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Background Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. Methods This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. Results A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. Conclusion A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy. [ABSTRACT FROM AUTHOR]

The authors comment on the article "Ensuring Safety While Achieving Beauty: Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity." Topics include obesity's detrimental effects on surgical outcomes, the author's recommendation that a delayed reconstruction over immediate reconstruction may be preferable, and the need to consider some factors in selecting the optical surgical treatment for breast cancer.

Background  The novel coronavirus disease 2019 (COVID-19) has swept the world in the last several months, causing massive disruption to existing social, economic, and health care systems. As with all medical fields, plastic and reconstructive surgery has been profoundly impacted across the entire spectrum of practice from academic medical centers to solo private practice. The decision to preserve vital life-saving equipment and cancel elective procedures to protect patients and medical staff has been extremely challenging on multiple levels. Frequent and inconsistent messaging disseminated by many voices on the national stage often conflicts and serves only to exacerbate an already difficult decision-making process. Methods  A survey of relevant COVID-19 literature is presented, and bioethical principles are utilized to generate guidelines for plastic surgeons in patient care through this pandemic. Results  A cohesive framework based upon core bioethical values is presented here to assist plastic surgeons in navigating this rapidly evolving global pandemic. Conclusion  Plastic surgeons around the world have been affected by COVID-19 and will adapt to continue serving their patients. The lessons learned in this present pandemic will undoubtedly prove useful in future challenges to come. [ABSTRACT FROM AUTHOR]

Limited knowledge of the changes in estrogen receptor (ER) signaling during the transformation of the normal mammary gland to breast cancer hinders the development of effective prevention and treatment strategies. Differences in estrogen signaling between normal human primary breast epithelial cells and primary breast tumors obtained immediately following surgical excision were explored. Transcriptional profiling of normal ER+ mature luminal mammary epithelial cells and ER+ breast tumors revealed significant difference in the response to estrogen stimulation. Consistent with these differences in gene expression, the normal and tumor ER cistromes were distinct and sufficient to segregate normal breast tissues from breast tumors. The selective enrichment of the DNA binding motif GRHL2 in the breast cancerspecific ER cistrome suggests that it may play a role in the differential function of ER in breast cancer. Depletion of GRHL2 resulted in altered ER binding and differential transcriptional responses to estrogen stimulation. Furthermore, GRHL2 was demonstrated to be essential for estrogen-stimulated proliferation of ER+ breast cancer cells. DLC1 was also identified as an estrogen-induced tumor suppressor in the normal mammary gland with decreased expression in breast cancer. In clinical cohorts, loss of DLC1 and gain of GRHL2 expression are associated with ER+ breast cancer and are independently predictive for worse survival. This study suggests that normal ER signaling is lost and tumor-specific ER signaling is gained during breast tumorigenesis. Unraveling these changes in ER signaling during breast cancer progression should aid the development of more effective prevention strategies and targeted therapeutics. [ABSTRACT FROM AUTHOR]

Nanotechnology, in conjunction with convection-enhanced delivery (CED), has gained traction as a promising method to treat many debilitating neurological diseases, including gliomas. One of the key parameters to evaluate the effectiveness of delivery is the volume of distribution (V d ) of nanoparticles within the brain parenchyma. Measurements of V d are commonly made using fluorescent reporter systems. However, reported analyses lack accurate and robust methods for determining V d . Current methods face the problems of varying background intensities between images, high intensity aggregates that can shift intensity distributions, and faint residual backgrounds that can occur as artifacts of fluorescent imaging. These problems can cause inaccurate results to be reported when a percentage of the maximum intensity is set as the threshold value. Here we show an implementation of Otsu’s method more reliably selects accurate threshold values than the fixed-threshold method. We also introduce a goodness of fit value η that quantifies the appropriateness of using Otsu’s method to calculate V d . Adoption of Otsu’s method and reporting of η may help standardize fluorescent image analysis of nanoparticles administered by convection-enhanced delivery. [ABSTRACT FROM AUTHOR]

The purposes of this study were to determine if use of a powered drill or trainee involvement during tympanoplasty is associated with a decline in sensorineural hearing, as well as to examine whether trainee involvement affected tympanic membrane (TM) closure rates. his study was a chart review (February 2006 to October 2011) of 172 pediatric otolaryngology patients undergoing type I tympanoplasty for TM perforation of any etiology at a tertiary-care pediatric otolaryngology practice. Data collected included air conduction (AC) at 250 to 8,000 Hz, speech reception thresholds, bone conduction (BC) at 500 to 4,000 Hz, and air-bone gap (ABG) at 500 to 4,000 Hz. Rates of surgical success did not change significantly if a trainee assisted during surgery (69.6% with an assistant vs. 77.4% without; p = 0.297). AC hearing was not found to be significantly different between the two groups preoperatively or postoperatively at 250, 500, 1,000, 2,000, 4,000, or 8,000 Hz (p > 0.05). here were no significant differences in AC hearing outcomes between patients in whom a surgical drill was used and those in whom no drill was used (p > 0.05). BC and ABG did not change significantly at any frequency (p > 0.05). In conclusion, no correlation between high-frequency hearing loss and use of a powered drill for canalplasty during type I tympanoplasty was found in this pediatric population. No significant difference was found in surgical success rates or AC hearing outcomes when a surgical trainee was present. [ABSTRACT FROM AUTHOR]

