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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 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 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

BACKGROUND The submucous cleft palate can be overt or occult and may require surgical repair. The double-opposing Z-plasty (Furlow repair) is the authors' center's preferred approach. This study evaluated complication rates, differences in outcome between overt and occult types, and patient factors associated with surgical failure. METHODS This retrospective study reviewed documentation on all patients who underwent Furlow Z-plasty for submucous cleft palate at a single center between 2004 and 2018. Speech pathology was quantified using the Pittsburgh Weighted Speech Score. RESULTS A total of 351 patients were included (125 overt and 226 occult cases). Furlow Z-plasty was successful (postoperative Pittsburgh Weighted Speech Score

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

Advanced practice provider (APP) employment is becoming common in pediatric otolaryngology practices, though few studies have evaluated the consequences that APP-led clinics have on access to care. The objectives of this study were: 1) to investigate whether access to bilateral myringotomy with tympanostomy tube placement (BMT) for recurrent acute otitis media (RAOM) differed between patients seen in otolaryngologist and APP-led clinics 2) to compare clinical characteristics of patients seen by provider type.Retrospective cohort study at an academic, tertiary care pediatric otolaryngology practice. All children were18 years old and underwent evaluation for RAOM followed by BMT. We compared time in days from scheduling pre-operative appointment to appointment date and time from appointment to BMT between patients seen by APPs and otolaryngologists using Mann-Whitney U tests and multivariate linear regression models. We compared clinical characteristics by provider type using Mann-Whitney U tests and Fisher exact tests.A total of 957 children were included. Children seen by APPs had significantly shorter wait times for appointments (median 19 vs. 39 days, P .001) and shorter times from preoperative appointment to BMT (median 25 vs. 37 days, P .001). Patients seen by otolaryngologists had increased prevalence of craniofacial abnormalities, Down Syndrome, hearing loss, history of otologic surgery, and higher ASA physical status classification.Children seen by APPs received care more quickly than those seen by otolaryngologists. Patients seen by otolaryngologists tended to be more medically complex. Implementation of independent APP clinics may expedite and improve access to BMT for children with RAOM.3 Laryngoscope, 131:2133-2140, 2021.

OBJECTIVE: (1) Review a multidisciplinary vascular anomalies center’s practice regarding peri-procedural anticoagulation for venous malformations (VM) and the associated risk of thromboembolic and disseminated intravascular coagulation (DIC) events. (2) Compare the risk of thromboembolic events and DIC post-procedure between head and neck (H&N) and extremity VM patients. METHODS: An Institutional Review Board (IRB)-approved, retrospective chart review was performed on 120 VM patients. A thromboembolic event was defined as a thrombus formation post-sclerotherapy or post-surgery within 2 months in a distant or local venous structure not directly addressed by the procedure. RESULTS: There were 39 cases involving the H&N and 81 cases based at the extremities. There were eight cases of post-procedure thrombus formation within the extremity VM group (8/71; 11.3%) as opposed to 0 cases in the H&N group (OR: 0, 95% CI .00–.09), p = .049. There was no difference in incidence of post-procedure thromboembolic events between those with elevated D-dimer (H&N: 0%, extremity: 22.7%, 5/22) and normal D-dimer values (H&N: 0%, extremity: 6.3% [1/16], P = .370). There was no difference in incidence of post-procedure thromboembolic events between those who received peri-procedural anticoagulation (H&N: 0%, extremity: 21%, 4/19) and those who did not (H&N: 0%, extremity: 8.2%, 4/49), (Extremity: OR: 3.00, .67–13.50, P = .206). CONCLUSION: Post-procedure thromboembolism is rare in the treatment of venous malformations, especially in the head and neck subsite. Regardless of anticoagulation use, there were no thromboembolic events for H&N VM patients. Such events are rare, and the odds may approach zero, especially with small sample size.

Objectives/hypothesis The incidence of human papillomavirus-positive (HPV+) oropharyngeal cancer is rising, but public knowledge about this diagnosis remains low. This study aimed to investigate the quality and readability of online information about HPV+ oropharyngeal cancer. Study design Cross-sectional website analysis. Methods This study conducted a total of 12 web searches across Google, Yahoo, and Bing to identify websites related to HPV+ oropharyngeal cancer. The QUality Evaluation Scoring Tool (QUEST) was used to measure quality based on seven website criteria. The Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) were used to measure readability, with scores estimating the education level a reader would require to understand a piece of text. Readability improves as FRES increases and FKGL decreases. Results Twenty-seven unique web pages were evaluated. The mean USA reading grade level as measured by FKGL was 10.42 (standard deviation = 1.54). There was an inverse relationship between quality and readability, with a significant positive correlation between QUEST score and FKGL (r = 0.343, P = .040) and a significant negative correlation between QUEST score and FRES (r = -0.537, P = .002). Conclusions With a mean USA reading grade level more than four grades above the American Medical Association's recommendation and results indicating that readability suffers as quality improves, these findings suggest that the currently available online information about HPV+ oropharyngeal cancer is insufficient. Improved patient education practices and resources about this diagnosis are needed. Level of evidence NA Laryngoscope, 131:87-94, 2021.

