Rebecca J. Howell

Complications in Pediatric Deep Neck Space Abscesses

Objectives. To determine the incidence and demographic profile of children who develop complications from deep neck space abscess. Study Design. Case series. Setting. Tertiary children’s hospital. Subjects and Methods. One hundred thirty-eight patients admitted for deep neck space abscesses between 1998 and 2008. Inclusion criteria were age younger than 18 years and computed tomography scan demonstrating an abscess in the retropharyngeal, parapharyngeal, or peritonsillar spaces. Children were diagnosed with abscess if purulence was encountered on operative incision and drainage. Results. In the first 5 years of the study, 45 children met the inclusion criteria, whereas in the latter 5 years, 93 children were treated for abscesses. There were no differences between these cohorts in terms of age (P = .70), gender (P = .08), abscess site (P = .23), or rate of surgical intervention (P = .83). The total major complication rate was 9.4% (n = 13) with mediastinitis being the most frequent (n = 9) complication. The number of complications between the first (n = 3) and second (n = 10) groups was not significantly different (P = .55). The factors that predisposed patients to develop complications were younger age at presentation and retropharyngeal abscess location. Children with complications were more likely to have Staphylococcus aureus identified as the causative organism (P = .007). Only 1 of 4 children with methicillin-resistant S aureus had a complicated clinical course. Conclusions. Deep neck space abscesses continue to cause significant morbidity in children. Factors that predict complications include young age, retropharyngeal location, and S aureus. Providers must maintain a high index of suspicion to promptly diagnose and treat these complications.

Outcomes of Balloon Dilation in Pediatric Subglottic Stenosis

Objectives: We report outcomes of balloon dilation in the endoscopic management of pediatric subglottic stenosis (SGS) and discuss the role of balloon dilation in both primary and adjuvant therapy. Methods: We performed a retrospective review of treatment with noncompliant, high-pressure balloons for SGS in the past 2 years at a tertiary pediatric hospital. Fifty-one dilations were performed in 28 children with SGS. The childrens mean age was 42 months. The mean SGS grade was 2.46. Results: Fifteen children had primary balloon dilation, and 13 had adjuvant balloon dilation. Overall, 16 children (57.1%) had successful balloon dilation. Of those who underwent primary dilation, 9 (60.0%) were able to avoid open reconstruction or tracheotomy and 6 had their symptoms temporarily improved (average, 36 days) until definitive open reconstruction. Of the patients who underwent adjuvant dilation, 7 (53.8%) were successfully decannulated. Nine of the 12 failed balloon dilations were in children who had concomitant airway disorders; in contrast, only 6 of 16 children in whom treatment was successful had concomitant airway disorders (p = 0.048). There was no statistical association between successful versus failed treatment and age (51.6 versus 27.9 months; p = 0.23), degree of stenosis (grade 2.3 versus grade 2.6; p = 0.41), presence of lung disease (33.3% versus 70%; p = 0.07), or soft versus firm stenosis (60.0% versus 53.1%; p = 0.71). Conclusions: Balloon dilation plays an important role in the primary and adjuvant management of pediatric SGS. The presence of concomitant airway lesions is significantly associated with failure of balloon dilation treatment. Meticulous surveillance of the dilated airway is necessary, given this failure rate.

Unexpected pathologies in pediatric parotid lesions: Management paradigms revisited

OBJECTIVES To present case vignettes of unusual pediatric parotid pathologies and discuss management paradigms in the context of these lesions. STUDY DESIGN Retrospective case series. SETTING Free-standing, academic tertiary care pediatric hospital. METHODS All patients over the past 18 months undergoing parotidectomy for a parotid mass were reviewed (N=5). RESULTS Ages ranged from 17 months to 16 years. All presented with a remarkably similar clinical course, consisting of a persistent parotid mass for more than 3 months which was usually painless. Most (4/5 patients) had been treated with antibiotics prior to Otolaryngology consultation. Fine-needle aspiration (FNA) was performed on 3 patients and was diagnostic in one. Complete excision of the mass was performed in each child through a parotidectomy approach (3 total, 2 lateral lobe). The final pathology showed metastatic neuroblastoma (17 months old), undifferentiated primitive sarcoma (22 months old), mucoepidermoid carcinoma (11 years old), nodular fasciitis (12 years old), and hyperplastic lymph node (16 years old). The patient with neuroblastoma died from complications of bone marrow transplant. CONCLUSIONS The differential diagnosis for a persistent pediatric parotid mass is expansive and differs from that found in the adult population. As this series highlights, in many cases, it is impossible to discern the pathology, or rule out malignancy, based upon the clinical course, imaging, or FNA results. Surgical excision remains the standard for management of these patients and is both diagnostic and therapeutic. Our anecdotal case series highlights the importance of having a low threshold for parotidectomy in these children.

Resident physicians' perspectives on health care reform.

Objective. To investigate the perspectives of resident physicians, in otolaryngology and other specialties, with respect to various health care reform proposals. Also, to determine if these opinions vary between residents training to become general medical doctors versus surgeons and specialists and between those with various levels of educational debt. Study Design and Participants. Survey of resident physicians across the United States. Methods. Opinions of participants were measured on a 5-point Likert scale. Results. Of the 1576 respondents, the majority agreed that tort reform and electronic medical records would improve quality of care and help contain health care costs. However, few residents agreed that bundling of services (BOS), hospital-acquired conditions penalties (HACP), and quality-based reimbursement (QBR) would improve the quality of care. Specialists and surgeons, in comparison to generalists, were (1) less likely to agree that BOS, HACP, or QBR would improve the quality of care; (2) more likely to agree that tort reform would help contain health care costs; and (3) more likely to believe that BOS, HACP, or QBR would decrease physician compensation. Higher educational debt burden was also an independent predictor of increased skepticism about health care reforms effects on physician compensation. Conclusions. Residents in general medicine and surgery/specialty training programs agreed that tort reform and electronic medical records would help improve the quality of health care and help contain costs. However, both groups expressed strong concern that certain elements of the Patient Protection and Affordable Care Act would not achieve these goals.