Objective Ossicular chain disruption in children leads to conductive hearing loss. Few studies have focused on factors influencing successful results in pediatric ossicular chain reconstruction (OCR). We aim to determine whether demographic or surgical factors affect hearing outcomes in pediatric OCR. Methods We conducted a retrospective chart review of 120 patients undergoing OCR at our institution, a tertiary care hospital, between 2003 and 2014, with median length of follow-up of 2.2 years (range 0.1–9.3 years). Pediatric patients (<18 years old at time of surgical procedure) who had current procedural terminology (CPT) codes of OCR, and available pre- and post-operative audiograms were included in the study. Demographic information, surgical details, and pre- and post-operative pure-tone averages (PTA), speech reception thresholds (SRT), and air-bone gaps (ABG) were recorded from clinic notes, audiograms and operative reports. Differences between PTA, SRT and ABG pre- and post-operatively, as well as demographic and surgical factors, were evaluated using Wilcoxon rank-sum tests. Factors influencing revision were evaluated using Log-rank tests. Results A total of 120 patients (123 ears) were included. 35.8% of cases were revised, most commonly due to displaced prostheses. 28.5% of surgeries resulted in normal hearing (PTA ≤25 dB) post-operatively. Post-operative SRT and ABG were significantly better in patients with partial ossicular replacement prosthesis (PORP) compared with those with total ossicular replacement prosthesis (TORP) (p = 0.016, 0.027). Titanium prostheses resulted in better post-operative PTA and larger changes in PTA compared with all other materials (p = 0.034, p = 0.038). Conclusions In our experience, children with titanium prostheses had better hearing outcomes than those with other materials, and children with PORP had better hearing outcomes than those with TORP. [ABSTRACT FROM AUTHOR]

Objectives 1. To report our experience in children with sudden-onset sensorineural hearing loss (SSNHL). 2. To describe the etiology and management of children with SSNHL. Methods Retrospective review of 20 children with SSNHL, from 2000 to 2013 at a tertiary pediatric facility. Patients had the following inclusion criteria: history of normal hearing, hearing loss occurring in less than 3 days, and audiogram documentation. Results The average age of patients presenting with SSNHL is 11 years 3 months (22months-18years). Only 6 (30%) children presented prior to 2 weeks. Tinnitus (55%) was the most common associated symptoms followed by otalgia (25%), and vertigo (20%). Eight patients had bilateral hearing loss, 6 only right and 6 only left. Hearing loss severity ranged from profound (45%) being most common to mild. Etiology was unknown (30%), viral (25%), anatomic abnormality (25%), Meniere's disease (5%), autoimmune (5%), perilymphatic fistula (5%), and suppurative labyrinthitis (5%). Eight patients had initial treatment with oral steroids of which 50% had improvement on audiograms. Two patients underwent intratympanic injections, both showed improvement. Of the 12 patients with no treatment, only 1 had improved hearing. Conclusions The true incidence of pediatric SSNHL is not well established in our literature. Unique aspects of pediatric SSNHL are delayed presentation and higher percent of anatomic findings. In our study 70% presented more than 2 weeks after experiencing symptoms. Anatomic abnormalities are in 40% of patients. Hearing improvement occurred in 50% of children treated with oral steroids. Intratympanic steroid treatment is another option but may have practical limitation in the pediatric population. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the associations between proxy measures of socioeconomic status (SES) and usage of cochlear implants. Study Design: Retrospective case series. Methods: Usage outcomes were measured among patients with a cochlear implant and data logging at a tertiary care children's hospital between 2002 and 2017. Time per day with cochlear implant turned on, coil off, and listening to speech in noise and speech in quiet were extracted from audiology records, averaging right and left ear usage for those with bilateral implants. Associations between cochlear implant usage and demographic factors such as insurance type and median household income for zip code were assessed. Results: There were 142 total patients; 74 had bilateral usage data. Mean on air time was 10.76 hours (SD: 4.4). Those with private insurance had 1.2 hour more on air time/day (P =.047) and 0.9 hour more quiet time/day (P =.011) compared to those with public insurance. Younger age at last visit was associated with increased speech in quiet (B = −.08; 95% CI: −0.12-[−0.05], P <.001) and coil off (B = −0.06; 95% CI: −0.11-[−0.02], P =.006). Younger age at implant was associated with longer duration since last data logging visit (B = −10.46; 95% CI: −18.41-[−2.51], P =.010), more daily use (on air; B = −0.23; 95% CI: −0.43-[−0.03], P =.026), and increased time spent listening to speech in noise (B = −0.07; 95% CI: −0.14-[−0.01], P =.024). No other significant associations between datalogging output and each proxy SES factor were found. Conclusions: Lack of private insurance and older age at implantation decreased access to binaural hearing for children and young adults with cochlear implants. [ABSTRACT FROM AUTHOR]

This work shows that radio‐frequency (RF) fields can simultaneously align carbon nanotubes (CNTs) dispersed in a resin and induce Joule heating to cure the resin. The timescales of alignment and curing using RF heating are numerically computed and compared at different field strengths in order to determine a temperature where alignment happens before the matrix crosslinks. Composites are experimentally fabricated at the desired target temperature and are optically analyzed and quantified; the CNT network is successfully aligned in the direction of the applied electric field. This methodology can be used to create composites where the local alignment can be varied across the sample. Composites fabricated using RF fields have higher electrical conductivity in the direction of the aligned CNTs than an oven‐cured, randomly aligned sample. Also, RF‐cured nanocomposites exhibit higher tensile strength and modulus in the direction of alignment compared to an oven‐cured sample. Finally, it is further demonstrated how this methodology can be coupled with a direct ink writing additive manufacturing process to induce alignment in any desired direction, even orthogonal to the shear forces in the extrusion direction. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Metopic craniosynostosis can be treated by fronto-orbital advancement or endoscopic strip craniectomy with postoperative helmeting. Infants younger than 6 months of age are eligible for the endoscopic repair. One-year postoperative anthropometric outcomes have been shown to be equivalent, with significantly less morbidity after endoscopic treatment. The authors hypothesized that both repairs would yield equivalent anthropometric outcomes at 5-years postoperative. METHODS: This study was a retrospective chart review of 31 consecutive nonsyndromic patients with isolated metopic craniosynostosis treated with either endoscopic or open correction. The primary anthropometric outcomes were frontal width, interfrontal divergence angle, the Whitaker classification, and the presence of lateral frontal retrusion. Peri-operative variables included estimated blood loss, rates of blood transfusion, length of stay, and operating time. RESULTS: There was a significantly lower rate of lateral frontal retrusion in the endoscopic group. No statistically significant differences were found in the other 3 anthropometric outcomes at 5-years postoperative. The endoscopic group was younger at the time of surgery and had improved peri-operative outcomes related to operating time, hospital stay and blood loss. Both groups had low complication and reoperation rates. CONCLUSIONS: In our cohort of school-aged children with isolated metopic craniosynostosis, patients who underwent endoscopic repair had superior or equivalent outcomes on all 4 primary anthropometric measures compared with those who underwent open repair. Endoscopic repair was associated with significantly faster recovery and decreased morbidity. Endoscopic repair should be considered in patients diagnosed with metopic craniosynostosis before 6 months of age. [ABSTRACT FROM AUTHOR]