Congenital ear anomalies are associated with congenital cardiac and renal defects. Renal ultrasounds, electrocardiogram, and echocardiogram can be utilized for diagnosis of these concurrent defects. No standard of care exists for the workup of patients with microtia. The goals of this study were to describe the utilization of diagnostic testing for cardiac and renal anomalies and to identify their prevalence in patients with microtia.Case series with chart review.Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center.This study is an Institutional Review Board-approved retrospective review of consecutive patients born between 2002 and 2016 who were diagnosed with microtia and seen in the otolaryngology clinic at a tertiary care children's hospital. Demographics, sidedness and grade of microtia, comorbid diagnoses, and details of renal and cardiovascular evaluations were recorded. Factors associated with retroperitoneal ultrasound and cardiac testing were assessed with logistic regression.Microtia was present in 102 patients, and 98 patients were included as they received follow-up. Microtia was associated with craniofacial syndrome in 34.7% of patients. Renal ultrasound was performed in 64.3% of patients, and 12.9% of patients with ultrasounds had renal aplasia. Cardiac workup (electrocardiogram or echocardiogram) was completed in 60.2% of patients, and of this subset, 54.2% had a congenital heart defect.Diagnostic testing revealed renal anomalies and cardiac defects in patients with isolated microtia at a higher rate than in the general population. This suggests the need for further evaluation of the role of routine screening in patients with microtia.

Objective: To evaluate Eustachian tube dysfunction in the ipsilateral and contralateral ears, in children with unilateral cleft lip and palate (UCLP). Design: Retrospective chart review. Setting: Tertiary care children’s hospital. Patients: Seventy-four consecutive patients with UCLP born between 2005 and 2011 and treated at UPMC Children’s Hospital of Pittsburgh Cleft-Craniofacial Center were included. Main Outcome Measures: Conductive hearing loss, tympanogram type, number of middle ear effusions, tympanostomy tubes, and complications. Hypothesis was formulated prior to data collection. Results: Conductive hearing loss was nearly twice as common in the ipsilateral ear (43.2%) compared with contralateral (23.0%; P = .001, McNemar test). There were no significant differences in the frequency of each type of tympanogram between the contralateral and ipsilateral ears. The proportions of ipsilateral (90.5%) and contralateral (91.9%) ears with effusion were not significantly different. The total number of tubes received was not significantly different between the 2 ears (median of 2 bilaterally). When combined, complications (retractions, perforations, and cholesteatomas) were significantly more common in the ipsilateral ear (29.7%) compared with the contralateral ear (18.9%; P = .039, McNemar test). Conclusion: In children with UCLP, there were significantly more instances of conductive hearing loss and complications on the cleft side compared to the noncleft side. This suggests that Eustachian tube dysfunction may indeed be more severe on the cleft side. Considering this information, clinicians may need to be especially observant of the ipsilateral ear.

Objective:To determine whether timing of palatoplasty (early, standard, or late) is associated with speech and language outcomes in children with cleft palate.Design:Retrospective case series.Setting:Tertiary care children’s hospital.Participants:Records from 733 children born between 2005 and 2015 and treated at the Cleft Craniofacial Clinic of a tertiary children’s hospital were retrospectively reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, syndromes, staged palatoplasty, and introduction to clinic after 12 months of age. Data from 232 children with cleft palate ± cleft lip were analyzed.Interventions:Palatoplasty.Main Outcome Measures:Speech/language delays and disorders at 20 months and 5 years of age based on formal hospital or community-based testing or screening evaluation in the Cleft Craniofacial Clinic; additional speech surgery.Results:Median age at palatoplasty was 12.6 months (range: 8.8-21.9 months). Age at palatoplasty was classified as early (13 months, n = 46). Late palatoplasty was associated with increased odds of speech/language delays and speech therapy at 20 months, and language delays at 5 years, compared with standard or early palatoplasty ( P < .05 for all comparisons). However, speech sound production disorders, velopharyngeal incompetence, tube replacement, and hearing loss were not significantly associated with age at palatoplasty.Conclusions:Late palatoplasty may be associated with short- and long-term delays in speech/language development. Future studies with standardized surgical technique/timing and outcome measures are required to more definitively describe the impact of age at palatoplasty on speech/language development.

HYPOTHESIS: Aerosols are generated during mastoidectomy and mitigation strategies may effectively reduce aerosol spread. BACKGROUND: An objective understanding of aerosol generation and the effectiveness of mitigation strategies can inform interventions to reduce aerosol risk from mastoidectomy and other open surgeries involving drilling. METHODS: Cadaveric and fluorescent three-dimensional printed temporal bone models were drilled under variable conditions and mitigation methods. Aerosol production was measured with a cascade impactor set to detect particle sizes under 14.1 µm. Field contamination was determined with examination under UV light. RESULTS: Drilling of cadaveric bones and three-dimensional models resulted in strongly positive aerosol production, measuring positive in all eight impactor stages for the cadaver trials. This occurred regardless of using coarse or cutting burs, irrigation, a handheld suction, or an additional parked suction. The only mitigation factor that led to a completely negative aerosol result in all eight stages was placing an additional microscope drape to surround the field. Bone dust was scattered in all directions from the drill, including on the microscope, the surgeon, and visually suspended in the air for all but the drape trial. CONCLUSIONS: Aerosols are generated with drilling the mastoid. Using an additional microscope drape to cover the surgical field was an effective mitigation strategy to prevent fine aerosol dispersion while drilling.

Objective The American Academy of Otolaryngology-Head and Neck Surgery Foundation's (AAO-HNSF's) 3D-Printed Temporal Bone Working Group was formed with the goal of sharing information and experience relating to the development of 3D-printed temporal bone models. The group conducted a multi-institutional study to directly compare several recently developed models. Study design Expert opinion survey. Setting Temporal bone laboratory. Methods The working group convened in 2018. The various methods in which 3D virtual models had been created and printed in physical form were then shared and recorded. This allowed for comparison of the advantages, disadvantages, and costs of each method. In addition, a drilling event was held during the October 2018 AAO-HNSF Annual Meeting. Each model was drilled and evaluated by attending-level working group members using an 15-question Likert scale questionnaire. The models were graded on anatomic accuracy as well as their suitability as a simulation of both cadaveric and operative temporal bone drilling. Results The models produced for this study demonstrate significant anatomic detail and a likeness to human cadaver specimens for drilling and dissection. Models printed in standard resin material with a stereolithography printer scored highest in the evaluation, though the margin of difference was negligible in several categories. Conclusion Simulated 3D temporal bones created through a number of printing methods have potential benefit in surgical training, preoperative simulation for challenging otologic cases, and the standardized testing of temporal bone surgical skills.

