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Humans use cognitive shortcuts, or heuristics, to quickly assess and respond to situations and data. When applied inappropriately, heuristics have the potential to redirect analysis of available information in consistent ways, creating systematic biases resulting in decision errors. Heuristics have greater effect in high-pressure, high-stakes decisions, particularly when dealing with incomplete information, in other words, daily medical and surgical practice. This article discusses 2 major categories: cognitive biases, which affect how we perceive and interpret clinical data; and implicit biases, which affect how we perceive and respond to other individuals, and also discusses approaches to recognize and alleviate bias effects.

Semiconductor nanowires have been shown to exhibit novel optoelectronic properties with respect to bulk specimens made of the same material. However, if a semiconductor alloy has a miscibility gap in its phase diagram, at equilibrium it will phase separate, leading to deterioration of the aforementioned properties. One way to prevent this separation is to grow the material at low temperatures and therefore to suppress kinetics. Such growth often needs to be followed by high-temperature annealing in order to rid the system of undesirable growth-induced defects. In this study, we propose a method to control phase separation in core-shell nanowires during high temperature annealing by tailoring geometry and strain. Using a phase field model we determined that phase separation in nanowires begins at the free surface and propagates into the bulk. We discovered that including a thin shell around the core delays the phase separation whereas a thick shell suppresses the separation almost entirely.

Objective To describe geographic variation in spending and evaluate regional Medicare expenditures for otolaryngologist services with population- and beneficiary-related factors, physician supply, and hospital system factors. Study Design Cross-sectional study. Methods The average regional expenditures for otolaryngology physician services were defined as the total work relative value units (wRVUs) collected by otolaryngologists in a hospital referral region (HRR) per thousand Medicare beneficiaries in the HRR. A multivariable linear regression model tested associations with regional sociodemographics (age, sex, race, income, education), the physician and hospital bed supply, and the presence of an otolaryngology residency program. Results In 2012, the mean Medicare expenditure for otolaryngology provider services across HRRs was 224 wRVUs per thousand Medicare beneficiaries (standard deviation [SD] 104), ranging from 31 to 604 wRVUs per thousand Medicare beneficiaries. In 2013, the average Medicare expenditures for each HRR was highly correlated with expenditures collected in 2012 (Pearson correlation coefficient .997, P = .0001). Regional Medicare expenditures were independently and positively associated with otolaryngology, medical specialist, and hospital bed supply in the region, and were negatively associated with the supply of primary care physicians and presence of an otolaryngology residency program after adjusting for other factors. The magnitude of associations with physician supply and hospital factors was stronger than any population or Medicare beneficiary factor. Conclusion Wide variations in regional Medicare expenditures for otolaryngology physician services, highly stable over 2 years, were strongly associated with regional health system factors. Changes in health policy for otolaryngology care may require coordination with other physician specialties and integrated hospital systems. Level of Evidence NA. Laryngoscope, 127:1312–1317, 2017

Objectives To describe the deployment of otolaryngologists and evaluate factors associated with the geographic distribution of otolaryngologists in the United States. Study Design Cross-sectional study. Methods The otolaryngology physician supply was defined as the number of otolaryngologists per 100,000 in the hospital referral region (HRR). The otolaryngology physician supply was derived from the American Medical Association Masterfile or from the Medicare Enrollment and Provider Utilization Files. Multiple linear regression tested the association of population, physician, and hospital factors on the supply of Medicare-enrolled otolaryngologists/HRR. Results Two methods of measuring the otolaryngology workforce were moderately correlated across hospital referral regions (Pearson coefficient 0.513, P = .0001); regardless, the supply of otolaryngology providers varies greatly over different geographic regions. Otolaryngologists concentrate in regions with many other physicians, particularly specialist physicians. The otolaryngology supply also increases with regional population income and education levels. Using AMA-derived data, there was no association between the supply of otolaryngologists and staffed acute-care hospital beds and the presence of an otolaryngology residency-training program. In contrast, the supply of otolaryngology providers enrolled in Medicare independently increases for each HRR by 0.8 per 100,000 for each unit increase in supply of hospital beds (P < .0001) and by 0.49 per 100,000 in regions with an otolaryngology residency-training program (P = .006), accounting for all other factors. Conclusion Irrespective of methodology, the supply of otolaryngologists varies widely across geographic regions in the United States. For Medicare beneficiaries, regional hospital factors—including the presence of an otolaryngology residency program—may improve access to otolaryngology services. Level of Evidence N/A. Laryngoscope, 2016