Objective: We compared adherence rates by attending otolaryngologists (OTOs) and advanced practice providers (APPs) to the 2013 American Academy of Otolaryngology—Head and Neck Surgery Foundation clinical practice guideline (CPG) for children with recurrent acute otitis media (RAOM) undergoing bilateral myringotomy and tympanostomy tube placement (BMT). Methods: Patients aged 6 months to 12 years old undergoing BMT for RAOM who had a pre-operative visit with an independent APP or OTO were reviewed. Patients satisfied CPG criteria if middle ear effusion was identified at the pre-operative visit (pre-op) or if they did not have effusion but met exception criteria based on their risk for developmental difficulties and contraindications to medical therapy. Adherence rates between APPs and OTOs were compared. Agreement between pre-op and time-of-surgery middle ear effusion identification was assessed. Results: Nine hundred twenty-three patients were included. Six hundred one patients were seen by OTOs and 322 by APPs. Middle ear effusion was identified at pre-op in 84% of APP patients and in 76% of OTO patients (P =.005). Eight percent of APP patients and 11% of OTO patients met exception criteria (P =.138). Overall, 87% of OTO patients and 92% of APP patients met either CPG or exception criteria for BMT (P =.037). A logistic regression model demonstrated that pre-op provider type did not significantly impact rates of agreement between pre-op visit and time-of-surgery middle ear effusion identification. Conclusions: Independent APP-led clinics can reliably and effectively deliver evidence-based care for prevalent conditions such as RAOM at similar rates of adherence to CPGs as OTOs. [ABSTRACT FROM AUTHOR]

Although it is recognized that the mechanical stresses associated with physical activity augment bone mineral density and improve bone quality, our understanding of how exercise modulates bone homeostasis at the molecular level is lacking. In a before and after trial involving 43 healthy adults, we measured the effect of six months of supervised exercise training on the spontaneous and phytohemagglutinin-induced production of osteoclastogenic cytokines (interleukin-1α, tumor necrosis factor-α), antiosteoclastogenic cytokines (transforming growth factor-β1 and interleukins 4 and 10), pleiotropic cytokines with variable effects on osteoclastogenesis (interferon-γ, interleukin-6), and T cell growth and differentiation factors (interleukins 2 and 12) by peripheral blood mononuclear cells. We also measured lymphocyte phenotypes and serum markers of bone formation (osteocalcin), bone resorption (C-terminal telopeptides of Type I collagen), and bone homeostasis (25 (OH) vitamin D, estradiol, testosterone, parathyroid hormone, and insulin-like growth factor 1). A combination of aerobic, resistance, and flexibility exercises done on average of 2.5 hours a week attenuated the production of osteoclastogenic cytokines and enhanced the production of antiosteoclastogenic cytokines. These changes were accompanied by a 16% reduction in collagen degradation products and a 9.8% increase in osteocalcin levels. We conclude that long-term moderate intensity exercise exerts a favorable effect on bone resorption by changing the balance between blood mononuclear cells producing osteoclastogenic cytokines and those producing antiosteoclastogenic cytokines. This trial is registered with Clinical Trials.gov Identifier: NCT02765945. [ABSTRACT FROM AUTHOR]

Utilizing a novel histopathological scoring system and subglottic stenosis (SGS) rabbit model, we aimed to compare degrees of inflammation and severity of narrowing in the subglottis between two minimally invasive therapeutic modalities: endoscopic balloon dilation (EBD) alone versus EBD with placement of a bioabsorbable ultra-high ductility magnesium (UHD-Mg) alloy stent. SGS was induced endoscopically via microsuspension laryngoscopy in 23 New Zealand white rabbits. The control group (n = 11) underwent EBD alone, the study arm (n = 12) underwent EBD with implantation of bioabsorbable UHD-Mg alloy stents. Rabbits were euthanized at 2-, 3-, and 6-weeks after SGS induction, coinciding with wound healing stages. Using Optical Coherence Tomography (OCT), cross-sectional areas of airways were compared to calculate the mean percentage of intraluminal area at sequential time points. A novel histopathological scoring system was used to analyze frozen sections of laryngotracheal complexes. The degree of inflammation was quantified by scoring changes in inflammatory cell infiltration, epithelial ulceration/metaplasia, subepithelial edema/fibrosis, and capillary number/dilation. Univariate analysis was utilized to analyze these markers. We found rabbits implanted with the bioabsorbable UHD-Mg alloy stent had statistically significantly higher scores in categories of hyperplastic change (stents vs controls: 1.48 vs 0.46 p < 0.001), squamous metaplasia (22 vs 5 p < 0.001), and neutrophils/fibrin in lumen (31 vs 8, p < 0.001). Rabbits who received EBD alone had higher scores of subepithelial edema and fibrosis (2.70 vs 3.49, p < 0.0256). The stented rabbits demonstrated significantly increased mean percent stenosis by intraluminal mean area compared to controls at 2 weeks (88.56 vs 58.98, p = 0.032), however at all other time points there was no significant difference between intraluminal subglottic stenosis by mean percent stenosis area. Rabbits with SGS treated with UHD-Mg alloy stents demonstrated histopathologic findings suggestive of lower levels of tracheal fibrosis. This could indicate a reduced tendency towards the development of stenosis when compared to EBD alone. There was not a difference in luminal size between stent and non-stented rabbits at the six-week end point. Histologically, however, overall the use of bioabsorbable UHD-Mg alloy stenting elicited a greater tissue response at the level of the superficial mucosa rather than fibrosis of the lamina propria seen in the stented rabbits. This suggests more favorable healing and less of a tendency towards fibrosis and stenosis even though there may not be a benefit from a luminal size standpoint during this early healing period. Compared to known complications of currently available non-bioabsorbable metal or silicone-based stents, this proof-of-concept investigation highlights the potential use of a novel biodegradable UHD-Mg stent as a therapeutic modality for pediatric SGS. [ABSTRACT FROM AUTHOR]