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.

To assess the effect of 3-dimensional (3D)-printed surgical simulators used in an advanced pediatric otolaryngology fellowship preparatory course on trainee education.Quasi-experimental pre/postsurvey.Multicenter collaborative course conducted at a contract research organization prior to a national conference.A 5-station, 7-simulator prep course was piloted for 9 pediatric otolaryngology fellows and 17 otolaryngology senior residents, with simulators for airway graft carving, microtia ear framework carving, and cleft lip/palate repair. Prior to the course, trainees were provided educational materials electronically along with presurveys rating confidence, expertise, and attitude around surgical simulators. In October 2018, surgeons engaged in simulation stations with direction from 2 attending faculty per station, then completed postsurveys for each simulator.Statistically significant increases (We demonstrate the benefit of high-fidelity, 3D-printed simulators in exposing trainees to advanced procedures, allowing them hands-on practice in a zero-risk environment. In the future, we hope to refine this course design, develop standardized tools to assess their educational value, and explore opportunities for integration into use in milestone assessment and accreditation.

Two of the most commonly employed bone-anchored hearing implant (BAHI) systems are the BAHA Connect and BAHA Attract. The BAHA Connect uses a skin-penetrating titanium abutment. The BAHA Attract uses an implanted magnet, leaving the overlying skin intact. Limited data is available on the difference in complication rates between the two systems. Our hypothesis was that there would be no difference in complications and audiologic data.Retrospective chart review was performed of patients who had BAHA Connect vs. Attract at our tertiary care pediatric hospital from 2006 to 2018. Pre- and post-operative information, including demographics, related diagnoses, outcomes and complications were compared between the systems using Mann-Whitney U tests and Firth logistic regression for one year post-implant. Audiology data was analyzed with Wilcoxon rank-sum and Wilcoxon matched pairs signed rank tests.Twenty-four Attract and 18 Connect BAHA surgeries were identified from 37 patients. Eleven Connect patients had the surgery completed in two stages. Connect patients followed up an average of 6.5 years post-implant and 15 months for Attract. A total of 58.8% of patients with Connect surgeries had complications within a year and 82.4% had a complication by their last follow-up. Aside from magnet strength related issues, there were no major complications with Attract surgery at any time point. Patients with Connect surgeries had significantly more skin overgrowths, cultured infections, times on antibiotics, nursing phone calls, and ENT visits within the first year and for all records, p .05. The pure-tone average was significantly lower for both Connect [unaided-M(SD) = 61.7(9.8); aided-M(SD) = 26.4(5.5) and Attract (unaided-M(SD) = 66.0(22.5); aided-M(SD) = 25.6(6.1)] after implant, p .001.Implantation of both systems lead to improved hearing outcomes with profoundly different complication rates.

To describe the impact of timing of tympanostomy tube insertion on the number of tubes received and complications in children with routine tube placement.Retrospective case series.Tertiary care children's hospital.Records from a consecutive sample of 401 children with cleft palate were reviewed. Sixty-five patients with isolated cleft palate and 82 patients with cleft lip and palate had follow-up until 5 years of age and were included.Tympanostomy tubes.Number of tubes received and tube-related complications. The hypothesis was formulated prior to data collection.Males comprised 55.8% of included patients, and tubes were placed in 98.6% of patients at a median age of 6.5 months. Effusion was documented at first tube placement for 96.5% of patients. Most (67.4%) patients required replacement of tubes, and 10.6% required long-term tubes. Complications included otorrhea (71.0%), myringosclerosis (35.2%), granulation (22.8%), perforation (17.9%), retained tubes (5.5%), and cholesteatoma (1.4%). Cleft lip and palate (Nearly universal effusion in patients with cleft palate supports the need for routine tube placement. The potential for otorrhea and requiring more tubes should be weighed against the risks associated with prolonged effusion when considering tube placement before palatoplasty.

Objective A subglottic hemangioma (SGH) is a benign tumor of infancy that can cause severe obstruction of the airway. Infantile hemangiomas, in general, are the most common head and neck tumor in children, affecting 4–5% of the pediatric population. This retrospective cohort study characterizes subglottic infantile hemangiomas at a single vascular anomaly center over a 5-year period (2013–2017) during the era of propranolol treatment. Methods Queried the Vascular Anomaly Database at Children's Hospital of Pittsburgh for all infantile hemangioma(s) and then identified case of subglottic hemangiomas. Characterized key features of presentation, natural history and management for subglottic hemangiomas. A secondary differentiation focused on differences between subglottic hemangiomas associated with Beard Distribution (BD) vs not (NBD). Results Analysis of 761 cases of infantile hemangiomas demonstrated only 13 patients with subglottic hemangiomas (1.7%). Of those 13 patients, only 4 patients (30%) had BD while 2 patients (15%) had other cutaneous hemangiomas and 7 patients (55%) had no cutaneous hemangiomas. Secondarily, a total of 31 case of beard distribution cutaneous hemangiomas with 11 patients having oropharyngeal involvement (35%) but only 4 patients with subglottic hemangiomas (13%). Interestingly, 2 of the 4 BD patients had treatment failure on propranolol and required second line treatment with steroids or surgical excision while only 1 of 9 NBD patients failed propranolol treatment. As well the same 2 BD patients which failed propranolol also had PHACES syndrome. Conclusion Subglottic hemangiomas are a rare presentation of infantile hemangiomas but with significant morbidity. While the classic teaching that a segmental beard distribution hemangioma raises concern for a subglottic hemangioma, this cohort indicates subglottic hemangiomas occur in a NBD presentation (1.3%), and demonstrated only an approximate 10% incidence rate with a beard distribution. But more importantly, this study raises the question that beard distribution in setting of PHACES syndrome may herald a more recalcitrant and complicated natural history for a subglottic hemangioma. This is of significant concern as risk for CVA in setting of PHACES is highest with use of steroid treatment. None of our patients had high risk extra or intra cranial vascular arterial anomalies and no CVA were noted.

