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Objectives: The objective of this study is to compare serum allergen-specific IgE to IgE levels in nasal tissue taken from the inferior turbinates of pediatric patients undergoing turbinate reduction. Methods: Twenty-six pediatric patients were recruited at the time of turbinate reduction surgery. At the time of recruitment, parents of patients completed the validated 22 item Sinonasal Outcome Test (SNOT-22) to describe symptoms prior to surgery. A sample of turbinate tissue was taken during turbinate reduction and blood was collected. Tissue and serum IgE were measured and differences in the group characteristics were evaluated using Chi-square tests for binary variables and Wilcoxon-Mann-Whitney tests for continuous variables. Student’s t test was used to assess differences in means of total SNOT-22 scoring between the groups, and Wilcoxon-Mann-Whitney tests were used again for the rest of the SNOT-22 analysis. Results: Levels of IgE in the serum were compared to levels in the turbinate tissue from all patients for each individual allergen. Every allergen except Alternaria displayed significant correlation between the serum and turbinate IgE levels. Additionally, each allergen except Alternaria and oak tree resulted in a strong correlation ( r > .7) based on the correlation coefficients. Levels of Alternaria were found to be poorly correlative between serum and turbinate tissue, and significance was not achieved ( r = −.346, P = .11). Conclusion: Certain allergen-specific IgE antibodies in the nasal mucosa seem to be highly associated with those in the serum, based upon the significant correlations we found between the two.

Although the vast majority of pediatric neck masses are benign, pediatric malignancies commonly present in the supraclavicular region. We present the case of a 4-year-old male who presented with a mass in the trapezius muscle with accompanying lymphadenopathy. An extensive work-up was performed to exclude malignancy, and the patient was ultimately diagnosed with a benign monocytic mass, which surgically excised. He has been doing well since surgery with no evidence of recurrence. A review of the literature revealed this case to be the first of its kind to be reported.

Introduction An opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing. Methods A prospective, pilot study was performed in 10 patients (3–8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 μg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain. Results The study cohort included 10 patients, 3–8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients’ guardians were satisfied or highly satisfied with their child’s pain control. Conclusion This opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.

To provide preclinical medical students early access to otolaryngologists to learn about the specialty, facilitate acquisition of clinical skills, and provide one-on-one mentorship.Students are matched with a single otolaryngology faculty mentor from The Ohio State University/Nationwide Children's Hospital and attend 8 hours per month in the clinic or operating room, monthly lectures, and rounds, and they give a final presentation. Mentors complete performance evaluations, and surveys are administered longitudinally until Match Day.Thirty-five students and 17 faculty members have participated in the program since 2015. All mentors and students found the program to be a valuable experience. When compared to nonparticipating students, participants had significantly higher confidence scores for clinical performance, knowledge of anatomy, and familiarity with the department of interest. All students felt the program prepared them well for third and fourth years, and all 8 of the initial program participants successfully matched into residency with 4 entering otolaryngology.Medical students face a competitive residency application process in otolaryngology with limited exposure, which creates an opportunity for guidance in the pursuit of matching into this field. This novel preclinical mentorship program prepares students for their clinical years and residency by facilitating acquisition of various competencies. Students gain hands-on clinical exposure in a field of interest and support for navigating the application process.The structure of this program can be applied to other medical schools or specialties if the individual departments contain adequate resources of teaching faculty willing to participate.

Nonaccidental trauma is a common pediatric concern that often goes unrecognized. Although most patients present with bruising, burns, fractures, and head trauma, it is critical that physicians be able to diagnose and treat atypical presentations such as pharyngeal and esophageal trauma. In this report, we describe the presentation and management of a 5-week-old girl with an inflicted esophageal perforation.

A 9-year-old male with history of mixed hearing loss presented with petrous apex lesion following episode of meningitis. Serial imaging revealed persistence of the lesion necessitating biopsy to rule out malignancy. Biopsy revealed inflammatory changes. The management of petrous apex lesions following meningitis can be conservative but repeat imaging is necessary to rule out progression and to rule out neoplastic process.

BackgroundThe lack of an objective method to evaluate the eardrum is a critical barrier to an accurate diagnosis. Eardrum images are classified into normal or abnormal categories with machine learning techniques. If the input is an otoscopy video, a traditional approach requires great effort and expertise to manually determine the representative frame(s).MethodsIn this paper, we propose a novel deep learning-based method, called OtoXNet, which automatically learns features for eardrum classification from otoscope video clips. We utilized multiple composite image generation methods to construct a highly representative version of otoscopy videos to diagnose three major eardrum diseases, i.e., otitis media with effusion, eardrum perforation, and tympanosclerosis versus normal (healthy). We compared the performance of OtoXNet against methods with that either use a single composite image or a keyframe selected by an experienced human. Our dataset consists of 394 otoscopy videos from 312 patients and 765 composite images before augmentation.ResultsOtoXNet with multiple composite images achieved 84.8% class-weighted accuracy with 3.8% standard deviation, whereas with the human-selected keyframes and single composite images, the accuracies were respectively, 81.8% ± 5.0% and 80.1% ± 4.8% on multi-class eardrum video classification task using an 8-fold cross-validation scheme. A paired t-test shows that there is a statistically significant difference (p-value of 1.3 × 10−2) between the performance values of OtoXNet (multiple composite images) and the human-selected keyframes. Contrarily, the difference in means of keyframe and single composites was not significant (p = 5.49 × 10−1). OtoXNet surpasses the baseline approaches in qualitative results.ConclusionThe use of multiple composite images in analyzing eardrum abnormalities is advantageous compared to using single composite images or manual keyframe selection.

BACKGROUND: Corrective nasal surgery has historically been avoided in the pediatric population out of concerns surrounding the potential disruption of nasal growth centers. There is a paucity of data on the rate of complications or revision surgery following septoplasty in this population. As such, the purpose of this study is to review the long-term outcomes of a large cohort of children who underwent nasal septoplasty and to compare outcomes of septoplasty patients under the age of 14 to those 14 years and older. METHODS: A retrospective review was performed on all patients who received nasal septoplasty at our tertiary care pediatric referral center between October 2009 and September 2016. All patients who underwent septoplasty for a deviated nasal septum and were 0–18 years of age at the time of surgery were included in this analysis. Outcomes were compared between patients under the age of 14 to those 14 years and older. Demographic, surgical, and follow-up data were collected including complications and the need for revision surgery. RESULTS: A total of 194 pediatric patients were identified as meeting inclusion criteria for the study. Mean age for the total cohort was 14.6 years (0–18 years), with a mean of 15.9 years in the older group and 10.6 years in the younger group. Revision septoplasty was performed more frequently in the younger group. However, no significant difference in the rate of complications was seen between the two groups. CONCLUSIONS: To the best of our knowledge, this is the largest retrospective study examining outcomes following septoplasty in pediatric patients. We also specifically examine outcomes of very young septoplasty patients, a population for which limited evidence exists. Further retrospective studies are needed to validate the use of nasal septoplasty in the pediatric population.