Children with a button battery impaction present with nonspecific symptoms that may account for a delay in medical care. We conducted a retrospective study of the clinical presentation, management, and complications associated with button battery ingestion in the pediatric aerodigestive tract and to evaluate the associated long-term morbidity. We reviewed the medical records of 23 patients who were treated for button battery impaction at our tertiary care children's hospital from Jan. 1, 2000, through July 31, 2013. This population was made up of 14 boys and 9girls, aged 7days to 12years (mean: 4yr). Patients were divided into three groups based on the site of impaction; there were 9 impactions in the esophagus and 7 each in the nasal cavity and stomach. We compiled information on the type and size of each battery, the duration of the impaction, presenting symptoms, treatment, and outcomes. The mean duration of battery impaction was 40.6, 30.7, and 21.0 hours in the esophagus, nasal cavity, and stomach, respectively. We were able to identify the specific type of battery in 13 cases; 11 of these cases (85%) involved a 3-V20-mm lithium ion battery, including all cases of esophageal impaction in which the type of battery was identified. The most common presenting signs and symptoms were vomiting (n = 7 [30%]), difficulty feeding (n = 5 [22%]), cough (n = 5), and bloody nasal discharge (n = 5); none of the presenting signs and symptoms predicted the severity of the injury or the outcome. The median length of hospital stay was far greater in the esophageal group (12 days) than in the nasal and stomach groups (1 day each; p = 0.006). Battery impaction in the esophagus for more than 15 hours was associated with a significantly longer postoperative hospital stay than impaction for less than 15 hours (p = 0.04). Esophageal complications included strictures (n = 5), perforation (n = 3), and tracheoesophageal fistula formation (n = 2). Clinicians should consider battery impaction in the upper aerodigestive tract as an emergency that can lead to significant long-term morbidity, and therefore immediate surgical intervention is required. [ABSTRACT FROM AUTHOR]

Objectives: Extensive literature exists documenting disparities in access to healthcare for patients with lower socioeconomic status (SES). The objective of this study was to examine access disparities and differences in surgical wait times in children with the most common pediatric otolaryngologic surgery, tympanostomy tubes (TT). Methods: A retrospective cohort study was performed at a tertiary children's hospital. Children ages <18 years who received a first set of tympanostomy tubes during 2015 were studied. Patient demographics and markers of SES including zip code, health insurance type, and appointment no-shows were recorded. Clinical measures included risk factors, symptoms, and age at presentation and first TT. Results: A total of 969 patients were included. Average age at surgery was 2.11 years. Almost 90% were white and 67.5% had private insurance. Patients with public insurance, ≥1 no-show appointment, and who lived in zip codes with the median income below the United States median had a longer period from otologic consult and preoperative clinic to TT, but no differences were seen in race. Those with public insurance had their surgery at an older age than those with private insurance (P <.001) and were more likely to have chronic otitis media with effusion as their indication for surgery (OR: 1.8, 95% CI: 1.2-2.5, P =.003). Conclusions: Lower SES is associated with chronic otitis media with effusion and a longer wait time from otologic consult and preoperative clinic to TT placement. By being transparent in socioeconomic disparities, we can begin to expose systemic problems and move forward with interventions. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objectives: Define aerosol and droplet risks associated with routine otolaryngology clinic procedures during the COVID-19 era. Methods: Clinical procedures were simulated in cadaveric heads whose oral and nasal cavities were coated with fluorescent tracer (vitamin B2) and breathing was manually simulated through retrograde intubation. A cascade impactor placed adjacent to the nares collected generated particles with aerodynamic diameters ≤14.1 µm. The 3D printed models and syringes were used to simulate middle and external ear suctioning as well as open suctioning, respectively. Provider's personal protective equipment (PPE) and procedural field contamination were also recorded for all trials using vitamin B2 fluorescent tracer. Results: The positive controls of nebulized vitamin B2 produced aerosol particles ≤3.30 µm and endonasal drilling of a 3D model generated particles ≤14.1 µm. As compared with positive controls, aerosols and small droplets with aerodynamic diameter ≤14.1 µm were not detected during rigid nasal endoscopy, flexible fiberoptic laryngoscopy, and rigid nasal suction of cadavers with simulated breathing. There was minimal to no field contamination in all 3 scenarios. Middle and external ear suctioning and open container suctioning did not result in any detectable droplet contamination. The clinic suction unit contained all fluorescent material without surrounding environmental contamination. Conclusion: While patients' coughing and sneezing may create a baseline risk for providers, this study demonstrates that nasal endoscopy, flexible laryngoscopy, and suctioning inherently do not pose an additional risk in terms of aerosol and small droplet generation. An overarching generalization cannot be made about endoscopy or suctioning being an aerosol generating procedure. Level of Evidence: 3 [ABSTRACT FROM AUTHOR]