Objective: This study evaluates the quality and readability of websites on ankyloglossia, tongue tie, and frenulectomy. Methods: Google was queried with six search terms: tongue tie, tongue tie and breastfeeding, tongue tie and frenulectomy, ankyloglossia, ankyloglossia and breastfeeding, and ankyloglossia and frenulectomy. Website quality was assessed using the DISCERN instrument. Readability was evaluated using the Flesch-Kincaid Reading Grade Level, Flesch Reading Ease Score, and Fry readability formula. Correlations were calculated. Search terms were analyzed for frequency using Google Trends and the NCBI database. Results: Of the maximum of 80, average DISCERN score for the websites was 65.7 (SD = 9.1, median = 65). Mean score for the Flesch-Kincaid Reading Grade Level was 11.6 (SD = 3.0, median = 10.7). Two websites (10%) were in the optimal range of 6 to 8. Google Trends shows tongue tie searches increasing in frequency, although the NCBI database showed a decreased in tongue tie articles. Conclusions: Most of the websites on ankyloglossia were of good quality; however, a majority were above the recommended reading level for public health information. Parents increasingly seek information on ankyloglossia online, while fewer investigators are publishing articles on this topic.

Pierre Robin Sequence (PRS) can be associated with skeletal dysplasias, presenting with craniocervical instability and devastating spinal injury if unrecognized. The authors present the case of an infant with PRS and a type II collagenopathy who underwent multiple airway-securing procedures requiring spinal manipulation before craniocervical instability was identified. This resulted in severe cervical cord compression due to odontoid fracture and occipitoatlantoaxial instability. This case highlights the importance of early cervical spine imaging and cautious manipulation in infants with PRS and suspected skeletal dysplasia.

Objectives/hypothesis The aims of this study were to determine the frequency of rebleeding in patients admitted for observation after presentation for nonactive hemorrhage in the post-tonsillectomy period, compare rebleeding rates between patients managed with observation versus initial operative control, and describe the complication profile associated with observation as a management strategy for post-tonsillectomy bleeding. Study design Case series with retrospective review of patients. Methods Patients presenting from September 1, 2013 to August 31, 2015 for post-tonsillectomy hemorrhage to a tertiary pediatric care center were evaluated for inclusion in the study. Inclusion criteria included patients ≤18 years of age without active bleeding at the time of the initial examination. Proportions were compared using χ2 and Fisher exact tests, whereas continuous data were compared using the Wilcoxon rank sum test. Results Of 3,866 tonsillectomy patients, 285 (7.4%) presented with concern for oropharyngeal bleeding in the postoperative period, of whom 224 were admitted for nonactive bleeding. Of patients with nonactive bleeding, 203 (90.6%) were managed with observation and 21 (9.4%) with operative intervention. Rate of rebleeding was 26/203 (12.8%) after inpatient observation and 3/21 (14.3%) after operative intervention (P = 1.000). Frequency of rebleeding requiring operative control in patients undergoing initial observation was 14/203 (6.9%). Conclusions In our pilot study, rates of rebleeding in patients observed for nonactive post-tonsillectomy hemorrhage was not statistically different than those managed with initial operative exploration. Although preliminary in nature, our data suggest observation may have comparable safety and efficacy when compared to operative management for pediatric patients presenting with nonactive post-tonsillectomy bleeding. Further data collection to establish an optimal management algorithm is ongoing. Level of evidence 4 Laryngoscope, 1958-1962, 2018.

There are massive hidden costs in the current paradigm of surgical training related to increased operative times for procedures with resident involvement and costs of medical errors. Shifting procedural training outside of the operating room through use of simulation has the potential to improve patient safety, minimize learning time to achieve competency, and increase operative efficiency. Investment in surgical simulation has the potential to reduce costs to health care systems through improved operating room efficiency and reduction of medical errors. This article explores the economic costs related to surgical training in otolaryngology and the value of investment in surgical simulation.

Introduction Submucous cleft palate (SMCP) classically involves bifid uvula, zona pellucida, and notched hard palate. However, patients may present with more subtle anatomic abnormalities. The ability to detect these abnormalities is important for surgeons managing velopharyngeal dysfunction (VPD) or considering adenoidectomy. Objectives Validate an assessment protocol for diagnosis of occult submucous cleft palate (OSMCP) and identify physical examination features present in patients with OSMCP in the relaxed and activated palate positions. Methods Study participants included patients referred to a pediatric VPD clinic with concern for hypernasality or SMCP. Using an appropriately encrypted iPod touch, transoral video was obtained for each patient with the palate in the relaxed and activated positions. The videos were reviewed by two otolaryngologists in normal speed and slow-motion, as needed, and a questionnaire was completed by each reviewer pertaining to the anatomy and function of the palate. Results 47 patients, with an average age of 4.6 years, were included in the study over a one-year period. Four videos were unusable due to incomplete view of the palate. The most common palatal abnormality noted was OSMCP, diagnosed by each reviewer in 26/43 and 30/43 patients respectively. Using the assessment protocol, agreement on palatal diagnosis was 83.7% (kappa = 0.68), indicating substantial agreement, with the most prevalent anatomic features being vaulted palate elevation (96%) and visible notching of hard palate (75%). Conclusion The diagnosis of subtle palatal anomalies is difficult and can be subjective. Using the proposed video-analysis method and assessment protocol may improve reliability of diagnosis of OSMCP.

