Stacey L. Ishman

Clinical Practice Guideline Allergic Rhinitis

Objective Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates

Temporal Bone Fractures: Traditional Classification and Clinical Relevance

2 to

Racial/ethnic and socioeconomic disparities in the diagnosis and treatment of sleep-disordered breathing in children

5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as

Prevalence and severity of obstructive sleep apnea and snoring in infants with Pierre Robin sequence.

2 to

The effects of Anesthesia and opioids on the upper airway: A systematic review

4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options. Purpose The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients. Action Statements The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Depression, sleepiness, and disease severity in patients with obstructive sleep apnea

Objectives/Hypothesis: The objectives were to evaluate the clinical relevance of traditional temporal bone radiographic descriptors and to investigate the efficacy of an alternative fracture classification scheme.

Systematic review of site of obstruction identification and non-CPAP treatment options for children with persistent pediatric obstructive sleep apnea.

OBJECTIVE Although racial/ethnic and socioeconomic healthcare disparities in pediatric primary care are widely documented, little is known regarding health disparities for common otolaryngic conditions. Pediatric sleep-disordered breathing (SDB) is highly prevalent, associated with significant physical and neurocognitive sequelae, and a common reason for pediatric otolaryngology referral. We sought to synthesize information from published findings related to racial/ethnic and socioeconomic disparities in children with SDB. METHODS Qualitative systematic review of MEDLINE database for articles reporting on racial/ethnic or socioeconomic differences in prevalence, diagnosis or surgical treatment of SDB in children over 30 years. RESULTS Of 210 abstracts identified, 33 met inclusion criteria. 24 articles directly addressed differences in race/ethnicity and socioeconomic status, and 10 had findings which identified a disparity. Differences were identified in prevalence, sleep patterns, and sequelae of pediatric SDB (24/33) and in access to care and utilization of adenotonsillectomy (10/33). Black children (12/33) and children with socioeconomic deprivation (17/33) were the most common minority groups studied. Although conclusions were broad, common study findings showed: (1) children in racial/ethnic and socioeconomic minorities may have higher prevalence and greater risk for SDB, and (2) In the U.S., white children or children with private insurance are more likely to undergo adenotonsillectomy. CONCLUSIONS Racial/ethnic and socioeconomic disparities are prevalent among children with SDB. Disparities in multiracial populations and disparities in access to care, treatment, and utilization of services for pediatric SDB require more detailed investigation. Given the potential negative impact of SDB in children, as well as its economic consequences, the evaluation of disparities should be prioritized in health policy research.

Characterization of Obstructive Sleep Apnea Before and After Tongue-Lip Adhesion in Children With Micrognathia

Objective To evaluate the prevalence and severity of obstructive sleep apnea in infants with Pierre Robin sequence prior to airway intervention and determine whether snoring correlates with the presence of obstructive sleep apnea in this population. Design Retrospective case series. Setting Urban tertiary care teaching hospital. Participants/Methods Review of infants with Pierre Robin sequence who underwent polysomnography in the first year of life from 2002 to 2007. Only results from the initial polysomnography were analyzed. A subgroup of consecutive prospectively tested patients was also evaluated. Results A total of 33 infants with Pierre Robin sequence were identified. Of these, 13 (39%), 11 girls and two boys, underwent polysomnography in the first year of life. The mean age at evaluation was 48 days (range, 7 to 214 days). Seven nonconsecutive and six consecutive patients were included, and no significant differences were seen between groups. Obstructive sleep apnea was identified in 11 of 13 (85%) infants. The mean obstructive apnea-hypopnea index was 33.5 (range, 0 to 85.7). Obstructive sleep apnea severity was mild in 2 of 11 (18%), moderate in 3 of 11 (27%), and severe in 6 of 11 (55%). Mean end-tidal Pco2 measurements were elevated at 59 mm Hg (range, 47 to 76 mm Hg). Mean oxygen saturation nadir was decreased at 80% (range, 68% to 93%). Snoring occurred in only 7 of 13 (54%). Of the subjects with obstructive sleep apnea, snoring occurred in 6 of 11 (55%). Conclusion The high incidence of obstructive sleep apnea in this group suggests that polysomnography should be promptly performed in children with Pierre Robin sequence. Although snoring was seen in the majority, the absence of snoring did not exclude the presence of obstructive sleep apnea.

A case‐control comparison of lingual tonsillar size in children with and without down syndrome

Drug‐induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are poorly understood. Our aim was to systematically review existing literature on the effects of anesthetic agents on the upper airway.

Plastic bronchitis: An unusual bronchoscopic challenge associated with congenital heart disease repair

To determine if a relationship exists between depression, disease severity, and sleepiness in patients with obstructive sleep apnea (OSA).