Background: With increased attention around a value-based healthcare system, continuous emphasis has been made on the evaluation of hospital volume and its association with cost and outcomes. The aim of this study was to analyze nationwide cost variation and outcomes in relation to hospital case volume and geographical location for lower extremity flap reconstruction. Methods: A retrospective analysis of the National Inpatient Sample database was performed. Participants were patients who were admitted with the diagnosis of lower extremity trauma and underwent flap reconstruction, inclusive of pedicled and free flaps. The primary variable of interest was hospital cost. Additionally, we evaluated patient demographics, hospital characteristics, and outcomes of postoperative complications and length of stay. Results: A total of 1200 patients were extracted. Median hospital cost for each procedure was $67,845.09. High volume hospitals had significantly lower costs than medium and low volume hospitals (p = 0.011), with median cost being $56,498.77. On regression analysis, hospital volume was not independently associated with increased hospital costs; however, notable factors identified included surgical and systemic complications, as well as longer length of stay. Of note, high volume hospitals were also associated with significantly fewer surgical complications (p = 0.002) and shorter length of stay (p < 0.001). The Western region was also independently associated with increased hospital costs. Conclusions: High hospital case volume appears to be indirectly associated with decreased hospital costs. The results of this study highlight the constant need to improve cost efficiency and reduce excess utilization costs while maintaining optimal patient outcomes. Level of evidence: Level IV, risk/prognostic study. [ABSTRACT FROM AUTHOR]

Background: Official recommendations differ regarding tympanostomy-tube placement for children with recurrent acute otitis media.Methods: We randomly assigned children 6 to 35 months of age who had had at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months with at least one episode within the preceding 6 months, to either undergo tympanostomy-tube placement or receive medical management involving episodic antimicrobial treatment. The primary outcome was the mean number of episodes of acute otitis media per child-year (rate) during a 2-year period.Results: In our main, intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P = 0.66). Because 10% of the children in the tympanostomy-tube group did not undergo tympanostomy-tube placement and 16% of the children in the medical-management group underwent tympanostomy-tube placement at parental request, we conducted a per-protocol analysis, which gave corresponding episode rates of 1.47±0.08 and 1.72±0.11, respectively. Among secondary outcomes in the main analysis, results were mixed. Favoring tympanostomy-tube placement were the time to a first episode of acute otitis media, various episode-related clinical findings, and the percentage of children meeting specified criteria for treatment failure. Favoring medical management was children's cumulative number of days with otorrhea. Outcomes that did not show substantial differences included the frequency distribution of episodes of acute otitis media, the percentage of episodes considered to be severe, and antimicrobial resistance among respiratory isolates. Trial-related adverse events were limited to those included among the secondary outcomes of the trial.Conclusions: Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management. (Funded by the National Institute on Deafness and Other Communication Disorders and others; ClinicalTrials.gov number, NCT02567825.). [ABSTRACT FROM AUTHOR]

Objective: During the COVID-19 era, a reliable method for tracing aerosols and droplets generated during otolaryngology procedures is needed to accurately assess contamination risk and to develop mitigation measures. Prior studies have not investigated the reliability of different fluorescent tracers for the purpose of studying aerosols and small droplets. Objectives include (1) comparing vitamin B2, fluorescein, and a commercial fluorescent green dye in terms of particle dispersion pattern, suspension into aerosols and small droplets, and fluorescence in aerosolized form and (2) determining the utility of vitamin B2 as a fluorescent tracer coating the aerodigestive tract mucosa in otolaryngology contamination models. Methods: Vitamin B2, fluorescein, and a commercial fluorescent dye were aerosolized using a nebulizer and passed through the nasal cavity from the trachea in a retrograde-intubated cadaveric head. In another scenario, vitamin B2 was irrigated to coat the nasal cavity and nasopharyngeal mucosa of a cadaveric head for assessment of aerosol and droplet generation from endonasal drilling. A cascade impactor was used to collect aerosols and small droplets ≤14.1 µm based on average aerodynamic diameter, and the collection chambers were visualized under UV light. Results: When vitamin B2 was nebulized, aerosols ≤5.4 µm were generated and the collected particles were fluorescent. When fluorescein and the commercial water tracer dye were nebulized, aerosols ≤8.61 µm and ≤2.08 µm respectively were generated, but the collected aerosols did not appear visibly fluorescent. Endonasal drilling in the nasopharynx coated with vitamin B2 irrigation yielded aerosols ≤3.30 µm that were fluorescent under UV light. Conclusion: Vitamin B2's reliability as a fluorescent tracer when suspended in aerosols and small droplets ≤14.1 µm and known mucosal safety profile make it an ideal compound compared to fluorescein and commercial water-based fluorescent dyes for use as a safe fluorescent tracer in healthcare contamination models especially with human subjects. [ABSTRACT FROM AUTHOR]

COVID-19 (COVID) delayed access to speech and hearing services. The objective of this study was to identify interactions between socioeconomic status (SES) and cochlear implant (CI) usage during COVID. Consecutive pediatric patients (age 0–17) with CI and audiology visits between 2019 and 2022 at a tertiary care children's hospital were reviewed. Age, sex, race, insurance type, and proxy measures for SES using zip code were recorded. Hours spent with CI on and in different listening environments were compared between pre-COVID (1/1/2019–12/31/2019), COVID (4/1/2020–3/31/2021), and most recent (6/1/2021–5/31/2022) time periods. Most patients were male (32/59, 54 % ears of 48 patients) and White, non-Hispanic (45/59, 76 %). Median age at implant was 2.0 years (range:0.6–12.2). There were no significant differences in hours spent with CI on during COVID compared with pre-COVID. However, children spent more time listening to louder noises (70–79 dB and ≥80 dB) recently compared with during COVID (p = 0.01 and 0.006, respectively). During COVID, children living in areas with greater educational attainment showed smaller reductions in total hours with CI on (β = 0.1, p = 0.02) and hours listening to speech in noise (β = 0.03, p = 0.005) compared with pre-COVID. In the most recent time period, children of minority race (β = −3.94 p = 0.008) and those who were older at implant (β = −0.630, p = 0.02) were more likely to experience reductions in total hours with CI on compared with during COVID. Interventions which mitigate barriers of implant use and promote rich listening home-environments for at risk populations should be implemented during challenging future social and environmental conditions. [ABSTRACT FROM AUTHOR]