Objective This study looks to correlate telemetry data gathered on patients with Pierre Robin Sequence (PRS) with sleep study data. Strong correlation might allow obstructive sleep apnea (OSA) to be reasonably predicted without the need for sleep study. Methods Charts from forty-six infants with PRS who presented to our children's hospital between 2005 and 2015 and received a polysomnogram (PSG) prior to surgical intervention were retrospectively reviewed. Correlations and scatterplots were used to compare average daily oxygen nadir, overall oxygen nadir, and average number of daily desaturations from telemetry data with apnea-hypopnea index (AHI) and oxygen nadir on sleep study. Results were also categorized into groups of AHI ≥ or Results Our data did not show significant correlations between telemetry data and sleep study data. Patients with O2 nadir below 80% on telemetry were not more likely to have an O2 nadir below 80% on sleep study. Patients with an average O2 nadir below 80% did show some correlation with having an AHI greater than 10 on sleep study but this relationship did not reach significance. Of 22 patients who did not have any desaturations on telemetry below 80%, 16 (73%) had an AHI >10 on sleep study. Conclusions In the workup of infants with PRS, the index of suspicion is high for OSA. In our series, telemetry data was not useful in ruling out severe OSA. Thus our data do not support forgoing sleep study in patients with PRS and concern for OSA despite normal telemetry patterns.

Objectives: To characterize the nature of surgical preparation among otolaryngology residents nationwide, determine the self-rated effectiveness and efficiency of case preparation practices, and identify potential means for educational improvement. Methods: A survey examining the study objectives was developed and distributed to otolaryngology residents nationwide. Survey response data were submitted to descriptive analysis and comparative analyses between junior and senior residents. Literature regarding case preparation among otolaryngology residents was reviewed. Results: Among 108 resident respondents, the most commonly used resources included textbooks (86.1%), surgical education websites (74.1%), and surgical atlases (66.7%). Time was the primary limitation (cited by 84.3%) and convenience the predominant factor influencing resource selection (92.5%). On a 5-point Likert scale, mean scores regarding effectiveness and efficiency of case preparation were 3.53 ± 0.68 and 3.19 ± 0.88, respectively. Senior residents compared to junior residents were more likely to rate their preparation as effective (3.75 ± 0.54 vs 3.40 ± 0.72, P = .008) and efficient (3.45 ± 0.85 vs 3.03 ± 0.86, P = .02). Conclusion: Otolaryngology residents do not consistently rate their case preparation as effective or efficient. While there appears to be progress in self-directed learning throughout residency, room for improvement remains, with potential avenues for such improvement explored here.

Introduction Tonsillectomy is the second most common procedure performed in the United States. Over 530,000 tonsillectomies are performed on children under 15 years of age in the United States, accounting for 16% of surgeries in this age group, resulting in missed school for patients of school-age and also resulting in missed work for caregivers. This study compared parent preferences for in-clinic follow-up (CFU) to telephone interview follow-up (TFU) after tonsillectomy. Materials and methods One hundred twenty-one parents of children who underwent a tonsillectomy and/or adenoidectomy were recruited to complete a survey about their child's post-operative visit. Results Statistical analyses were performed using t -test, Wilcoxon rank-sum, and Fischer's exact tests where appropriate. 60.3% of the surveys were completed as a TFU and the remainder were completed as a CFU. There were no statistical differences in the children's age, the time to follow-up, satisfaction with their follow-up, or the frequency of unresolved symptoms. Of parents receiving TFU, 91.8% disagreed they would have preferred a CFU, with 86.3% strongly disagreeing, and only 5.5% expressing that they would have preferred a CFU. Of the parents with CFU, 47.9% expressed a preference for a TFU. For CFU, 43.9% of parents missed work and 58.1% of their school-age children missed school. Conclusion Our study results indicate that parents receiving phone follow-up strongly preferred this method to an in-clinic follow-up, and that nearly half of all parents receiving in-clinic follow-up would have preferred a telephone follow-up. In select patients, telephone follow-up after tonsillectomy may increase patient satisfaction and decrease days of missed work and school.

To determine the accuracy of chest x-ray measurements in children using ingested radiopaque foreign bodies of known size.A database of foreign body ingestions at a tertiary care children's hospital was queried from 2013 to 2016 for children who had ingested a US coin, had a pre-operative chest x-ray and documentation of coin type at the time of endoscopic removal. Four blinded research subjects measured the coin diameter on chest x-ray using iSite PACS software and based on the measurement, predicted the coin type. Measurements were compared to the known coin diameters published by the US Mint.A total of 51 patients with sixteen esophageal quarters (diameter 24.26 mm), fourteen nickels (21.21 mm), fourteen pennies (19.05 mm) and seven dimes (17.91 mm) were included in the study. The four subjects had a mean accuracy of 60.3% (range 49.0%-72.5%) in predicting the correct coin type. Across all raters, there was poor agreement for pennies (kappa = 0.161) and dimes (kappa = 0.131), fair agreement for nickels (kappa = 0.259), good agreement for quarters (kappa = 0.687), and fair agreement overall (kappa = 0.371). The study measurements overestimated the coin size in 203 of the 204 measurements by a mean of 1.84 mm (range -0.31-3.85 mm). The mean size discrepancy was larger (2.40 vs. 1.30 mm, p 0.001) and accuracy of coin type identification was worse (44.6% vs. 74.1%, p = 0.001) in children4 years old.Measurement of esophageal coins on chest x-ray is relatively inaccurate and overestimates the size in the majority of cases. Clinicians should use caution when performing fine measurements on chest x-rays, especially in children younger than 4 years old.