This study investigates outcomes of surgical management of pediatric patients with nasal dermoids with prior infection. A retrospective review at Nationwide Children’s Hospital, a large free-standing pediatric hospital in the Midwestern USA, was performed. Patients were identified by the Current Procedural Terminology codes 30124 (simple excision of dermoid cyst) and 30125 (complex excision of nasal dermoid cyst) from 2011 to 2016. Demographic, imaging data, surgical findings, microbiological data and recurrence rates were collected for these patients. Descriptive statistical investigation was performed. In total, 14 patients were identified, 4 of the 14 patients (28.5%) had recurrent infection and required additional surgery. Three of seven patients required incision and drainage prior to definitive excision. One of seven patients in the infected group had recurrence. Prior infection does not increase the recurrence rate and almost half of the patients required I&D prior to definitive management.

Despite advances in surgical technique, postoperative hemorrhage remains a common cause of mortality and morbidity for patients following tonsillectomy. Application of biomaterials at the time of tonsillectomy can potentially accelerate mucosal wound healing and eliminate the risk of post-tonsillectomy hemorrhage (PTH). To understand the current state and identify possible routes for the development of the ideal biomaterials to prevent PTH, topical biomaterials for eliminating the risk of PTH were reviewed. Alternative topical biomaterials that hold the potential to reduce the risk of PTH were also summarized.

Objectives Chronic rhinosinusitis is a common, costly condition often treated with endoscopic sinus surgery and intraoperative placement of intranasal sinus implant materials. Whereas these materials aid in postoperative healing, they also support bacterial biofilm formation and thus contribute to negative outcomes. This study examined pretreatment of sinus implant materials with antibody against an essential bacterial biofilm structural component, the DNABII family of DNA-binding proteins, as a strategy to prevent biofilm formation. Methods Sinus implant materials were equilibrated in immunoglobulin G (IgG)-enriched antiserum against the DNABII protein integration host factor (IHF), individually or in combination with amoxicillin-clavulanate prior to inoculation with nontypeable Haemophilus influenzae (NTHI), a predominant pathogen of chronic rhinosinusitis. After 16 hours, the bacterial burden was quantitated and compared to pretreatment with saline, IgG-enriched naive serum, or amoxicillin-clavulanate alone. Results NTHI readily formed biofilms on all three materials in vitro. However, pretreatment of each material with IgG-enriched anti-IHF resulted in a significant decrease in bacterial burden compared to controls (P ≤ 0.05). Moreover, a significant and synergistic outcome was achieved with a cocktail of anti-IHF plus amoxicillin-clavulanate (P ≤ 0.05) with complete inhibition of NTHI biofilm formation on all three materials. Conclusions Biofilm formation was well supported in vitro on three sinus implant materials that vary in composition and resorption characteristics; however, pretreatment of each with DNABII protein targeted antibodies in combination with a previously ineffective antibiotic was highly effective to prevent the formation NTHI biofilms. These data demonstrate the potential for clinical utility of pretreatment of sinus implant and additional surgical materials with anti-DNABII antibodies. Level of evidence NA Laryngoscope, 130:1364-1371, 2020.

Objectives: To evaluate the impact of allograft and xenograft in pediatric tympanoplasty on patient outcomes. Methods: A retrospective cohort study of 50 pediatric patients undergoing tympanoplasty at a single tertiary pediatric hospital system that received either autograft, allograft, or xenograft. Patients were evaluated for persistent perforation, recurrent perforation, revision surgery, and postoperative infection. Hearing outcomes, operative charges, and operative time were also evaluated. Statistical analyses included chi-square and Fisher exact tests for categorical data and Wilcoxon-Mann-Whitney tests for continuous data. Results: Half of the cohort received autografts, whereas 38% received xenografts and 14% received allografts. Although there was not a significant difference in charges associated with these procedures, xenografts had the shortest mean operative time (mean: 39 vs 68 minutes in autografts, p = .05). Overall, the rate of persistent perforation was 10%, recurrent perforation was 20%, revision surgery was 16%, and postoperative infection was 18%. There were no differences in the rates of these outcomes by graft type. Furthermore, there was no observed difference in hearing outcomes among autograft and xenograft recipients, but allograft recipients had significantly improved hearing postoperatively. Conclusions: Similar rates of complications were observed among autografts, xenografts, and allografts, providing preliminary evidence that they are safe to use in pediatric tympanoplasty.

Objective: Overnight admission may be necessary following adenotonsillectomy (T&A) in pediatric patients. This practice may reduce unplanned revisits following hospital discharge. Study design: Retrospective cohort study. Subjects: Children from the PHIS database. Methods: T&A performed in children during the years 2007-2015 were identified in the Pediatric Health Information System. The primary outcome was 7-day, all-cause readmission or emergency department (ED) revisit. Secondary analysis examined specific revisit types and 30-day revisits. The primary exposure was each institution's annual rate of overnight stay after T&A. Results: The analysis included 411,876 procedures at 48 hospitals. Hospitals' annual rates of overnight stay following T&A ranged from 3% to 100%, and 7-day revisit rates varied from 0% to 15%. The percentage or rate of 7-day revisits did not differ based on the use of overnight stay following T&A. At hospitals with higher overnight admission rates after T&A, 7-day revisits were more likely to take the form of inpatient admission rather than an ED visit. Conclusions: The current study confirms that pediatric hospitals vary widely in inpatient admission practices following T&A. This variation is not associated with differences in revisit rates at 7 and 30 days related to any cause. Although no mortality was noted in the current study, caution is suggested when deciding on the disposition of patients with comorbid conditions as risks related to various patients, anesthetic, and surgical-related issues exist. Risk stratification with appropriate identification of patients requiring overnight stay may be the most important for preventing acute care revisits after T&A.

