold Growth as a Function of Age

5905.10/2.08 days, respectively; P < .001). The CTHs had higher odds of complications compared with NCTHs (odds ratio [OR], 1.48; 95% CI, 1.15-1.91; P = .002) but not when compared with NTHs (OR, 1.19; 95% CI, 0.89-1.59; P = .23). The CTHs were significantly more likely to care for patients with comorbidities (P < .001). Conclusion Significant differences in costs, outcomes, and patient factors exist for inpatient tonsillectomy based on hospital type. Although reasons for these differences are not discernable using isolated claims data, findings provide a foundation to further evaluate patient, institutional, and system-level factors that may reduce cost of care and improve value for inpatient tonsillectomy.

The Pursuit of Otolaryngology Subspecialty Fellowships

IMPORTANCE Paradoxical vocal fold motion (PVFM) affects almost 1 million adolescents in the United States. However, to date, no disease-specific objective measure exists to assess symptom severity and response to treatment in adolescents with exercise-induced PVFM. OBJECTIVES To validate the Dyspnea Index (DI) quality-of-life instrument (previously validated for adults with breathing disorders) in children aged 12 to 18 years with exercise-induced PVFM and to determine the minimum significant DI change corresponding to patient-reported or caregiver-reported improvement or worsening of symptoms. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study of 56 patients (age range, 12-18 years) diagnosed as having exercise-induced PVFM and their caregivers from February 1, 2013, to September 30, 2013, in an outpatient pediatric otolaryngology office practice. INTERVENTIONS The DI was administered to patients and caregivers, with items modified to reflect the perspective of caregivers. MAIN OUTCOMES AND MEASURES Appropriate DI change was measured to reflect improvement or worsening of symptoms. Test-retest reliability was accomplished by having a subset of patients and caregivers complete the instrument twice within 2 weeks before therapy. Internal consistency was assessed by calculation of Cronbach α. Discriminant validity and convergent validity were determined by comparing DIs with assessment of global change in symptoms. RESULTS The patient and caregiver mean (SD) DI changes were -12.9 (9.6) and -14.7 (9.3), respectively (P < .001 for both). Reliability was established by test-retest analysis with an intraclass correlation coefficient of 0.8 and by calculation of Cronbach α = 0.80, demonstrating internal consistency. Discriminant validity was determined by assessing for a significant DI change when patients globally perceived that a change existed after treatment (P < .001). A DI change of 8 or higher (P < .001) correlated with patient-reported significant change. Convergent validity was demonstrated by evaluating for significant DI change when no change was reported following treatment (P < .001). CONCLUSIONS AND RELEVANCE The DI appears to be a valid and reliable instrument to assess quality of life in exercise-induced pediatric PVFM. A DI change of 8 or higher seems significant. This instrument can serve as an objective tool to assess change in exercise-induced pediatric PVFM following speech therapy.

Operation Airway The First Sustainable, Multidisciplinary, Pediatric Airway Surgical Mission

OBJECTIVES To describe a novel technique for closure of moderate-sized nasoseptal perforations and to review the current literature on various techniques for closure of nasoseptal perforations. DESIGN Retrospective review. SETTING Academic research. PATIENTS We performed a retrospective review of a successful novel technique that has been used at a facial plastic and reconstructive surgery practice for closure of nasoseptal perforations during 3 years (January 1, 2008, to January 1, 2011). MAIN OUTCOME MEASURES Medical records were reviewed to identify patient characteristics, symptoms, causes of nasoseptal perforations, and outcomes, including patient satisfaction and rate of recurrent nasoseptal perforation. RESULTS During 3 years at our institution, 7 patients were identified with nasoseptal perforations that had been closed using bilateral mucosal advancement flaps (one inferiorly based flap advanced from the floor of the nose and another superiorly based flap advanced from the lateral nasal wall). The nasoseptal perforations ranged from 0.6 to 1.6 cm. Most patients had excellent outcomes, with resolution of symptoms and no recurrence. CONCLUSIONS Nasoseptal perforations have traditionally been closed using 2 superiorly based flaps or 2 inferiorly based flaps. We present a novel technique combining both flaps for closure of moderate-sized nasoseptal perforations. This procedure decreases the risk for recurrence of the perforation, necrosis of the flaps, and development of a new perforation.