Acute Interventional Perioperative Pain Service consultants have routinely placed paravertebral nerve block (PVB) catheters for the continuous release of ropivacaine following stage I microtia reconstruction with costal cartilage graft at our institution since 2010. A retrospective chart review from July 2006 was performed to compare the length of hospital stay, median pain score (0-10 scale), and opioid use of patients receiving PVB with those of historical controls. Statistical analysis included t, Mann-Whitney U, and Fisher's exact tests. A total of 15 stage I microtia surgeries were included, 10 with PVB and 5 without. Patients with and without PVB had high peak pain scores (8.4 vs 7.8), remained in the hospital for 3.5 and 3.8 days, and consumed 0.69 and 0.36 mg/kg morphine equivalents, respectively. These findings highlight the feasibility of PVB, but larger studies are needed to optimize pain relief in this population.

Previous studies identified hazardous noise levels from packaged toys. Sound levels may increase when packaging is removed and therefore, complicate the ability to accurately assess noise levels before purchase. The goal of this study was to evaluate how packaging affects the decibel (dB) level of toys by: 1) Assessing dB level of toys with and without packaging. 2) Evaluating the percentage of packaged and unpackaged toys that exceed a safety limit of 85 dB.Thirty-five toys were selected from the 2009-2011 Sight and Hearing Association (SHA) based on availability for purchase. Toys' speakers were categorized as Exposed, Partially Exposed, or Covered, based on its packaging. The dB level of each toy was tested at 0 cm and 25 cm from the speaker using a handheld digital sound meter in a standard audiometric booth. T tests and ANOVA were performed to assess mean change in sound level before and after packaging removal.Significant dB increases were noted after packaging was removed (mean change 11.9 dB at 0 cm; and 2.5 dB at 25 cm, p 0.001). Sixty-four percentage of Covered toys (n = 14) had dB greater than 85 dB when packaged and this increased to 100% when unpackaged.Many manufactured toys have hazardous sound levels. Caregivers and healthcare providers should be aware that toys tested in the store may actually be louder when brought home and removed from their packaging. Limits on and disclosure of dB level of toys should be considered nationally.

Objective: To characterize differences in the clinical presentation and treatment outcomes of laryngomalacia in patients with and without craniosynostosis. Methods: A retrospective cohort study was performed comparing all patients with concomitant laryngomalacia and craniosynostosis seen at a tertiary care children’s hospital between 2000 and 2016 with a control group of patients with isolated laryngomalacia. Thirty-two patients with craniosynostosis (59% male) and 68 control patients (56% male) were included. There were no significant differences in age of diagnosis or incidence of prematurity. Symptom presentation, disease severity, swallowing function, comorbidities, treatment modalities, and outcomes were examined using logistic regression. Results: Patients with craniosynostosis had increased odds of presenting with stertor (odds ratio [OR] = 3.41, P = .022), increased work of breathing (OR = 18.8, P = .007), obstructive sleep apnea (OR = 8.48, P = .003), dysphagia (OR = 3.40, P = .008), and aspiration (OR = 40.2, P < .001) and decreased odds of presenting with stridor (OR = 0.0804, P < .001) compared with controls. Patients with craniosynostosis had increased odds of severe laryngomalacia (OR = 5.00, P = .031) and other airway anomalies such as tracheomalacia (OR = 5.73, P = .004), bronchomalacia (OR = 15.5, P = .013), and subglottic stenosis (OR = 2.75, P = .028). Treatment of patients with craniosynostosis was more likely to include tracheostomy (OR = 24.8, P < .001) and gastrostomy tube (OR = 88.4, P < .001). There were no significant differences in rates of supraglottoplasty. Conclusion: Clinical presentations, comorbidities, and treatments of laryngomalacia are significantly different in the context of craniosynostosis.

Objective:To investigate whether awake endoscopy can diagnose base-of-tongue obstruction as reliably as sleep endoscopy in infants with Pierre Robin sequence (PRS).Design:The study was retrospective with the clinicians blinded to patient identity. Endoscopy findings were assessed and measured by the performing pediatric otolaryngologist.Setting:Tertiary care children’s hospital.Patients:All infants with PRS managed between January 2005 and July 2015 were included. There were 141 patients, of which 35 underwent both awake endoscopy (AE) and drug-induced sleep endoscopy (DISE).Interventions:Bedside AE and DISE in the operating room.Main Outcome Measures:Presence of moderate or severe base-of-tongue collapse was assessed. Sensitivity, specificity, and positive likelihood ratio of AE findings as well as intertest differences between AE and DISE were calculated.Results:AE had 50.0% sensitivity (95% confidence interval [CI] 27.2%-72.8%) and 86.7% specificity (95% CI 59.5%-98.3%) for detecting base-of-tongue obstruction compared to DISE; false negative rate was 50.0% (n = 10). Positive likelihood ratio was 3.75 (CI 0.96-14.65). Compared to AE, DISE demonstrated significantly more cases of base-of-tongue obstruction ( P = .039).Conclusions:Bedside AE has low sensitivity for detecting base-of-tongue collapse in infants with PRS. Because of the substantial false negative rate, AE may not be a reliable diagnostic modality for ruling out base-of-tongue obstruction in this susceptible population. DISE may be indicated in high-risk patients to avoid underdiagnosing upper airway obstruction.

Objectives:To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes.Design:Retrospective cohort study.Setting:Tertiary care children’s hospital.Participants:Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained.Main Outcome Measure:Number of tubes.Results:Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P = .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P = .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years).Conclusion:Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population.