Objectives/hypothesis Oxymetazoline is an α-adrenergic agonist that is commonly used as a topical hemostatic agent in the operating room during ear, nose, and throat surgery. There are limited data on oxymetazoline pharmacokinetics in children who undergo general anesthesia. We assessed the hemodynamic effects and systemic absorption of topically applied oxymetazoline in children undergoing various nasal procedures. Study design Prospective trial. Methods Children ages 2 to 17 years undergoing functional endoscopic sinus surgery, turbinate resection, or adenoidectomy were enrolled. The surgeon placed oxymetazoline-soaked pledgets (1.5 mL of 0.05% solution) according to our usual clinical practice. Blood samples for oxymetazoline assay were drawn at 5, 10, 20, 45, 90, and 150 minutes, and hemodynamic data were recorded at 5-minute intervals. Data analysis included mixed-effects regression and population pharmacokinetic/pharmacodynamic modeling. Results The analysis included 27 patients, age 7 ± 4 years, who received between 2 and 12 pledgets (3-18 mL) of oxymetazoline. Relative bioavailability compared to the spray formulation was 2.3 (95% confidence interval [CI]: 1.6-3.2), with slow absorption from the mucosal surface (absorption half-life 64 minutes; 95% CI: 44-90). Mean arterial pressure did not increase with oxymetazoline instillation at the observed oxymetazoline serum concentrations (0.04-7.6 μg/L). Conclusions Despite concerns regarding oxymetazoline administration to mucosal membranes, we found that hemodynamic changes were clinically negligible with our usual clinical use of pledgets soaked in oxymetazoline. Compared to data on oxymetazoline in spray formulation, bioavailability was increased twofold with pledgets, but systemic absorption was very slow, contributing to low serum concentrations and limited hemodynamic effects. Level of evidence 1b. Laryngoscope, 129:2775-2781, 2019.

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.

OBJECTIVES/HYPOTHESIS To evaluate the ability of humanized monoclonal antibody fragments directed against a bacterial DNABII protein plus ofloxacin delivered directly into the chinchilla middle ear via tympanostomy tube (TT) to enhance the ability of ofloxacin to eradicate biofilms formed by nontypeable Haemophilus influenzae (NTHI). STUDY DESIGN A blinded pre-clinical study of comparative efficacy of single versus combinatorial treatment strategies. METHODS NTHI was allowed to form biofilms in the middle ears of chinchillas prior to TT placement. Ofloxacin, humanized Fab fragments against a bacterial DNABII protein that disrupts biofilms or Fab fragments plus ofloxacin were instilled into the middle ear via TT. For two consecutive days, ofloxacin was delivered twice-a-day, Fab fragments were delivered once-a-day, or these treatments were combined. Relative biofilm resolution (as determined via two outcome measures) and eradication of viable NTHI were assessed 1-day later. RESULTS Whereas ofloxacin alone did not resolve biofilms or eradicate NTHI from the middle ear, delivery of Fab fragments significantly reduced both biofilms and NTHI burden over this short course of treatment. Notably, co-delivery of ofloxacin plus humanized Fab fragments eradicated both NTHI and biofilms from the middle ear, an enhanced outcome compared to receipt of either treatment alone. CONCLUSION This study demonstrated a powerful combinatorial approach to release bacteria from their protective biofilms and rapidly render them vulnerable to killing by a previously ineffective antibiotic. An approach to combine ofloxacin with humanized Fab fragments that disrupt biofilms has tremendous potential to quickly resolve chronic otorrhea suffered by children with chronic suppurative otitis media or chronic post-tympanostomy tube otorrhea and thereby improve their quality of life. LEVEL OF EVIDENCE NA Laryngoscope, 131:E2698-E2704, 2021.

Tympanic membrane (TM) diseases are among the most frequent pathologies, affecting the majority of the pediatric population. Video otoscopy is an effective tool for diagnosing TM diseases. However, access to Ear, Nose, and Throat (ENT) physicians is limited in many sparsely-populated regions worldwide. Moreover, high inter- and intra-reader variability impair accurate diagnosis. This study proposes a digital otoscopy video summarization and automated diagnostic label assignment model that benefits from the synergy of deep learning and natural language processing (NLP). Our main motivation is to obtain the key visual features of TM diseases from their short descriptive reports. Our video database consisted of 173 otoscopy records from three different TM diseases. To generate composite images, we utilized our previously developed semantic segmentation-based stitching framework, SelectStitch. An ENT expert reviewed these composite images and wrote short reports describing the TM's visual landmarks and the disease for each ear. Based on NLP and a bag-of-words (BoW) model, we determined the five most frequent words characterizing each TM diagnostic category. A neighborhood components analysis was used to predict the diagnostic label of the test instance. The proposed model provided an overall F1-score of 90.2%. This is the first study to utilize textual information in computerized ear diagnostics to the best of our knowledge. Our model has the potential to become a telemedicine application that can automatically make a diagnosis of the TM by analyzing its visual descriptions provided by a healthcare provider from a mobile device.

The accurate diagnosis of otitis media (OM) and other middle ear and eardrum abnormalities is difficult, even for experienced otologists. In our earlier studies, we developed computer-aided diagnosis systems to improve the diagnostic accuracy. In this study, we investigate a novel approach, called OtoPair, which uses paired eardrum images together rather than using a single eardrum image to classify them as ‘normal’ or ‘abnormal’. This also mimics the way that otologists evaluate ears, because they diagnose eardrum abnormalities by examining both ears. Our approach creates a new feature vector, which is formed with extracted features from a pair of high-resolution otoscope images or images that are captured by digital video-otoscopes. The feature vector has two parts. The first part consists of lookup table-based values created by using deep learning techniques reported in our previous OtoMatch content-based image retrieval system. The second part consists of handcrafted features that are created by recording registration errors between paired eardrums, color-based features, such as histogram of a* and b* component of the L*a*b* color space, and statistical measurements of these color channels. The extracted features are concatenated to form a single feature vector, which is then classified by a tree bagger classifier. A total of 150-pair (300-single) of eardrum images, which are either the same category (normal-normal and abnormal-abnormal) or different category (normal-abnormal and abnormal-normal) pairs, are used to perform several experiments. The proposed approach increases the accuracy from 78.7% (±0.1%) to 85.8% (±0.2%) on a three-fold cross-validation method. These are promising results with a limited number of eardrum pairs to demonstrate the feasibility of using a pair of eardrum images instead of single eardrum images to improve the diagnostic accuracy.

ObjectivesWith the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video.MethodsFive Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer-assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image.ResultsThere were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter-reader agreement was moderate.ConclusionEqual to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/family counseling, and clinical training.Level of EvidenceLevel 3

Oral surgeons remove third molars (wisdom teeth) to prevent impaction. Given the close anatomical relationship to the maxillary sinus, perforation and displacement of third molars into the maxillary sinus is a well-known phenomenon that is typically removed with a buccal mucoperiosteal flap or through a Caldwell–Luc approach. However, a less invasive route of endoscopic removal has been utilized to success in one report. A literature review shows few reports of displaced molars into the maxillary sinus and no reported patient below the age of 18. A 14-year-old patient presented with a displaced third molar into her maxillary sinus following third molar extraction with her oral surgeon. The tooth was removed successfully, utilizing endoscopic sinus surgery (ESS) with a transition to transoral retrieval to prevent nasal trauma. This is the first reported case of displaced third molar into the right maxillary sinus in a pediatric patient that was removed via ESS.