Pediatric laryngotracheal stenosis is a complex congenital or acquired airway injury that may manifest into a potentially life-threatening airway emergency condition. Depending on the severity of obstruction, treatment often requires a combination of endoscopic techniques, open surgical repair, intraluminal stenting, or tracheostomy. A balloon expandable biodegradable airway stent maintaining patency while safely degrading over time may address the complications and morbidity issues of existing treatments providing a less invasive and more effective management technique. Previous studies have focused on implementation of degradable polymeric scaffolds associated with potentially life-threatening pitfalls. The feasibility of an ultra-high ductility magnesium-alloy based biodegradable airway stents was demonstrated for the first time. The stents were highly corrosion resistant under in vitro flow environments, while safely degrading in vivo without affecting growth of the rabbit airway. The metallic matrix and degradation products were well tolerated by the airway tissue without exhibiting any noticeable local or systemic toxicity. Wu et al. demonstrate utility of a novel, ultrahigh ductility Mg alloy-based biodegradable stent in vitro and in vivo for use in congenital disorders like pediatric laryngotracheal stenosis. Tested in both bioreactor system and rabbit airway model, these stents display higher corrosion resistance and better in vivo degradation without affecting growth of rabbit airway. [ABSTRACT FROM AUTHOR]

Abstract Objectives To improve the recognition of differences in presentation amongst patients with type 1 laryngeal clefts of various ages and better understand the age dependent outcomes of injection laryngoplasty. A second aim was to analyze the discrepancies between swallow assessment modalities in various age groups with type I laryngeal clefts undergoing injection laryngoplasty. Methods A retrospective review of electronic medical records of patients who underwent injection laryngoplasty from 2009 through 2015 at a tertiary care children's hospital. Data extracted included: Demographics, histories and physical exam findings, diagnostic studies, and medical and surgical treatments. Results Most (72/102, 70.6%) patients were male with a median gestational age at birth of 37 weeks (range 24–41 weeks). Formula thickening and GERD medications were used in 94/102 (92.2%) and 97/102 (95.1%) patients, respectively. Comorbid GERD, laryngomalacia, tracheomalacia, and subglottic stenosis were present in 98/102 (96.1%), 40/102 (39.2%), 9/102 (8.8%), and 14/102 (13.7%) patients, respectively. There was no significant difference in demographics, comorbidities or medical therapy between age groups. Symptoms at presentation differed between age groups with stridor (χ2(1) = 11.6, p = 0.002) and cyanosis (χ2(1) = 8.13, p = 0.012) being more common in the 0–3-month group compared to the 12–36 month group. Symptom resolution and the odds of undergoing additional surgery (second injection or suture repair) over time, however, did not differ. There was a significant reduction in aspiration with thins during FEES (McNemar χ2(1) = 10.7, p = 0.002) and aspiration with nectar during MBS (McNemar χ2(1) = 5.26, p = 0.035) post-injection. After injection, there was significant agreement in aspiration with thins between FEES and MBS (kappa = 0.308 ± SE 0.170, p = 0.035). However, finding aspiration with thins was more common during MBS than during FEES (McNemar χ2(1) = 7.00, p = 0.016). There were no differences in swallow evaluation findings between the age groups. Conclusions Symptoms of type I laryngeal clefts may differ by age. However, there was no impact of age on the safety and efficacy of surgical intervention. [ABSTRACT FROM AUTHOR]

• Violent and self-inflicted injuries occur in dissimilar populations and result in distinctive patterns of injury. • Violently inflicted UE GSWs occur in young, black men; self-inflicted gunshot wounds more often occur in older, comorbid, Caucasian men. • Violent injuries exhibit a bimodal distribution at the shoulder/arm level and again at the hand level. • Accidental, self-inflicted GSWs most often occur distally at the hand or wrist. • There is a trend that more distal injuries of the hand and wrist, particularly bony injuries, are more likely to require operative management. Upper Extremity gunshot wounds represent a significant strain on community and hospital resources, and reports of their epidemiology are varied. We hypothesized that demographic and socioeconomic variables would be associated with variable injury patterns and management, and that two distinct populations would be affected by upper extremity ballistic injury based on violent versus accidental, self-inflicted mechanism. Retrospective review of all adult patients sustaining ballistic injury to the upper extremity at a single urban Level I trauma center over 10 years (n = 797). Demographic, injury pattern, treatment, and outcomes data were collected. Comparisons between groups were conducted with unpaired t-tests and chi-square testing where appropriate. Most patients were male (89.1%) and mean age was 30.1 years (18-83). Violence accounted for 89.1% of injuries. Black individuals were disproportionately affected at 87% of patients. Shoulder injuries were most common (34%), and wrist least common (7%). Demographics and injury pattern varied significantly between patients sustaining violent injury and those with self-inflicted mechanisms. Patients sustaining violent injury were most often young, Black men more likely to be injured proximally, whereas patients with self-inflicted injuries were more likely to be older, Caucasian men with more comorbidities injured distally. Cumulatively, 35.3% of patients required operative intervention. Distal injuries were more likely operative. The most commonly injured structure across all levels was bone (53%), and 54.3% of fractures required operation. Median follow-up was 24.5 months. Complication rate was 13.6%. Gunshot wounds of the upper extremity create complex patterns of injury which vary based on level of injury and mechanism. Violent and self-inflicted injuries occur in dissimilar populations and result in distinctive injury patterns. [ABSTRACT FROM AUTHOR]

Endocrine therapy resistance invariably develops in advanced estrogen receptor-positive (ER+) breast cancer, but the underlying mechanisms are largely unknown. We have identified C-terminal SRC kinase (CSK) as a critical node in a previously unappreciated negative feedback loop that limits the efficacy of current ER-targeted therapies. Estrogen directly drives CSK expression in ER+ breast cancer. At low CSK levels, as is the case in patients with ER+ breast cancer resistant to endocrine therapy and with the poorest outcomes, the p21 protein-activated kinase 2 (PAK2) becomes activated and drives estrogen-independent growth. PAK2 overexpression is also associated with endocrine therapy resistance and worse clinical outcome, and the combination of a PAK2 inhibitor with an ER antagonist synergistically suppressed breast tumor growth. Clinical approaches to endocrine therapy-resistant breast cancer must overcome the loss of this estrogen-induced negative feedback loop that normally constrains the growth of ER+ tumors. [ABSTRACT FROM AUTHOR]

