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Importance The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child’s consultation is not known. Objective To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent–clinician communication. Design, Setting, and Participants Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist. Main Outcomes and Measures The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient’s treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents). Results A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as “Other.” Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34). Conclusions and Relevance In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Pathologie Quiz Case 1 A 14-month-old black girl was referred for evaluation of a slowly enlarging left submandibular mass that had been present for 3 weeks. A tuberculin skin test was nonreactive, and the mass enlarged despite 10 days of amoxicillin–clavulanate therapy. The patient was otherwise healthy, without fever, cough, or other systemic complaints. Her head and neck examination was remarkable only for a 3X3-cm mass in the left submandibular triangle, which was firm but not fixed. The mass was neither warm nor tender, and no changes were present in the overlying skin. No other significant adenopathy was found on head and neck and general physical examinations. Computed tomography with intravenous contrast showed a submandibular mass with low attenuation centrally and some rim enhancement (Figure 1[arrow indicates the mass]). Fine-needle aspiration was performed, revealing a polymorphous population of mononuclear cells and occasional large reactive histiocytes containing intact lymphocytes (Figure 2).

A full-term4260-g infantwas transferred to a neonatal intensive care unit on day 1 of life after he had respiratory distress in thedelivery suite requiring endotracheal intubation.He was delivered by cesarean delivery following a maternal history of cesarean delivery. Prenatal ultrasonography showed polyhydramnios and a fetus that was large for gestational age. In the neonatal intensive care unit, 6F catheters would not pass through either side of the nose, and fiberopticnasalendoscopydemonstratedafirm,mucosalcoveredposteriorwall of thebilateralnasal cavitieswithout opening into the nasopharynx. The infant also had zygomatic hypoplasia, micrognathia, and bilateral grade III microtia with atresia of the external auditory canals. Echocardiogram demonstrated large left patent ductus arteriosus andpatent foramenovalewith left to right shunt,milddecrease inRVsystolic function, and elevatedpulmonaryarterypressures.Results fromheadandabdominalultrasonographand an ophthalmologic evaluation were unremarkable. Computed tomographic (CT) imaging was performed to plan transnasal repair of clinically suspected choanal atresia. This scan showedbonyposteriornasalobstruction,withthehardpalateextendingdirectly tothesphenoid bone, with irregular shape and inferior position of the basisphenoid (Figure). The infant remained intubated until, at 11 days of age, he underwent tracheotomy and examination of the nose and nasopharynx under general anesthesia. Quiz at jamaotolaryngology.com Sagittal view A Axial view B

Objective: To review the results of a simple technique of closure of persistent tracheocutaneous fistula (TCF) in children. Design: Retrospective case series. Setting: Tertiary pediatric otolaryngology referral center. Patients: Children (age, Interventions: Surgical closure of persistent TCF using multilayered closure of de-epithelialized local tissue. Tracheal dissection was not performed. A thermal hemostatic scalpel was used in some cases to assist in de-epithelialization and provide hemostasis without electrocautery near the airway. Main Outcome Measures: Success of closure and number and types of complications. Results: Nine procedures were performed in 8 children. Seven (88%) of 8 primary procedures were successful, but early recurrent TCF developed in 1 patient. Revision surgery using an identical surgical technique, but maintaining endotracheal intubation for 48 hours, was successful in this patient. No complications occurred. Conclusions: This procedure is a simple, reliable method for closure of TCF in children. Arch Otolaryngol Head Neck Surg. 1997;123:1066-1068.

Importance Although children with low socioeconomic status (SES) have increased risk for sleep-disordered breathing (SDB), their access to subspecialty care is often limited. Polysomnography (PSG) is the gold standard diagnostic test used to characterize SDB and diagnose obstructive sleep apnea; however, it is unknown whether SES impacts timeliness of obtaining PSG and surgical treatment with adenotonsillectomy (AT). Objective To evaluate the impact of SES on the timing of PSG, surgery with AT, and loss to follow-up for children with SDB. Design, Setting, and Participants Retrospective cohort analysis conducted in tertiary outpatient pediatric otolaryngology clinics among patients newly evaluated for SDB over a 3-month period who did not have prior PSG ordered and had a minimum of 1-year follow-up. Main Outcomes and Measures Public insurance (Medical Assistance [MA]) was used as a proxy for low SES. Demographics and disposition between groups were compared using t tests and χ 2 analysis. Logistic regression adjusting for disposition and insurance was used to predict loss to follow-up. Days to PSG and days to AT were evaluated using the Kaplan-Meier estimator, and the log-rank test was used to compare distribution of time to events between insurance groups. Results A total of 136 children (without PSG) were evaluated for SDB over the course of 3 months; 62 (45.6%) had MA. Polysomnography was recommended for 55 children (27 of 55 [49%] with MA vs 28 of 55 [50%] with private insurance; P > .99). After the initial visit, 24 of 55 children with PSG requested (44%) were completely lost to follow-up (9 of 27 [33%] with MA vs 15 of 28 [54%] private insurance; P = .34). Children with MA who obtained PSG experienced longer intervals between initial encounter and PSG (mean interval, 141.1 days) than privately insured children (mean interval, 49.9 days) ( P = .001). For those children who ultimately underwent AT surgery after obtaining PSG (n = 14), mean (SD) time to AT was longer for children with MA (222.3 [48.2] days vs 95.2 [66.1] days; P = .001). Conclusions and Relevance Children with public insurance experienced longer intervals from initial evaluation to PSG or surgery. Almost half of patients with PSG requested were lost to follow-up, regardless of SES. These findings suggest that PSG may be a deterrent for definitive care for all children, and particularly for children with public insurance or low SES. This study emphasizes the need to understand factors contributing to disparities surrounding delay in care with PSG and surgery for children with SDB.