To compare the incidence of middle ear effusion (MEE) at the time of bilateral tympanostomy tube insertion (BTI) for recurrent acute otitis media (rAOM) patients initially seen in-office or via telehealth.After obtaining IRB approval from Nationwide Children's Hospital, a total of 524 patients evaluated for rAOM were retrospectively reviewed after being divided into two cohorts: those seen via a telehealth visit from April to June of 2020 (n = 140), and those seen via an in-person visit from April to June of 2019 (n = 384). Recommendation for BTI was captured for each patient following their visit. Clinical characteristics documented at the time of the visit, such as history of intramuscular (IM) antibiotic use and hearing or speech concerns were also captured to determine whether both telehealth and in-person cohorts were similar in clinical presentation. For BTI patients, the presence or absence of MEE in either ear at the time of BTI was recorded. Patients with cleft palate or prior BTI were excluded.51.43% (72/140) of patients in the telehealth cohort were recommended for BTI. Of those recommended, 87.50% (63/72) underwent BTI. Of these, 31.75% (20/63) had a MEE at the time of BTI. In the in-office cohort, 69.01% (265/384) of patients were recommended for BTI. Of those recommended, 92.83% (246/265) underwent BTI. Of these, 69.92% (172/246) had a MEE at the time of BTI.There were significantly less middle ear effusions in the telehealth cohort compared to the in-office cohort (p 0.0001). It is well understood that telehealth is limited in its physical exam capabilities. It is possible that the use of telehealth for the surgical management of rAOM may lead to more procedures on patients without MEE.

The purpose of this paper is to explore the current literature on telemedicine in otolaryngology, focusing on the potential for telemedicine in the field and the major modalities available. Ultimately, the goal is to summarize telemedicine implementation in otolaryngology during the COVID-19 pandemic and potential long term applications. This paper analyzes a variety of studies that have evaluated the efficacy of different telemedicine approaches in otolaryngology, with commentary on what these results mean for the potential of telemedicine during the COVID-19 pandemic. Otolaryngology is well-suited for telemedicine, and this technology is viewed favorably by both patients and physicians. However, its application cannot be generalized to such a wide-ranging specialty. Furthermore, store and forward technology, which has been traditionally used to provide care to remote and underserved populations, and synchronous technology both have the potential to limit unnecessary in-person visits—ultimately keeping both patients and providers safe as social distancing continues.

Sinusitis is a common pediatric illness that can be complicated by periorbital or intracranial extension. Patients can be managed with antimicrobials alone or in conjunction with surgical intervention. This article examines management patterns and outcomes in pediatric patients presenting with complicated sinusitis.Case series with chart review.Tertiary care pediatric hospital.An evaluation of 168 pediatric patients with complicated sinusitis with periorbital complications presenting at a single institution from 2008 to 2018 was performed. Demographics, disease characteristics, in-hospital management, and outcomes were recorded and analyzed.The most common complication was orbital cellulitis, seen in 49% of children. Surgical intervention occurred in 49% of patients, with 36% receiving medical therapy followed by surgery (MTS). Chandler I patients underwent surgical intervention 30% of the time, Chandler II patients 29%, and Chandler III patients 83%. Nineteen percent of initially nonoperative patients started on ampicillin-sulbactam required MTS vs 57% of those started on other antibiotic regimens (Nonoperative early stage patients started on ampicillin-sulbactam had a lower risk of MTS. MTS did not cost significantly more than SMT, and there were no significant outcome differences seen.

Ear diseases are frequently occurring conditions affecting the majority of the pediatric population, potentially resulting in hearing loss and communication disabilities. The current standard of care in diagnosing ear diseases includes a visual examination of the tympanic membrane (TM) by a medical expert with a range of available otoscopes. However, visual examination is subjective and depends on various factors, including the experience of the expert. This work proposes a decision fusion mechanism to combine predictions obtained from digital otoscopy images and biophysical measurements (obtained through tympanometry) for the detection of eardrum abnormalities. Our database consisted of 73 tympanometry records along with digital otoscopy videos. For the tympanometry aspect, we trained a random forest classifier (RF) using raw tympanometry attributes. Additionally, we mimicked a clinician’s decision on tympanometry findings using the normal range of the tympanogram values provided by a clinical guide. Moreover, we re-trained Inception-ResNet-v2 to classify TM images selected from each otoscopic video. After obtaining predictions from each of three different sources, we performed a majority voting-based decision fusion technique to reach the final decision. Experimental results show that the proposed decision fusion method improved the classification accuracy, positive predictive value, and negative predictive value in comparison to the single classifiers. The results revealed that the accuracies are 64.4% for the clinical evaluations of tympanometry, 76.7% for the computerized analysis of tympanometry data, and 74.0% for the TM image analysis while our decision fusion methodology increases the classification accuracy to 84.9%. To the best of our knowledge, this is the first study to fuse the data from digital otoscopy and tympanometry. Preliminary results suggest that fusing information from different sources of sensors may provide complementary information for accurate and computerized diagnosis of TM-related abnormalities.

Although one of the most commonly performed surgical procedures in children and frequently performed as outpatient surgery, the postoperative course following tonsillectomy may include nausea, vomiting, poor oral intake, and pain. These problems may last days into the postoperative course. Although opioids may be used to treat the pain, comorbid conditions such as obstructive sleep apnea may mandate limiting the dose and the frequency of administration. Adjunctive agents may improve the overall postoperative course of patients and limit the need for opioid analgesics. Dexamethasone is a frequently administered intraoperatively as an adjunctive agent to decrease inflammation and pain, limit the potential for postoperative nausea and vomiting, and improve the overall postoperative course. The following manuscript reviews the use of dexamethasone to improve outcomes following tonsillectomy or adenotonsillectomy, discusses the controversies regarding its potential association with perioperative bleeding, and investigates options for dosing regimens which may maintain the beneficial physiologic effects while limiting the potential for bleeding.

Acute complicated sinusitis can occur in children and can lead to significant morbidity and mortality. While medical management is critical, it is important to provide multi-disciplinary care to involve surgical specialists. Since intracranial and extracranial complications can result from acute sinusitis, active communication among all these specialists is paramount to achieve the best patient outcomes. Children with these conditions are best managed at centers where appropriate pediatric medical and surgical subspecialty care is available.