Stress velopharyngeal incompetence: Two case reports and options for diagnosis and management

Objective To evaluate change in true vocal fold length as a function of age. Study Design Prospective study. Setting Tertiary aerodigestive center. Subjects and Methods In total, 205 patients (aged 1 month to 20 years), of whom 87 (42.4%) were female and 118 (57.6%) male, were included. Lengths of the total vocal fold (TVFL), membranous vocal fold (MVFL), and cartilaginous vocal fold (CVFL) were measured during direct laryngoscopy. Membranous-to-cartilaginous (M/C) ratios were calculated. Results For patients younger than 1 year, mean (SD) MVFL was 4.4 (1.3) mm for females and 4.9 (1.8) mm for males. At age 17 years, mean (SD) MVFL was 12.3 (2.1) mm for females and 14.0 (1.4) mm for males. Mean TVFL, MVFL, and CVFL increased an average of 0.7 mm, 0.5 mm, and 0.2 mm per year in linear fashion, respectively (linear regression, P < .0001). The M/C ratio did not significantly change with age (P = .33). Mean TVFL, MVFL, and CVFL showed no statistical difference between males and females (P = .27, .11, and .75, respectively). Conclusion This is the largest longitudinal pediatric study specifically examining vocal fold length as a function of age. Each length of the true vocal fold appeared to linearly increase for both females and males. The M/C ratio remained relatively constant, unlike previously reported data, possibly due to in vivo vs cadaveric measurements. These findings suggest that critical periods of development in females and males are not explainable by changes in vocal fold length alone, and other factors such as vocal fold layers need further exploration.

Laryngeal Reinnervation Using a Split-Hypoglossal Nerve Graft in a Canine Model

Objectives To examine otolaryngology resident interest in subspecialty fellowship training and factors affecting interest over time and over the course of residency training Study Design Cross-sectional study of anonymous online survey data. Setting Residents and fellows registered as members-in-training through the American Academy of Otolaryngology–Head and Neck Surgery. Subjects and Methods Data regarding fellowship interest and influencing factors, including demographics, were extracted from the Section for Residents and Fellows Annual Survey response database from 2008 to 2014. Results Over 6 years, there were 2422 resident and fellow responses to the survey. Senior residents showed a statistically significant decrease in fellowship interest compared with junior residents, with 79% of those in postgraduate year (PGY) 1, 73% in PGY-2 and PGY-3, and 64% in PGY-4 and PGY-5 planning to pursue subspecialty training (P < .0001). Educational debt, age, and intended practice setting significantly predicted interest in fellowship training. Sex was not predictive. The most important factors cited by residents in choosing a subspecialty were consistently type of surgical cases and nature of clinical problems. Conclusions In this study, interest in pursuing fellowship training decreased with increased residency training. This decision is multifactorial in nature and also influenced by age, educational debt, and intended practice setting.

New Technology: Use of Cine MRI for Velopharyngeal Insufficiency

Objective: This study aimed to describe the development and implementation of the first sustainable, multidisciplinary, pediatric airway surgical mission in an underserved country. Methods: This prospective, qualitative study was conducted for the first 4 Operation Airway missions in Quito, Ecuador. The major goals of the missions were to assist children with aerodigestive abnormalities, create a sustainable program where the local team could independently provide for their own patient population, develop an educational curriculum and training program for the local team, and cultivate a collaborative approach to provide successful multidisciplinary care. Results: Twenty patients ages 4 months to 21 years were included. Twenty-three bronchoscopies, 5 salivary procedures, 2 tracheostomies, 1 T-tube placement, 1 tracheocutaneous fistula closure, 2 open granuloma excisions, and 6 laryngotracheal reconstructions (LTRs) were performed. All LTR patients were decannulated. A new type of LTR (1.5 stage) was developed to meet special mission circumstances. Two videofluoroscopic swallow studies and 40 bedside swallow evaluations were performed. One local pediatric otolaryngologist, 1 pediatric surgeon, 3 anesthesiologists, 7 intensivists, 16 nurses, and 2 speech-language pathologists have received training. More than 25 hours of lectures were given, and a website was created collaboratively for educational and informational dissemination (http://www.masseyeandear.org/specialties/pediatrics/pediatric-ent/airway/OperationAirway/). Conclusion: We demonstrated the successful creation of the first mission stemming from a teaching institution with the goal of developing a sustainable, autonomous surgical airway program.

Comparison of Hybrid Laryngotracheal Reconstruction to Traditional Single- and Double-Stage Laryngotracheal Reconstruction

Stress velopharyngeal incompetence (SVPI) commonly affects brass and wind musicians. We present a series of two patients who presented with nasal air emission following prolonged woodwind instrument practice. Neither patient demonstrated audible nasal air emission during speech, but endoscopy revealed localized air escape/bubbling from different sites for each patient with instrument playing only. Both underwent tailored surgical treatment with resolution of symptoms during performance. Diagnosis of SVPI requires examination during the action that induces VPI to allow for directed management. Treatment should be targeted based on nasopharyngoscopy findings.