Objective The goal of this study is to measure the quality and readability of websites related to laryngomalacia, and to compare the quality and readability scores for the sites accessed through the most popular search engines. Introduction Laryngomalacia is a common diagnosis in children but is often difficult for parents to comprehend. As information available on the internet is unregulated, the quality and readability of this information may vary. Methods An advanced search on Google, Yahoo, and Bing was conducted using the terms “laryngomalacia” OR “soft larynx” OR “floppy voice box.” The first ten websites meeting inclusion and exclusion criteria were evaluated, for each search engine. Quality and readability were assessed using the DISCERN criteria and the Flesch reading ease scoring (FRES) and Flesch-Kincaid grade level (FKGL) tests, respectively. Results The top 10 hits on each search engine yielded 15 unique web pages. The median DISCERN score (out of a possible high-score of 80) was 48.5 (SD 12.6). The median USA grade-level estimated by the FKGL was 11.3 (SD 1.4). Only one website (6.7%), had a readability score in the optimal range of 6th to 8th grade reading level. DISCERN scores did not correlate with FKGL scores (r = 0.10). Conclusion Online information discussing laryngomalacia often varies in quality and may not be easily comprehensible to the public. It is important for healthcare professionals to understand the quality of health information accessible to patients as it may influence medical decision-making by patient families.

Simulation is an emerging and viable means to increase pediatric airway surgical training. A variety of simulators currently exist that may be used or modified for laryngoscopy, bronchoscopy, and endoscopic intervention, although anatomic realism and utility for complex procedures are limited. There is a need for further development of improved endoscopic and anatomic models. Innovative techniques are enabling small-scale manufacturing of generalizable and patient-specific simulators. The high acuity of the pediatric airway patient makes the use of simulation an attractive modality for training, competency maintenance, and patient safety quality-improvement studies.

Objective Describe the impact of hearing loss, tympanostomy tube placement before palatoplasty, and number of tubes received on speech outcomes in children with cleft palate. Study Design Case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods Records from 737 children born between April 2005 and April 2015 who underwent palatoplasty at a tertiary children's hospital were reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, sensorineural or mixed hearing loss, no tubes, first tubes after palatoplasty, or first clinic after 12 months of age. Data from 152 patients with isolated cleft palate and 166 patients with cleft lip and palate were analyzed using Wilcoxon rank-sum, χ2, and Fisher exact test and logistic regression. Results Most patients (242, 76.1%) received tubes before palatoplasty. Hearing loss after tubes, but not before, was associated with speech/language delays at 24 months ( P = .005) and language delays ( P = .048) and speech sound production disorders (SSPDs, P = .040) at 5 years. Receiving tubes before palatoplasty was associated with failed newborn hearing screen ( P = .001) and younger age at first posttubes type B tympanogram with normal canal volume ( P = .015). Hearing loss after tubes ( P = .021), language delays ( P = .025), SSPDs ( P = .003), and velopharyngeal insufficiency ( P = .032) at 5 years and speech surgery ( P = .022) were associated with more tubes. Conclusion Continued middle ear disease, reflected by hearing loss and multiple tubes, may impair speech and language development. Inserting tubes before palatoplasty did not mitigate these impairments better than later tube placement.

Objectives Tonsillectomy is a common treatment for obstructive sleep apnea (OSA). The Internet allows patients direct access to medical information. Since information on the Internet is largely unregulated, quality and readability are variable. This study evaluates the quality and readability of the most likely visited websites presenting information on sleep apnea and tonsillectomy. Methods The three most popular search engines (Google, Bing, Yahoo) were queried with the phrase “sleep apnea AND tonsillectomy.” The DISCERN instrument was used to assess quality of information. Readability was evaluated using the Flesch-Kincaid Reading Grade Level (FKGL) and Flesch Reading Ease Score (FRES). Results Out of the maximum of 80, the average DISCERN quality score for the websites was 55.1 (SD- 12.3, Median- 60.5). The mean score for FRES was 42.3 (SD- 15.9, Median- 45.5), which falls in the range defined as difficult. No website was above the optimal score of 65. The mean score for the FKGL was US grade-level of 10.7 (SD- 1.6, Median- 11.6). Only 4(27%) websites were in the optimal range of 6–8. There was very weak correlation between FRES and DISCERN (r = 0.07) and FKGL and DISCERN (r = 0.21). Conclusions Tonsillectomy is one of the most common surgeries in the US. However, the internet information readily available to patients varies in quality. Additionally, much of the information is above the recommended grade level for comprehension by the public. By being aware of what information patients are reading online, physicians can better explain treatments and address misunderstandings. Physicians may consider using similar methods to test the readability for their own resources for patient education.

For children with a history of persistent Eustachian tube dysfunction (ETD) or otitis media with effusion presenting with recurring tympanic membrane (TM) perforation, surgeons must often balance the treatment goals of correcting the perforation and maintaining ventilation to the middle ear to prevent future perforation formation. A partial gelfoam myringoplasty with ventilation tube placement is a previously unreported procedural option for addressing these goals. The objective of this study is to describe the partial myringoplasty technique and report preliminary outcome data for the procedure.Retrospective cohort study of 29 children18 years old undergoing partial myringoplasty at a tertiary care children's hospital or satellite location. Size and course of initial perforation, time to tube extrusion, audiogram findings, and need for future otological procedures were studied.During a partial myringoplasty, a tympanostomy tube is placed in a TM perforation larger than the tube itself. The edges of the perforation are freshened, a tube is placed, and a piece of gelfoam is inserted to support the tube and to cover any remaining perforation. Out of 32 ears in 29 patients, 23 procedures were completed to correct existing perforations. The remainder were indicated in placement (n = 7) or replacement (n = 2) where the myringotomy or existing perforation was deemed too large to retain the tympanostomy tube without further support due to atelectatic or monomeric tympanic membranes. Thirteen tubes extruded within 1 year, of which 12 were Armstrong tubes and 1 was a T-tube. Out of 25 TM perforations corrected, 4 shrank in size and 2 did not close. For patients who underwent pre-surgical audiograms with findings indicating conductive hearing loss and had post-operative audiograms at follow-up, 8/10 showed improvement and 2/10 showed no change in hearing.A partial myringoplasty is a simple procedure to close existing TM perforations while maintaining ventilation to the middle ear that can potentially improve hearing, provide ongoing ventilation, and eventually result in TM closure without the need for more complex repair. It may serve as a reasonable first line treatment for repair of perforations, reserving tympanoplasty for patients who fail this procedure.