Objective The objective is to describe variations in the otolaryngology morbidity and mortality (MM) conference and to compare with other specialties. Design Cross-sectional survey. Setting The setting included otolaryngology departments across the United States and nonotolaryngology medical and surgical departments at 4 academic medical centers. Subjects and Methods Participants were members of a national otolaryngology quality/safety network and nonotolaryngology quality leaders at 4 large academic hospitals. Surveys were administered January 2017. Respondents described MM conference practices, goals, and educational role. Results Twenty-eight of 39 individuals representing 28 institutions completed the otolaryngology survey (72% response rate). Of 197 individuals, 60 (30% response rate) representing 11 surgical and 20 nonsurgical specialties completed the comparison survey. Twenty-seven of 28 otolaryngologists (46 of 60 nonotolaryngologists) worked in academic settings. All otolaryngology programs conducted an MM conference: 54% discussed all adverse events and errors; 32% used standard case selection processes; 70% used structured discussion, usually root cause analysis (64%); and 32% classified harm level. In comparison with other specialties, otolaryngology programs were more likely to discuss all adverse events and errors ( P = .01). Most conferences led to quality projects and intrainstitutional communication: 22% communicated to patients and families; 73% of respondents thought that MM conferences should be standardized or use "best practices." In both surveys, improving patient care was rated the conference's most important function, followed by trainee education and culture change. Patient care and practice-based learning were rated the most relevant Accreditation Council for Graduate Medical Education Core Competencies in both surveys. Conclusions Academic otolaryngology MM practices generally align with other specialties, but specifics vary widely, making collaborative quality improvement challenging. Educational and administrative priorities cross specialties. Most respondents thought that standardization and best practices are worthwhile. Nonacademic practice data are needed.

To date, ternary quantum-dot cellular automata (QCA) has been especially investigated and also is being advanced. Nonetheless, it should be possible to make interactions between binary QCA and ternary QCA circuits in order to have a versatile platform of designing. On the other hand, one of the most important concerns in QCA is minimising wire crossings because of low robustness caused by their manufacturing process and operational defects. In this study, a novel ternary-to-binary (and vice versa) converter is introduced firstly and a novel coplanar wire crossing scheme is proposed and presented afterwards. The latter scheme uses both kinds of binary and ternary QCA cells and provides a reliable crossover. Detailed circuit designs and results are presented to show correct functionality of the proposed circuits.

Transdermal patch administration results in a locally high concentration of drug that induce local toxicity, including tumorogenicity. As a worst-case scenario for consequences of repeated application on neoplastic growth, the melanin-binding drug, rasagiline, was used in a transdermal formulation applied directly to a human-derived melanoma to determine the effects on tumor growth.Rasagiline mesylate was administered either orally or transdermally to athymic mice implanted with human melanoma (SKMEL28) to determine the effects on tumor growth and survival. Over a 21-day period, animals were administered daily oral gavage (15 mg/kg) or one or two rasagiline mesylate transdermal patches every 3 days. After the last dose administration, blood samples were collected to confirm drug exposure.All animals from the untreated, vehicle and rasagiline groups survived to the end of the study; however, 7 out of the 10 cisplatin-treated animals died before the end of the study. Rasagiline mesylate dosed either via the oral or transdermal routes had comparable plasma exposure and, unexpectedly, significantly reduced absolute tumor volumes and tumor growth rates in the nude mouse SKMEL28 xenograft model.Transdermal delivery of melanin-binding rasagiline does not increase melanoma growth in the xenograft model. Because rasagiline decreases melanoma growth, it may be candidate for combination therapy for melanoma.