Objective Routine plain film radiographs are often obtained to confirm proper placement of electrode after pediatric cochlear implant surgery. Objective is to evaluate necessity of routine radiographs in pediatric cochlear implant cases. Study design Retrospective review. Setting Two tertiary care academic centers. Subjects and methods Review of all children that underwent cochlear implantation from January 2003 thru June 2015. Exclusions include patients without intraoperative evoked compound action potential (ECAP) data or radiographs and patients undergoing revision surgeries. Results 235 pediatric patients underwent 371 cochlear implants. ECAP measurements were not available in two cases and were excluded from study. Radiographs were obtained in 35/369 cases due to intraoperative concern and four had abnormal findings. All four cases underwent change in management. One other patient had an x-ray because of difficult insertion and abnormal ECAP. Radiograph was normal; however, incision was opened and electrodes inserted further. Overall, 5/369 cases had changes in management intraoperatively. In all five cases, abnormalities were suspected by clinician judgment or abnormal ECAP measurements. Routine radiographs were completed in 349/369 cases and one was abnormal. This patient had known partial insertion due to cochlear fibrosis from meningitis and abnormal radiograph did not result in change in management. Conclusion Clinician suspicion and/or abnormal ECAP prompted suspicion for abnormal electrode placement prior to evaluation with radiograph in all cases in which change in management occurred. Intraoperative radiographs may be valuable in setting of clinical suspicion. Routine radiographs do not result in change in management and are, therefore, unnecessary. [ABSTRACT FROM AUTHOR]

Objective To review all cases intratemporal and intracranial complications of acute otitis media (AOM) in infants and children from 1998 to 2013. Methods Retrospective chart review of 109 consecutive patients admitted for complications of AOM during a 15-year period at a tertiary-care children's hospital. The main outcomes are: (1) complications of AOM, (2) bacteriology, (3) management strategies. Results In our population, complications included mastoiditis (86.1%), subperiosteal abscess (38%), facial nerve palsy (16.7%), sigmoid sinus thrombosis (8.3%) and epidural abscess (7.4%). Other complications included post-auricular cellulitis, otic hydrocephalus and elevated intracranial pressure, internal jugular thrombosis, cranial nerve VI palsy and Gradenigo's syndrome, labyrinthine fistula, sensorineural hearing loss, and cerebellar infarct. Sixty-one patients (56%) received antibiotics prior to presentation. Cultures revealed Streptococcus pneumoniae in 36 patients (33.3%), other bacteria in 30 patients (27.8%), and “no growth” in 33 patients (30.5%). Nine patients (8.3%) did not undergo culture. Of the patients with S. pneumoniae , 20 cultures (55%) were found to be multidrug-resistant. Eleven patients (10.2%) were treated non-surgically, 31 (31%) were treated with myringotomy and intravenous antibiotics. Forty patients (97.5%) presenting with subperiosteal abscess required mastoid surgery. Thirteen of 18 (72.2%) patients with facial paralysis had full recovery. Eight of 10 (80%) patients with epidural abscess empyema required mastoid surgery and incision and drainage of the abscess. Conclusion Complications of AOM are uncommon, yet continue to have potentially serious consequences. The bacteriology in this population reveals an increasing trend of multi-drug resistant S. pneumoniae as the causative organism. [ABSTRACT FROM AUTHOR]

Children with Down syndrome (DS) have a higher incidence of tympanostomy tube insertion (TTI) than children in the general population. As there were no studies investigating factors that are associated with multiple TTIs in children with DS, we sought to determine what factors increase or decrease the likelihood of repeat TTI in children with DS. A retrospective case-control study was performed on consecutive children with DS from 2007 to 2018 with first TTI at a large tertiary children's hospital and follow-up duration at least 27 months since first TTI. 277 patients met the inclusion criteria. Repeat TTI rate was 61.4%. Having an indication of chronic otitis media with effusion (COME) at first TTI was an adjusted risk factor for increased rate of repeat TTI (OR: 2.01, 95%CI: 1.15–3.51, p =.014), while being older at first TTI was an adjusted protective factor for decreased rate of repeat TTI (OR: 0.84, 95%CI: 0.74–0.95, p =.004). Adenotonsillectomy at or before first TTI was not an adjusted protective factor for decreased rate of repeat TTI (OR: 0.915, 95%CI: 0.448–1.872, p =.809) and bilateral intra-operative fluid was not an adjusted risk factor for repeat TTI (OR: 1.97, 95%CI: 0.99–3.90, p =.054). Children with DS were more likely to undergo repeat TTI if they were of younger age and if the indication for surgery was COME. The repeat TTI rate for children with DS was high at 61.4%. Prospective studies are warranted to more precisely investigate factors associated with repeat TTIs in this unique patient population. [ABSTRACT FROM AUTHOR]

Objectives As data continue to emerge demonstrating improved hearing outcomes associated with younger age at time of cochlear implantation, more children aged 12 months or younger are undergoing this procedure. Drilling a well to house the cochlear implant receiver/stimulator (R/S) may carry an increased risk in this group of patients as the calvarium is thin and drilling an adequate well may require exposure of the underlying dura. Our group has employed a technique in this age group which involves securing the R/S in a subperiosteal pocket without creating a bony well. We report our experience with six infants 12 months of age or younger undergoing cochlear implantation with the subperiosteal pocket technique. Methods Cases were identified by searching an IRB approved research registry. Charts were reviewed for demographics, surgical technique, and clinical outcomes. Descriptive statistics were calculated. Results Six patients 12 months of age or younger underwent cochlear implantation over a one year period. Simultaneous bilateral implantation was performed in all cases, for a total of 12 implanted ears. The average age at time of implantation was 9.8 months (SD 2.1 months). There were no postoperative wound complications. No evidence of device migration was noted in any patient as of the most recent follow-up appointment. There was one device hard failure at 32 months. Average length of follow-up was 28.4 months (SD 13.8 months). Conclusions No wound complications or device migrations occurred in 12 cochlear implantations in six children aged 12 months or younger. Advantages of this technique include no risk to the dura in this location, smaller incisions, and shorter surgical time. A potential disadvantage is the increased device profile from the lack of a well. New thinner implant designs may minimize this concern. Further prospective study is justified to confirm our initial experience in this small group. [ABSTRACT FROM AUTHOR]