Objectives To evaluate self-reported workforce needs and demands, professional activities, and the clinical practices of pediatric otolaryngologists in the United States for the purpose of better understanding the pediatric otolaryngology workforce and predicting manpower needs. Design A Web-based survey was sent to all members of the American Society of Pediatric Otolaryngology (ASPO). It achieved a 39.3% response rate, with a total of 99 US member respondents. We compared this sample to the overall US ASPO membership to determine if our respondent cohort was representative of ASPO demographics. Participants All members of ASPO. Main Outcome Measures Responses were categorized by demographics and nature of respondent practice (academic vs private practice). Results Respondents were representative of the US ASPO membership. Most of the respondents practiced in an academic setting (n = 70; 70%). Academicians reported seeing a higher percentage of patients with Medicaid public insurance than did private practitioners (34% vs 25.0%) ( P = .03). Academicians spent a greater portion of their time than private practitioners on research (14.4% vs 6.6% of time) ( P P = .002). With the exception of choanal atresia repair, there were no differences in the types of airway, otologic, head and neck, and plastic and reconstructive surgery performed by the 2 groups. Although fewer than half of the respondents (47%; n = 44) believed that there presently is a shortage of pediatric otolaryngology manpower, most (68%; n = 63) ( P = .01) believed that there would be a shortage in 5 years. Conclusions Pediatric otolaryngologists predict an increased demand for their services in the near future. The only differences in the clinical practices of academic and private pediatric otolaryngologists are patient payer mix and the amount of time devoted to teaching.

Objective To determine the effectiveness of the Z-meatoplasty technique for enlargement of the external auditory meatus of children undergoing modified radical mastoidectomy. Design Case series. Setting Pediatric otolaryngology practice in an academic setting. Patients Consecutive sample of children (≤18 years old) who had undergone modified radical mastoidectomy performed by the author from 1995 to 2005. Intervention Z-meatoplasty technique used as part of modified radical mastoidectomy. Main Outcome Measure Development of postoperative stenosis of the external auditory meatus that required additional surgery. Results A total of 28 children and 29 ears were treated with modified radical mastoidectomy during the study period. The Z-meatoplasty was used in 24 ears, and 3 (12.5%) required revision meatoplasty for meatal stenosis. Twenty-one ears (87.5%) treated with Z-meatoplasty had excellent healing and cosmesis without stenosis, during a mean follow-up period of 40 months. Conclusion The Z-meatoplasty is an effective technique for use during modified radical mastoidectomy to treat children with cholesteatoma.

Objective To evaluate the long-term benefits of mandibular distraction on sleep-related upper airway obstruction in young children with mandibular hypoplasia. Design Cross-sectional study. Subjects were examined for sleep-disordered breathing using medical history, physical examination results, and a written questionnaire. Subjects underwent standard overnight polysomnography, during which measures of sleep-disordered breathing were collected. Setting Tertiary care hospital. Patients Five children with upper airway obstruction from craniofacial anomalies treated with mandibular distraction, with a minimum follow-up of 12 months. Main Outcome Measures Apnea-hypopnea index, oxygen saturation nadir, and peak end-tidal carbon dioxide value. Results Of the 5 children, 3 were cured of upper airway obstruction as documented by polysomnography, with an apnea-hypopnea index of less than 1.5 and no snoring. The fourth child had primary snoring without apnea. The fifth child had severe obstructive sleep apnea, with an apnea-hypopnea index of 20.2. Conclusions Most children who undergo mandibular distraction for upper airway obstruction associated with mandibular hypoplasia demonstrate significant clinical improvement of obstructive sleep apnea. However, those children who continue to have symptoms of sleep-disordered breathing after surgery should undergo polysomnography for evaluation of persistent obstructive sleep apnea.