Objectives To describe clinical findings from a multidisciplinary program for children with permanent hearing loss (PHL). Methods Retrospective chart review at a tertiary care children's hospital. Patients: Two hundred patients charts were selected from the population of 260 children with permanent hearing loss presenting between July 2005 and December 2006. Main outcome measures: PHL etiology; radiographic findings; clinical findings by genetics, ophthalmology, developmental pediatrics, speech pathology, and aural rehabilitation. Results Etiology of hearing loss was determined in 60% of subjects. Genetic causes of hearing loss were identified or presumed (positive history of first degree relative with hearing loss) in 27% of the children. Structural ear anomalies were found in 20% of children. Among the 36% of children with CNS imaging, abnormal findings were noted in 32%. There were a high rate of ophthalmological findings (53%) among children seen by ophthalmology (n = 105). Neurodevelopmental evaluations were completed in 58% of subjects and clinically significant findings were noted in 68%. Of the 61% of children who receiving received speech/language evaluations, 77% required intervention. Over half of the 40% of subjects who had an aural rehabilitation evaluation needed therapy. There were not significant differences in rates of findings for children with mild or unilateral hearing loss as compared to children with more severe degrees of hearing loss. Conclusions Interdisciplinary medical evaluation of children with PHL allows for the identification and treatment of clinically significant ophthalmologic, neurodevelopmental, genetic, and speech/language disorders. A high rate of CNS and temporal bone abnormalities were identified. These findings provide an understanding of the importance of considering thorough medical and developmental evaluations among children who are deaf/hard of hearing.

The ongoing childhood obesity epidemic has garnered significant attention among healthcare providers due to its short- and long-term sequelae. Multiple diseases have been associated with obesity, not limited to hypertension, diabetes, and attention deficit hyperactivity disorder. Over the past decade, the relationships between obesity and otologic conditions have been investigated. In this setting, otitis media has remained the focus of research, representing one of the most common pediatric illnesses. Initial studies suggesting a relationship between the two conditions have been supported with epidemiological studies controlling for socioeconomic factors. The purpose of this article is to review our current understanding of the relationship between otitis media and obesity and to discuss the healthcare implications of this association. In addition, several identifiable factors associated with each condition are discussed, as are potential pathophysiologic mechanisms that may help to elucidate the complex and multifactorial relationship between the two disease entities.

Program Description:Quality improvement (QI) activities emphasize systems to prevent or detect inevitable errors by fallible humans. Aside from intentional misconduct or impaired judgment, human errors often are attributed to system factors, deemphasizing the role of individual decision making as a potential cause of error. Convincing data show that cognitive and motivational biases affect how providers collect and apply clinical data. Our purpose is to increase audience awareness of cognitive “traps” in medical decision making. We will discuss illustrative case studies, practical ways to incorporate these concepts into QI and patient safety activities, and uses of “debiasing” and other strategies to improve individual decision making.Educational Objectives:(1) Describe the importance of individual cognitive processes in medical decision making and error and situations in which these processes might be either beneficial or harmful. (2) Describe cognitive processes, heuristics, and biases that play a role ...

(1) To describe the application of a detailed cost-accounting method (time-driven activity-cased costing) to operating room personnel costs, avoiding the proxy use of hospital and provider charges. (2) To model potential cost efficiencies using different staffing models with the case study of outpatient adenotonsillectomy.Prospective cost analysis case study.Tertiary pediatric hospital.All otolaryngology providers and otolaryngology operating room staff at our institution.Time-driven activity-based costing demonstrated precise per-case and per-minute calculation of personnel costs. We identified several areas of unused personnel capacity in a basic staffing model. Per-case personnel costs decreased by 23.2% by allowing a surgeon to run 2 operating rooms, despite doubling all other staff. Further cost reductions up to a total of 26.4% were predicted with additional staffing rearrangements.Time-driven activity-based costing allows detailed understanding of not only personnel costs but also how personnel time is used. This in turn allows testing of alternative staffing models to decrease unused personnel capacity and increase efficiency.