The inherent abilities of natural killer (NK) cells to recognize and kill target cells place them among the first cells with the ability to recognize and destroy infected or transformed cells. Cancer cells, however, have mechanisms by which they can inhibit the surveillance and cytotoxic abilities of NK cells with one believed mechanism for this: their ability to release exosomes. Exosomes are vesicles that are found in abundance in the tumor microenvironment that can modulate intercellular communication and thus enhance tumor malignancy. Recently, our lab has found cancer cell exosomes to contain the inhibitor of apoptosis (IAP) protein survivin to be associated with decreased immune response in lymphocytes and cellular death. The purpose of this study was to explore the effect of survivin and lymphoma-derived survivin-containing exosomes on the immune functions of NK cells. NK cells were obtained from the peripheral blood of healthy donors and treated with pure survivin protein or exosomes from two lymphoma cell lines, DLCL2 and FSCCL. RNA was isolated from NK cell samples for measurement by PCR, and intracellular flow cytometry was used to determine protein expression. Degranulation capacity, cytotoxicity, and natural killer group 2D receptor (NKG2D) levels were also assessed. Lymphoma exosomes were examined for size and protein content. This study established that these lymphoma exosomes contained survivin and FasL but were negative for MHC class I-related chains (MIC)/B (MICA/B) and TGF-β. Treatment with exosomes did not significantly alter NK cell functionality, but extracellular survivin was seen to decrease natural killer group 2D receptor (NKG2D) levels and the intracellular protein levels of perforin, granzyme B, TNF-α, and IFN-γ. [ABSTRACT FROM AUTHOR]

The spinal dorsal horn is a major site for the induction and maintenance of mechanical allodynia, but the circuitry that underlies this clinically important form of pain remains unclear. The studies presented here provide strong evidence that the neural circuits conveying mechanical allodynia in the dorsal horn differ by the nature of the injury. Calretinin (CR) neurons in lamina II inner convey mechanical allodynia induced by inflammatory injuries, while protein kinase C gamma (PKCγ) neurons at the lamina II/III border convey mechanical allodynia induced by neuropathic injuries. Cholecystokinin (CCK) neurons located deeper within the dorsal horn (laminae III–IV) are important for both types of injuries. Interestingly, the Maf + subset of CCK neurons is composed of transient vesicular glutamate transporter 3 (tVGLUT3) neurons, which convey primarily dynamic allodynia. Identification of an etiology-based circuitry for mechanical allodynia in the dorsal horn has important implications for the mechanistic and clinical understanding of this condition. • CR neurons are important for mechanical allodynia in inflammatory injuries • PKCγ neurons are important for mechanical allodynia in neuropathic injuries • CCK and tVGLUT3 neurons in deeper laminae convey both types of injuries • The Maf + subset of CCK neurons encompasses tVGLUT3 and conveys dynamic allodynia Peirs et al. identified distinct spinal cord microcircuits that underlie mechanical allodynia, depending on the injury type. The neurons engaged after neuropathic or inflammatory injuries include populations that express CCK, tVGLUT3, CR, and PKCγ. [ABSTRACT FROM AUTHOR]

Recent cochlear implant (CI) electrodes are designed to be atraumatic to inner ear structures. Studies in adults have demonstrated improved hearing preservation rates with the CI532/632 electrode, but none have examined this in children. Our objective is to describe the hearing preservation rate with CI532/632 in pediatric patients and determine factors that influence hearing preservation. We conducted a retrospective cohort study of children undergoing CI over a three-year period. Inclusion criteria were: CI with the 532/632 electrode, presence of pre-operative low frequency hearing defined by pure tone average (PTA) of ≤80 dB at 250 Hz or at the average of 250 and 500 Hz, and post-operative unaided audiometry. Other data collected included demographics, otologic history, imaging, and surgical details. A total of 13 patients and 15 ears were included. Hearing was preserved in 10/15 (66%) ears at an average follow-up of 6 months, similar to that reported in the adult literature. Patients with preserved hearing post-operatively were more likely to have a positive family history of hearing loss. There was a trend towards patients with anatomic inner ear abnormalities being more likely to lose hearing after CI, but this was not statistically significant. Pre-operative thresholds were not predictive of hearing preservation. Patients with preserved hearing had a significantly smaller shift in thresholds after cochlear implantation. Therefore, hearing preserved and non-preserved groups differed more by the magnitude of change in threshold, rather than their preoperative threshold. Other factors such as age, sex, surgeon, and surgery duration were not associated with hearing preservation. This study describes low frequency hearing preservation after pediatric CI532/632 implantation. The hearing preservation rate in our cohort was consistent with that reported in the adult literature. Our data suggest that preoperative thresholds do not solely determine which patients will go on to experience hearing preservation. We believe this will aid surgeons with patient-specific device selection and counseling potential pediatric CI recipients with preserved hearing. • Hearing preservation rate in this pediatric cohort was 66% with CI532/632. • Comparable to reports in adults with perimodiolar and lateral wall implants. • Anatomic inner ear abnormalities may confer higher risk of residual hearing loss. • Pre-operative thresholds are not strongly associated with hearing preservation. [ABSTRACT FROM AUTHOR]

Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3–29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2–9) and number of outpatient APP (mean/median/range = 6.3/5/1–30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0–5, 6–10 and > 11 years of tenure were $76–100K (65%), $100–150K (77%) and $100–150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity. [ABSTRACT FROM AUTHOR]