To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs.Survey of members of the American Academy of Pediatrics Section on Otolaryngology and Bronchoesophagology and the American Society of Pediatric Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology-Head and Neck Surgery.Pediatric otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. Pediatric otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000 people.Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need.

Objective To assess optimal surgical treatment with excision or curettage techniques in children with cervicofacial nontuberculous mycobacterial (NTM) adenitis. Design Retrospective case series. Setting Tertiary university-based pediatric referral center. Patients Patients younger than 18 years diagnosed as having cervicofacial NTM adenitis by positive mycobacterial cultures or stains, or by histopathologic evaluation. Interventions Fine-needle aspiration biopsy for diagnosis, surgical excision and/or curettage of head and neck lesions for treatment. Main Outcome Measures Number of procedures per patient, complications, resolution of mass. Results A total of 32 surgical procedures were performed in 25 children with cervicofacial NTM adenitis (mean, 1.3 procedures per patient; range, 1-3): 19 excisional and 13 curettage procedures. The 14 children who had excision as an initial procedure required no additional surgery. Of 11 children who had curettage as an initial procedure, 6 (55%) required additional procedures. Three of these children had additional surgery as planned staged procedures. Excisional surgery after initial curettage (5 patients) was simplified by initial debridement and secondary healing. No complications of curettage were noted. Transient marginal mandibular nerve weakness was seen in 4 patients who had excision. Fourteen of 16 fine-needle aspiration biopsy specimens were diagnostic for NTM adenitis. Conclusions Cervicofacial NTM adenitis can be treated with excision or curettage. Excision remains the treatment of choice because of the high cure rate with a single procedure. We now consider curettage as a staged procedure for lesions in proximity to the facial nerve or with extensive skin necrosis, with initial curettage simplifying subsequent excision and wound closure. Preoperative counseling should include discussion of planned or unplanned revision surgery after curettage. Fine-needle aspiration biopsy allows early diagnosis of NTM adenitis.

Thyroglossal duct remnants are the most common midline neck masses in childhood, representing more than 75% of such masses. Surgical treatment with the Sistrunk operation (wide excision of the cyst, duct, central hyoid, and a core of tongue base) remains the standard of care, with a low recurrence rate and minimal morbidity. Controversy exists over the appropriate preoperative evaluation of children with presumed TGD remnants since postoperative hypothyroidism can occur from inadvertent removal of the only functioning ectopic thyroid tissue. The options for evaluation include the following: • No preoperative studies • No preoperative studies; look for thyroid gland during surgery • Radioisotope scanning of the thyroid gland for all patients before surgery • Other imaging modalities, such as ultrasonography, computed tomography, or magnetic resonance imaging • Radioisotope scanning of the thyroid gland in selected patients before surgery based on a history suggestive of hypothyroidism, thyroid function tests, an inability to palpate thyroid gland, or other radiographic tests The following sections will discuss the relative merits of preoperative scanning of the thyroid gland in patients with suspected TGD remnants.

To the Editor. —The article by Brett et al in the January 1987 issue of theArchivesclassifies patients with a drug overdose into high- and low-risk groups based on the following criteria: need for intubation, seizures, unresponsiveness to verbal stimuli, arterial carbon dioxide pressure greater than or equal to 45 mm Hg, any rhythm except sinus rhythm, secondor third-degree atrioventricular block, QRS interval greater than or equal to 0.12 s, or a systolic blood pressure less than 80 mm Hg.1They concluded that patients observed for several hours and placed into the low-risk category did not develop high-risk conditions necessitating admission to the intensive care unit. An exception to their findings is the patient with acute lithium overdose. We recently cared for a patient with severe lithium intoxication who manifested a delayed rise of serum lithium levels. Report of a Case. —A 33-year-old man was seen at our

To the Editor. — In the Letter to the Editor that appeared in the January 27 issue of JAMA , Dr Kubin 1 asks that JAMA restrict the publication of articles about the acquired immunodeficiency syndrome (AIDS). I disagree with many of his statements. First, he maintains that practicing physicians are inundated with information about AIDS and that almost every issue of JAMA has an article about AIDS. It may seem that way to Dr Kubin, but the overall percentage of articles and letters concerning AIDS is not that great. To illustrate this point, I reviewed the table of contents of all issues of JAMA during the calendar year 1988, including all articles about AIDS, AIDS-related complex, or AIDS risk factors. As can be seen in the Table, only 13.1% of all articles published in JAMA over that period concerned AIDS. On further breakdown by journal section, the work of researchers