Importance The field of vascular anomalies presents diverse challenges in diagnosis and management. Although many lesions involve the head and neck, training in vascular anomalies is not universally included in otolaryngology residencies and pediatric otolaryngology (POTO) fellowships. Objective To explore the education in, exposure to, and comfort level of otolaryngology trainees with vascular anomalies. Design, Setting, and Participants A survey was distributed to 39 POTO fellows and 44 residents in postgraduate year 5 who matched into POTO fellowships from April 22 through June 16, 2014. Main Outcomes and Measures Survey responses from trainees on exposure to, education on, and comfort with vascular anomalies. Results Forty-four residents in postgraduate year 5 who applied to POTO fellowships and 39 POTO fellows were emailed the survey. Fourteen respondents were unable to be contacted owing to lack of a current email address. Thirty-six of 69 residents and fellows (18 fellows and 18 residents [52%]) responded to the survey. Twenty-seven trainees (75%) reported no participation in a vascular anomalies clinic during residency; 6 of these 27 individuals (22%) trained at institutions with a vascular anomalies clinic but did not participate in the clinic, and 28 of the 36 respondents (78%) reported that they had less than adequate or no exposure to vascular anomalies in residency. Among POTO fellows, 11 of 17 (65%) did not participate in a vascular anomalies clinic during fellowship, even though 8 of the 11 had a vascular anomalies clinic at their fellowship program. During fellowship training, 12 of 18 fellows (67%) reported that they had adequate exposure to vascular anomalies. Only 20 respondents (56%) felt comfortable distinguishing among diagnoses of vascular anomalies, and only 4 residents (22%) and 9 fellows (50%) felt comfortable treating patients with vascular anomalies. All fellows believed that training in vascular anomalies was important in fellowship, and 100% of respondents indicated that increased exposure to diagnosis and management of vascular anomalies would have been beneficial to their ability to care for patients. Conclusions and Relevance These data indicate that most otolaryngology trainees do not receive formal training in vascular anomalies in residency and that such training is valued among graduating trainees. Conversely, most POTO fellows felt their exposure was adequate and 50% of fellows felt comfortable treating vascular anomalies. However, 65% of POTO fellows had no participation in a vascular anomalies clinic, where many patients are managed by a multidisciplinary team. This finding may indicate that POTO fellows may have a false sense of confidence in managing patients with vascular anomalies and that residency and fellowship programs may consider changes in didactic and clinical programs.

Introduction The internet is increasingly a source of healthcare information utilized by parents, especially in rarer pathologies such as vascular malformations. The quality, validity and thoroughness of these websites is variable and unregulated. The goal of this study was to evaluate the quality and understandability of websites related to vascular malformations. Methods The terms “hemangioma”, “vascular malformation”, and “vascular anomalies” were searched in Google. The first 30 websites meeting inclusion and exclusion criteria were evaluated. Quality and readability were assessed using the DISCERN criteria and the Flesh-Kincaid Reading Grade Level (FKGL), respectively. Date of last update, HONcode accreditation, and the website category were recorded. Results Most websites were owned by academic institutions (n = 19, 63.3%). The mean DISCERN score for all websites was 2.97, or a partially valid source of information on a 1–5 scale. The average reading level estimated by FKGL was grade 12; only one website was scored at less than a grade 9 level. Two websites were HONcode accredited. Of the 18 sites giving an explicit date of last update, 12 (67.7%) had been updated in the previous 12 months. Conclusions Websites relating information about vascular anomalies may not be understandable to the general public, including parents. Health care providers should be cognizant of the quality and availability of such information as it may impact parent perspectives and bias toward treatment options.

Objective:To study the clinical and molecular epidemiology of vancomycin-resistantEnterococcus faeciumorganisms causing catheter-related bacteremia in patients with cancer.Design:Retrospective case-control study.Setting:University of Texas M. D. Anderson Cancer Center, a tertiary-care hospital in Houston, Texas.Patients:Case-patients were patients with cancer who had catheter-related vancomycin-resistantE. faeciumbacteremia and control-patients were patients with cancer and vancomycin-resistantE. faeciumgastrointestinal colonization without infection.Results:Ten case-patients with catheter-related vancomycin-resistantE. faeciumbacteremia were compared with 30 control-patients with gastrointestinal colonization by vancomycin-resistantE. faecium. Patients with catheter-related vancomycin-resistantE. faeciumbacteremia were more likely to have required mechanical ventilation (P< .01), received total parenteral nutrition (P< .01), and had polyurethane catheters (P< .01) inserted in the femoral vein (P= .01). With the use of pulsed-fleld gel electrophoresis, 4 of the 10 catheter-related vancomycin-resistantE. faeciumbacteremia isolates were genetically indistinguishable, whereas only 2 of the 30 control vancomycin-resistantE. faeciumisolates displayed this same DNA pattern (P= .03).Conclusion:This study suggests that catheter-related vancomycin-resistantE. faeciumbacteremia occurs more frequently in patients who receive total parenteral nutrition, mechanical ventilation, and femoral catheters. (Infect Control Hosp Epidemiol 2005;26:658-661)