OBJECTIVES Adequate pain control is an important component in the postoperative outcome for pediatric adenotonsillectomy patients with sleep-disordered breathing (SDB). Intravenous acetaminophen appears to be a favorable analgesic adjunct owing to its predictable pharmacokinetics and opioid-sparing effects; however, its role in pediatric adenotonsillectomy pain management remains unclear. METHODS In this prospective, randomized, double-blinded, controlled study, subjects with the diagnosis of SDB, aged 2 to 8 years, who required extended postoperative admission, received intravenous acetaminophen (15 mg/kg) or saline placebo intraoperatively in addition to morphine (0.1 mg/kg) for postoperative surgical analgesia. Pain scores in the postanesthesia care unit (PACU) using the FLACC (Faces, Leg, Activity, Cry, Consolability) score were used to determine the need for supplemental analgesic agents in the PACU. The PACU time and time to the first request for pain medication on the inpatient ward were also measured. RESULTS A total of 239 patients were included in the final data analysis (118 in the intravenous acetaminophen group and 121 in the saline placebo group). The 2 groups did not differ in the proportion of patients reaching FLACC scores = 4 in the PACU (p = 0.223); mean FLACC scores in the PACU (p = 0.336); mean PACU time (p = 0.883); or time to requesting pain medication on the inpatient ward (p = 0.640). CONCLUSIONS A single intraoperative dose of intravenous acetaminophen did not alter the postoperative course of pediatric patients with SDB following adenotonsillectomy.

Dexamethasone is currently recommended for routine prophylaxis against postoperative nausea and vomiting after tonsillectomy procedures. However, some studies have raised concern that dexamethasone use may lead to higher rates of post-tonsillectomy hemorrhage. Our objective was to determine whether higher doses of dexamethasone administered perioperatively during tonsillectomy procedures are associated with an increased risk of secondary post-tonsillectomy hemorrhage.We conducted a retrospective review of 9843 patients who underwent tonsillectomy and received dexamethasone at our institution from January 2010 to October 2014. We compared the dose of dexamethasone administered to patients who did and did not develop secondary post-tonsillectomy hemorrhage using Mann Whitney U tests. Multivariable logistic regression models were used to evaluate the association between dexamethasone dose and post-tonsillectomy hemorrhage after adjustment for demographic and clinical characteristics.A total of 280 (2.8%) patients developed secondary post-tonsillectomy hemorrhage. Patients who developed hemorrhage tended to be older (median (interquartile range) 7 (4-11) vs. 5 (3-8) years), p 0.001) and had undergone tonsillectomy more often for chronic tonsillitis but less often for tonsillar or adenotonsillar hypertrophy or sleep disturbances. Dexamethasone dose was significantly lower on average in patients who experienced secondary post-tonsillectomy hemorrhage (median (interquartile range) 0.19 (0.14, 0.23) mg/kg vs. 0.21 (0.17, 0.30), p 0.001). Multivariable modeling demonstrated that the dose of dexamethasone was not significantly associated with post-tonsillectomy hemorrhage after adjustment for age.There does not appear to be a dose-related increase in the risk of post-tonsillectomy hemorrhage for patients receiving dexamethasone during tonsillectomy procedures.

To determine the clinical impact of an initiative to use ultrasound (US) as the primary diagnostic modality for children with superficial face and neck infections versus use of computed tomography (CT).Children with a diagnosis of lymphadenitis, face or neck abscess, or face and neck cellulitis were retrospectively evaluated by the otolaryngology service. Patients were separated into two groups based on implementation of a departmental initiative to use US as the primary diagnostic modality. The pre-implementation cohort consisted of patients treated prior to the initiative (2006-2009) and the current protocol cohort consisted of patients treated after the initiative was started (2010-2013). Demographics, use of US or CT, necessity of surgical intervention, and failure of medical management were compared.Three hundred seventy three children were evaluated; 114 patients were included in the pre-implementation cohort and 259 patients were included in the current protocol cohort for comparison. Patients presenting during the current protocol period were more likely to undergo US (pre-implementation vs. current protocol, p-value) (12% vs. 49%, p 0.0001) and less likely to undergo CT (66% vs. 41%, p 0.0001) for their initial evaluation. There were no differences in the percentage of children who underwent prompt surgical drainage, prompt discharge without surgery, or trial inpatient observation. There were also no differences in the rate of treatment failure for patients undergoing prompt surgery or prompt discharge on antibiotics. For those patients who underwent repeat evaluation following trial medical management, US was used more frequently in the current protocol period (4% vs. 20%, p = 0.002) with no difference in CT use, selected treatment strategy, or treatment failure rates.Increased use of US on initial evaluation of children with superficial face and neck infections resulted in decreased CT utilization, without negatively impacting outcome. Decreasing pediatric radiation exposure and potential long-term effects is of primary importance.

This is a case of a 4 year old female with recalcitrant recurrent respiratory papillomatosis with decreasing intersurgical interval that had improvement in clinical course after administration of the quadrivalent HPV vaccine.

Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care.This is a retrospective chart review from the years of 2009-2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU.There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p 0.0001), and more severe classifications of OSA (p 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement.This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.

Objective To assess factors associated with repair of facial dog bites in the emergency department (ED) versus the operating room (OR) and to compare rates of surgical site infection and reoperation for each venue. Study Design Case series with chart review. Setting Single institution. Subjects and Methods All patients younger than 18 years of age who underwent surgical repair by a consulting surgical service within 24 hours of presentation for facial dog bites between 2010 and 2013 were included. Demographics, site of injury, associated evidence of complex injury, surgical site infections within 30 days, and reoperation within 2 years were compared between patients undergoing surgical repair in the ED versus the OR. Results One hundred sixty-five patients were evaluated; 75 patients underwent repair in the ED, and 90 patients were treated in the OR. Patients treated in the ED underwent surgery more promptly than patients treated in the OR (median time from arrival to procedure start 3.3 vs 6.8 hours, P < .001). Patients treated in the OR were more likely to have longer lacerations (3.0 cm vs 7.8 cm, P < .001), lacerations of the eyelid (17% vs 42%, P = .001), involvement of multiple regions of the face (11% vs 22%, P = .039), and multiple indicators of severe injury (3% vs 12%, P = .024). There were no differences in surgical site infections (1% vs 1%, P = .721) or reoperation rates (5% vs 13%, P = .071). Conclusions Surgical management of pediatric facial dog bites may be successfully performed in both the ED and OR settings. Severity of the injury should dictate the choice for management.