Miller fisher syndrome presents as an acute voice change to hypernasal speech.

The authors describe a 38‐year‐old man who presented with hypernasality, perioral and acroparesthesia, dyspnea, and dysphagia. Further evaluation revealed a diagnosis of Miller‐Fisher syndrome (MFS). MFS is a variant of Guillain‐Barré syndrome previously described in neurology and critical care journals; however, there is a paucity of work concerning this disease in the otolaryngology literature. An acute change in voice usually occurs secondary to inflammatory processes as seen after intubation and infection, but can occur as part of a more complex disease entity such as Guillain‐Barré or Miller‐Fisher syndrome. As such, clinicians should consider this in their evaluation of rhinolalia aperta. Laryngoscope, 2010

Strength of Titanium Intramedullary Implant versus Miniplate Fixation of Mandibular Condyle Fractures

Objective To test the strength of internal fixation of mandibular condyle fractures repaired with titanium miniplates versus titanium intramedullary implants. Study Design Prospective laboratory experimentation in urethane mandible models and human cadaveric mandibles. Setting Materials testing laboratory at an academic medical center. Methods Osteotomies of the mandibular condyle were created in 40 urethane hemimandible models and 24 human cadaveric specimens. Half of the samples in each group were repaired with traditional miniplates, and the other half were repaired with intramedullary titanium implants. Anteroposterior and mediolateral loads were applied to the samples, and the displacement was measured with reference to the applied force. Results Titanium intramedullary implants demonstrated statistically significant improved strength and stiffness versus miniplates in the urethane model experimental groups. Despite frequent plastic deformation and mechanical failures of the miniplates, a 1.6-mm-diameter titanium intramedullary pin did not mechanically fail in any of the cases. Intramedullary implantation failures were due to secondary fracture of the adjacent cortical bone or experimental design limitations including rotation of the smooth pin implant. Conclusion Mechanical implant failures that were encountered with miniplate fixation were not seen with titanium intramedullary implants. These intramedullary implants provide stronger and more rigid fixation of mandibular condyle fractures than miniplates in this in vitro model.

The Value of Otolaryngologists’ Services in America A National Survey

Objective. To evaluate the perceived monetary value of physician services within the general population and to foster academic discussion about the finances of clinical practice in the setting of recent health care reform. Study Design, Subjects, and Methods. National survey of 409 members of the general population and review of Centers for Medicare and Medicaid Services data. Results. The perceived monetary values of office visits were comparable to the actual physician reimbursements. However, the average perceived value associated with surgical treatments was significantly higher than the true Medicare reimbursement amount. For example, survey participants said that a reasonable price for a doctor to be paid for performing a tonsillectomy is

A Systematic Review of Patient- or Proxy-Reported Validated Instruments Assessing Pediatric Dysphagia.

955.58, whereas the national average Medicare reimbursement is

Office-based esophageal dilation in head and neck cancer: Safety, feasibility, and cost analysis: Office-Based Esophageal Dilation in HNCA

257.74. Furthermore, 59% of respondents also believe that insurers, Medicare, and Medicaid pay doctors more than the respondent’s perceived value for each service. Conclusion. The current patterns of Centers for Medicare and Medicaid Services reimbursement reveal a trend of declining payments for physician services. A survey of a sample of the general population indicated that most people believe that their doctors are paid far more than they actually are. It is important for otolaryngologists and head and neck surgeons to understand and discuss the economic forces that continue to shape our practices, and it is vital that we all play an active role in the discussions surrounding the evolution of the American health care system.

Maternity and paternity leave in otolaryngology residency training in the United States: Parental Leave Policies in Otolaryngology

Objective Pediatric dysphagia occurs in 500,000 children each year; however, there is not a common tool to assess these children. Our aim was to identify validated patient- or parent-reported outcome assessment tools evaluating pediatric dysphagia. Data Sources Scopus, EMBASE, PubMed, Cochrane Library, and CINAHL electronic databases (all indexed years through August 2014). Review Methods Inclusion criteria included English-language articles containing instruments evaluated in children. Two investigators independently reviewed all articles, and the review was performed according to PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Results The initial search yielded 1697 abstracts; 158 studies were assessed further. Four symptom questionnaires, validated in adults, were used to report pediatric dysphagia outcomes. Four outcomes tools assessing dysphagia were validated in pediatrics in selected populations. The Dysphagia in Multiple Sclerosis questionnaire and the Dysphagia Symptom Questionnaire for eosinophilic esophagitis were validated in adolescents and adults. The Symptom Questionnaire for Eosinophilic Esophagitis was validated in children with eosinophilic esophagitis. The Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module, validated in children with gastrointestinal disorders, includes 2 domains that assess swallowing function. Conclusion We did not identify any validated patient- or parent-reported outcome assessment tools examining dysphagia symptoms in a general pediatric population. However, we identified 4 questionnaires that have been validated in specific pediatric disease cohorts. Having a standardized assessment instrument validated in all children would allow clinicians to systematically report symptoms and compare results of pediatric clinical trials. With this in mind, we recommend establishing a standard questionnaire for the broader pediatric population.