Objectives Otitis media with effusion (OME) is a common disease of childhood that is largely asymptomatic. However, middle ear fluid can persist for months and negatively impact a child's quality of life. Many cases of OME remain chronic and require surgical intervention. Because biofilms are known to contribute to the persistence of many diseases, this study examined effusions collected from children with chronic OME for the presence of essential biofilm structural components, members of the DNABII family of bacterial DNA-binding proteins. Methods Middle ear effusions were recovered from 38 children with chronic OME at the time of tympanostomy tube insertion. A portion of each specimen was submitted for microbiology culture. The remaining material was assessed by immunoblot to quantitate individual DNABII proteins, integration host factor (IHF), and histone-like protein (HU). Results Sixty-five percent of effusions (24 of 37) were culture-positive for bacterial species or yeast, whereas 35% (13 of 37) were culture-negative. IHF was detected in 95% (36 of 38) at concentrations from 2 to 481 ng/μL effusion. HU was detected in 95% (36 of 38) and quantitated from 13 to 5,264 ng/μL effusion (P ≤ 0.05 compared to IHF). Conclusion Because DNABII proteins are essential structural components of bacterial biofilms, these data lend further support to our understanding that biofilms are present in the vast majority of chronic middle ear effusions, despite negative culture results. The presence and ubiquity of DNABII proteins in OME specimens indicated that these proteins can serve as an important clinical target for our novel DNABII-directed strategy to treat biofilm diseases such as chronic OME. Level of evidence NA Laryngoscope, 130:806-811, 2020.

Cutaneous kaposiform hemangioendothelioma (KHE) and tufted angioma (TA) are vascular tumors that are often misdiagnosed. Treatment urgency and type varies depending on which tumor-type is diagnosed, because of the differing rates of progression to Kasabach–Merritt phenomenon. An 11-month-old male presented with a facial mass and biopsy results favoring a diagnosis of TA. The diagnosis of KHE, was later favored over TA given the overall clinical picture of initial rapid growth. However, serial imaging showed no subsequent growth, suggesting that clinically diagnosed KHE, may follow a benign clinical course when biopsy results suggest a diagnosis of TA.

Peritonsillar abscess (PTA) in pediatric patients is a challenging condition to diagnose and treat, and recurrence can occur in up to 15% of patients. This condition can be managed in various settings and there may be outcome differences depending on the choice of inpatient/outpatient management. The objective of this study was to evaluate immediate and long-term outcomes, specifically recurrence, after PTA management in the inpatient versus outpatient setting as well as specific patient characteristics leading to hospital management decisions.We conducted a retrospective cohort study of all suspected cases of PTA seen at a tertiary pediatric hospital from 2008 to 2017, and 566 confirmed cases of PTA were included in this study. Demographics, PTA management, recurrence, and subsequent tonsillectomy (immediate or within 1 year of diagnosis) were ascertained from patient medical records. We compared characteristics of patients seen in the inpatient and outpatient setting using Chi-squared and Wilcoxon-Mann-Whitney tests.Patients treated in the outpatient setting were more likely to be older and have a lower rate of recurrent ear infections (p 0.0001 and p = 0.01 respectively). Additionally, no differences in gender, Down Syndrome, or autism were found. Patients who were admitted were more likely to undergo immediate tonsillectomy within a month or tonsillectomy within one year (p 0.0001 and p = 0.02 respectively), whereas patients in the outpatient setting were more likely to receive antibiotics alone (p 0.0001). Outpatient management was associated with no differences in recurrence rate within 30 days (p = 0.56). However, recurrence was associated with older age, a history of recurrent tonsillitis, but not a history of ear infections (p = 0.005, p 0.0001, and p = 0.49 respectively). A history of recurrent ear infections, recurrent tonsillitis and recurrent PTAs were associated with the decision to pursue a tonsillectomy (p = 0.003, p = 0.03, and p 0.0001 respectively).Patients seen in the outpatient setting are more likely to receive antibiotics alone as their initial treatment, likely a result of certain clinical characteristics and presenting features as well as uncertain diagnosis. Inpatient status was associated with a younger age and a history of ear infections while recurrence was associated with a history of recurrent tonsillitis and older age. The recurrence rates for outpatient management were not statistically different than inpatient, suggesting that triaging and treatment of patients was occurring appropriately. The association of tonsillectomies in the inpatient group within 12 months is likely due to the higher rate of preexisting tonsil issues considering that recurrent tonsillitis, ear infections and a higher rate of PTA recurrence were all statistically correlated.

Objectives The objective of this study is to examine the impact that an institution-wide policy to reduce radiation exposure in pediatric patients had on the use of computed tomography (CT) imaging in children presenting with suspected peritonsillar abscess (PTA)1. Methods A single institution retrospective review was conducted for all pediatric patients under the age of 18 who presented to the emergency department with suspected PTA over a ten-year period. Patients were divided into two groups; those that presented during the years prior to policy implementation and those that presented during the years following. Main outcome measures were the frequency of patients who underwent CT scanning as a part of their workup, the specialty of the ordering physician, and the treatment for suspected PTA. Results A total of 317 patients with suspected PTA were seen prior to policy implementation, with an additional 275 patients seen in the years after. The frequency of CT use was 41% (131/317) in pre-policy patients, and 28% (77/275) in post-policy patients (p = 0.004). The most common specialty of ordering physician was Pediatrics in the pre-policy patients (45%), and Otolaryngology in the post-policy patients (41%) (p = 0.0003). Of the 131 patient who underwent CT scanning before policy implementation, 36 patients (27%) required incision and drainage (I&D) of their PTA in the OR. This is in comparison to 42/77 patients (55%) in the post-policy group who underwent I&D in the OR (p Conclusion An institution-wide policy to decrease unnecessary imaging studies in pediatric patients resulted in a significant reduction in the use of CT imaging in the work-up for suspected PTA. Additionally, there was increase in the frequency of patients who underwent surgical intervention for their PTA after CT imaging, suggesting a more scrutinized approach to CT usage since policy implementation.

A 3-year-old female presented for evaluation of progressive snoring since birth. MRI revealed a fatty-appearing mass measuring 2.4 cm × 1.5 cm x 3.0 cm arising from the predental space of C1 and extending anteriorly through the prevertebral space into the retropharyngeal space. The patient underwent endoscopic trans-oral excision of the mass using electrocautery and blunt dissection, and pathological analysis yielded a diagnosis of fibrolipoma. CT imaging twelve months post-surgery showed no recurrence, and the patient remains symptom free two years later. Very few reported cases of nasopharyngeal fibrolipomas exist, and this is the first report of 2-year clinical follow-up.

To assess clinical evaluation, ultrasound, and previously published predictive score at preoperatively diagnosing midline neck masses and demographic or clinical associations that aid in differentiation of thyroglossal duct and dermoid cysts.Retrospective chart review.Tertiary care children's hospital.Patients18 years undergoing primary midline neck mass surgery with histopathologic diagnosis of thyroglossal duct or dermoid cyst who had preoperative ultrasound performed were included.An electronic medical record query generated 142 patients whose histopathologic diagnosis was thyroglossal duct cysts (TGDCs) or dermoid cysts (DCs). Charts were reviewed for demographic and clinical features. A radiologist blindly reviewed patients' ultrasounds for SIST (septae + irregular walls + solid components = thyroglossal) score components. Each patient received 3 preoperative diagnoses: clinical, ultrasound, and SIST. Statistical analyses were conducted to determine association of demographic, clinical, or radiographic variables with diagnoses. Specificity, sensitivity, and predictive values were evaluated for each candidate diagnosis.There were 83 TGDCs and 59 DCs. Tenderness, infection history, depth relative to strap muscles, and SIST components were more common among TGDCs. Sensitivity and positive and negative predictive values surpassed 63% for each diagnostic modality. SIST score outperformed other diagnostic modalities with sensitivity, positive predictive value, and negative predictive value of 84%, 91%, and 81%, respectively. Clinical and ultrasound assessments were largely inconclusive for dermoid cysts, but SIST correctly identified 89% of DCs.SIST score was the most accurate predictor of pediatric midline neck masses. Clinical and radiographic findings may help guide preoperative diagnosis, although further evaluation is required to develop more efficacious diagnostic tools.

Introduction Dog bite injuries to the face are a serious, yet modifiable public health concern. This study explores the relationship between dog breed and the risk of biting and injury. The objective of this study is to determine the relative risk and severity of dog bite injuries to the face by breed. Methods Retrospective chart review of facial dog bite injuries presenting to the University of Virginia Health System and Nationwide Children's Hospital. Additionally, descriptive data was collected from 240 patients over the last 15 years. Bite risk by breed was assessed by a literature search from 1970 to current. A composite measure was used to determine the severity of injury, and characterize each patient into an ordinal scale of bite severity. An average of each breed bite rate within each study was calculated and combined to create an empiric bite risk by breed. Dog breeds were also further characterized morphologically. Results Bite risk by breed from the literature review and bite severity by breed from our case series were combined to create a total bite risk plot. Injuries from Pitbull's and mixed breed dogs were both more frequent and more severe. This data is well-suited for a bubble plot showing bite risk on the x-axis, bite severity on the y-axis, and size of the bubble by number of cases. This creates a "risk to own" graphic for potential dog owners. Conclusions Breeds vary in both rates of biting and severity. The highest risk breeds had both a high rate of biting and caused significant tissue injury. Physical characteristics can also help determine risk for unknown or mixed dog breeds. Potential dog owners can utilize this data when assessing which breed to own.

Orbital abscess and subperiosteal abscess are pathologies which may require surgical treatment in the pediatric patient. Though rare, orbital cerebrospinal fluid (CSF) leak is a serious complication of abscess drainage. This paper presents a unique 5-month-old male with transorbital abscess drainage complicated by CSF leak. An endoscope was used to repair the defect through the orbitotomy incision. There was no evidence of persistent leak at follow-up. The surgical approach likely contributed to the complication, and the otolaryngologist played a key role in the leak repair. This case should serve to raise the awareness regarding considerations to avoid orbital CSF leak.

Background Postoperative pneumonia is a serious complication because it may be associated with morbidity, mortality and substantially increased cost of surgical care. Risk of postoperative pneumonia varies across surgical specialties, although its incidence and risk factors in pediatric otolaryngology have not been comprehensively elucidated. Objective To identify factors associated with postoperative pneumonia and determine whether a subset of children with a disproportionate risk of pneumonia can be identified. Methods Using the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups. Results Among the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3–28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53–15.48). Conclusions We identified key preoperative risk factors for postoperative pneumonia in children undergoing otolaryngology surgery. A small proportion (20%) of high-risk patients accounted for a large proportion (71%) of postoperative pneumonia indicating an underlying Pareto distribution and underscoring the need for targeted interventions for this “vital few”. Postoperative pneumonia in pediatric otolaryngology surgical inpatients was associated with longer hospital stay and a higher risk of mortality. Clinical trial number and registry Not applicable.

Pediatric soft tissue sarcomas of the oral/maxillofacial region are rare neoplasms that present significant difficulty with respect to treatment and local control measures. We report four cases of pediatric oral/maxillofacial soft tissue sarcomas from our tertiary care pediatric hospital and emphasize the rarity of these malignancies and the challenges encountered in treating these lesions, and suggest areas for further research. We conclude that multimodal therapy and interdisciplinary cooperation are paramount to successful management of these lesions.

Objectives/Hypothesis Otitis media is a common problem in the pediatric population. Despite antibiotic therapy, post-tympanostomy otorrhea can be difficult to treat. Biofilms have been shown to play a role in chronic and recurrent otitis media and are implicated in otorrhea. This study investigated both the microbial composition and the presence of biofilm fragments rich in extracellular DNA (eDNA) and the bacterial DNA-binding protein, integration host factor (IHF), in post-tympanostomy tube otorrhea. Study Design Clinical samples. Methods Institutional review board approval was obtained, and samples were recovered from pediatric patients with tympanostomy tubes and persistent otorrhea for both microbial culture and biofilm analysis. For biofilm assessment, frozen samples were sectioned and then labeled using a rabbit anti-IHF, which was detected with goat anti-rabbit IgG conjugated to AlexaFluor 594. Samples were then counterstained with 4',6-diamidino-2-phenylindole (DAPI) to detect DNA, and images were captured by inverted light microscopy. Results Of 15 pediatric otorrhea samples analyzed, nine (60%) contained solids that were positive for labeling of IHF in association with a lattice of eDNA, and 75% yielded positive bacterial cultures. Bacterial culture results included H. influenzae, Methicillin-resistant Staphylococcus aureus, S. pneumoniae, M. catarrhalis, and P. aeruginosa. Conclusion Positive labeling of otorrhea solids for eDNA and IHF, in combination with microbiological culture results, indicated that biofilms likely played a key role in chronic otorrhea. Moreover, as a known critical structural component of biofilms, these findings suggest that DNABII proteins in association with eDNA may serve as an important therapeutic target in post-tympanostomy tube otorrhea. Level of Evidence NA. Laryngoscope, 2016

There has been a rapid global spread of a novel coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which originated in Wuhan China in late 2019. A serious threat of nosocomial spread exists and as such, there is a critical necessity for well-planned and rehearsed processes during the care of the COVID-19 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be intimately familiar with strategies to mitigate the high-risk periods of viral contamination that are posed to the environment and healthcare personnel during tracheal intubation and extubation procedures. Since both the pediatric otolaryngologist and anesthesiologist are directly involved in emergency airway interventions, both specialties impact the safety of caring for COVID-19 patients and are a part of overall hospital pandemic preparedness. We describe our institutional approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital including operating room management and remote airway management. We outline our processes for the safe and effective care of these patients with emphasis on simulation and pathways necessary to protect healthcare workers and other personnel from exposure while still providing safe, effective, and rapid care.

Background and ObjectiveThe aim of this study is to develop and validate an automated image segmentation-based frame selection and stitching framework to create enhanced composite images from otoscope videos. The proposed framework, called SelectStitch, is useful for classifying eardrum abnormalities using a single composite image instead of the entire raw otoscope video dataset.MethodsSelectStitch consists of a convolutional neural network (CNN) based semantic segmentation approach to detect the eardrum in each frame of the otoscope video, and a stitching engine to generate a high-quality composite image from the detected eardrum regions. In this study, we utilize two separate datasets: the first one has 36 otoscope videos that were used to train a semantic segmentation model, and the second one, containing 100 videos, which was used to test the proposed method. Cases from both adult and pediatric patients were used in this study. A configuration of 4-levels depth U-Net architecture was trained to automatically find eardrum regions in each otoscope video frame from the first dataset. After the segmentation, we automatically selected meaningful frames from otoscope videos by using a pre-defined threshold, i.e., it should contain at least an eardrum region of 20% of a frame size. We have generated 100 composite images from the test dataset. Three ear, nose, and throat (ENT) specialists (ENT-I, ENT-II, ENT-III) compared in two rounds the composite images produced by SelectStitch against the composite images that were generated by the base processes, i.e., stitching all the frames from the same video data, in terms of their diagnostic capabilities.ResultsIn the first round of the study, ENT-I, ENT-II, ENT-III graded improvement for 58, 57, and 71 composite images out of 100, respectively, for SelectStitch over the base composite, reflecting greater diagnostic capabilities. In the repeat assessment, these numbers were 56, 56, and 64, respectively. We observed that only 6%, 3%, and 3% of the cases received a lesser score than the base composite images, respectively, for ENT-I, ENT-II, and ENT-III in Round-1, and 4%, 0%, and 2% of the cases in Round-2.ConclusionsFrame selection improves the diagnostic quality of composite images from otoscope video clips.

Acute infections of the middle ear are the most commonly treated childhood diseases. Because complications affect children’s language learning and cognitive processes, it is essential to diagnose these diseases in a timely and accurate manner. The prevailing literature suggests that it is difficult to accurately diagnose these infections, even for experienced ear, nose, and throat (ENT) physicians. Advanced care practitioners (e.g., nurse practitioners, physician assistants) serve as first-line providers in many primary care settings and may benefit from additional guidance to appropriately determine the diagnosis and treatment of ear diseases. For this purpose, we designed a content-based image retrieval (CBIR) system (called OtoMatch) for normal, middle ear effusion, and tympanostomy tube conditions, operating on eardrum images captured with a digital otoscope. We present a method that enables the conversion of any convolutional neural network (trained for classification) into an image retrieval model. As a proof of concept, we converted a pre-trained deep learning model into an image retrieval system. We accomplished this by changing the fully connected layers into lookup tables. A database of 454 labeled eardrum images (179 normal, 179 effusion, and 96 tube cases) was used to train and test the system. On a 10-fold cross validation, the proposed method resulted in an average accuracy of 80.58% (SD 5.37%), and maximum F1 score of 0.90 while retrieving the most similar image from the database. These are promising results for the first study to demonstrate the feasibility of developing a CBIR system for eardrum images using the newly proposed methodology.

Introduction The objective of this study was to determine if pre-operative oral midazolam administration decreased postoperative oral fluid intake after tonsillectomy with or without adenoidectomy. Methods A retrospective chart review identified 104 patients who were undergoing tonsillectomy with and without adenoidectomy who were not given midazolam preoperatively and 182 who were given midazolam preoperatively. Indications for tonsillectomy with or without adenoidectomy included obstructive sleep apnea, recurrent acute streptococcal pharyngotonsillitis, and, in selected cases, periodic fever with aphthous stomatitis, pharyngitis and adenopathy. All patients were evaluated in the pre-operative area by the attending anesthesiologist, who then determined whether or not he/she felt the patient would benefit from premedication with oral midazolam prior to surgery. Patients whom the attending anesthesiologist judged would benefit from midazolam were then given a 0.12–1.06 mg/kg dose (mean 0.35 mg/kg, STD 0.12), at the discretion of the anesthesiologist. Various methods were used to perform tonsillectomy, such as coblation and electrocautery, at the discretion of the otolaryngologist. Results were not stratified by surgical technique. Oral fluid intake was calculated by establishing the time of return to the floor from surgery and determining the documented oral fluid intake for the next 12 h. Oral fluid intake per kg per hour was then calculated. The amount of midazolam given was documented. Results There was no significant difference in oral fluid intake by group when adjusting for age and weight, F(1, 282) = 0.383, p = 0.537. Also, there was no significant difference in ml/kg/hr by group when adjusting for age and weight, F(1, 282) = 2.813, p = 0.095. Conclusions There was no significant difference in oral fluid intake between the no midazolam and midazolam groups, indicating that clinicians can continue to use their judgement in administering midazolam to select anxious patients prior to tonsillectomy with or without adenoidectomy. Future work could include multi-center retrospective reviews or a randomized placebo-controlled trial to examine more carefully the effects of midazolam on postoperative oral fluid intake. Level of evidence Level IV.

Importance Delay in response for telephone triage calls that need clinician input for resolution can result in delay of care and unintended frustration for patients and families. It can be a challenge to manage calls in a high-volume pediatric otolaryngology practice. Objective To improve the percentage of nurse triage clinically relevant phone calls returned within 2 hours to parents or caregivers. Design, Setting, and Participants This was a quality-improvement study of a tertiary care pediatric otolaryngology practice with more than 32 000 clinic visits and more than 9000 surgical patients per year. Interventions In 2014, a collaborative team was created at our center to determine the optimal time for triage callback to families and to define an optimal process that would allow more rapid response time for calls that the triage nurses needed to escalate to the patient’s managing surgeon. Several plan-do-study-act cycles were performed to optimize the process. The utilization of advanced practice nurses as an intermediary step was crucial in allowing a more efficient flow of communication. Main Outcomes and Measures Percentage of triage phone calls returned within 2-hour time frame. Results Over 40 months, 4839 clinically relevant phone calls occurred, averaging 128 calls per month. The baseline mean was 101 calls per month, and the postintervention mean was 130 calls per month. Prior to this project, only 42% of calls were being addressed within 2 hours. After our interventions, the average time for caregiver callback within 2 hours decreased from 15.3 hours preintervention to 3.9 hours postintervention. In addition, caregivers received clinician callback within 2.0 hours 76.7% of the time postintervention compared with 42.0% with a baseline shift (difference probability between preintervention and postintervention, 0.21; 95% CI, 0.15-0.27). Outcomes were sustained for 3 years and continue to be monitored. Conclusions and Relevance The most effective intervention was using advanced practice nurses to efficiently resolve patient triage concerns that were outside the scope of practice of the registered nurse. By establishing clear pathways of communication and standardized education among our team, we successfully improved our processes, which resulted in more optimal care for our patients.