Objective : To identify factors responsible for delays in diagnosis and treatment of pediatric sensorineural hearing impairment (SNHI), and to assess the thoroughness of medical evaluation in these children. Design : Retrospective analysis. Setting : State-supported school for the deaf. Patients and other participants : 291 children with SNHI, the vast majority of whom are profoundly hearing impaired. Data were collected from the school's database, individual student records, and a parental questionnaire. Main outcome measures : (1) The age of diagnosis and treatment of SNHI; (2) factors leading to a delay in diagnosis; (3) current medical evaluations used to determine the etiology of SNHI; and (4) the level of parental satisfaction with the evaluation process. Results : Many children with SNHI experience delays in diagnosis from the time of first suspicion of hearing loss. Children with a risk factor for SNHI are diagnosed no earlier than children without a risk factor. Caucasian children are diagnosed significantly earlier than either Black or Hispanic children, regardless of socioeconomic status. Inconsistent medical evaluation ensues following the diagnosis of SNHI, and parental satisfaction with this process is low. Conclusions : The average age of diagnosis of SNHI remains unacceptably high. There exists a need to enhance physician awareness of childhood deafness and to develop guidelines for the medical evaluation in cases of pediatric SNHI. Lastly, the importance of parental concern regarding a child's hearing or language development must be re-emphasized.

Pressure equalization tube (PET) placement is the most common surgical procedure performed during childhood. Current guidelines recommend more prompt management of children with otitis media with effusion who are at greater risk for speech-language and developmental problems. This study was designed to examine risk factors for continued post-PET hearing loss in a large pediatric clinical sample.Retrospective analysis using the electronic medical record.Tertiary care children's hospital.Pediatric patients undergoing PET placement between January 2009 and October 2012 who had audiometric tests.Demographics, patient diagnoses, and hearing loss information were extracted. Multivariate binary logistic regression models were used to identify associations between patient-specific characteristics and the presence of hearing loss.In total, 3949 children with 4598 audiology visits were included (2357 males and 1592 females; mean age, 3.3 years), and 1272 preoperative and 3329 postoperative audiograms were performed. Using multivariate modeling, the only variable significantly associated with preoperative hearing loss was low tympanometric static acoustic admittance. Postoperative hearing loss was positively associated with patient age, preoperative hearing loss, lower tympanometric equivalent canal volumes, and Down syndrome. Other factors, including cranial/facial anomalies, low birth weight or prematurity, allergies, and asthma, were not determined to be risk factors for hearing loss.Our results support hearing testing to identify candidates for PET surgery and to determine treatment effectiveness after surgery, since hearing loss cannot be predicted on the basis of risk or demographic factors. These data have important preoperative counseling and postoperative management implications.

Objectives:Pressure equalization tube (PET) placement is the most common surgical procedure performed during childhood. Current Academy guidelines recommend more aggressive management of children with otitis media with effusion (OME) who are at greater risk for speech-language and developmental problems. This study was designed to examine risk factors for continued hearing loss following PET placement in children with chronic OME. A large clinical sample ascertained through electronic medical records is used.Methods:All pediatric patients undergoing PET-placement between January 2009 andOctober 2012 at a tertiary-care children’s hospital who had audiometric tests were included. Demographics and patient diagnoses (craniofacial anomalies, allergies, prematurity, developmental delay, and speech-language delay) were extracted. A multivariate regression model was used to identify an association between patient-specific characteristics and the presence of pre- or postoperative hearing loss.Results:4083 children...

Program Description: Cultivation of career advancement of young physicians in private or academic practice requires significant investment of financial resources as well as time investment on the part of their senior mentors. As more women become otolaryngologists, gender differences that affect women’s expectations and communication style may lead to misunderstandings that interfere with career development. Understanding the impact of gender differences in the work place is important to strengthen physician practices by improving workforce retention and diversity. Over the past 30 years much research has emerged describing how gender affects overall career advancement. Differences in the ways that men and women see the world, their propensity to negotiate for resources, and the existence of cultural biases may significantly impact career advancement, especially for those aspiring to leadership positions. An overview of: 1) the current status of women in otolaryngology, 2) effective mentorship, and 3) gender differences that may create barriers or serve as strengths for women will be provided during the first half of this miniseminar. The program will conclude with an interactive panel whose members will share their insights regarding career development and mentorship.

Donepezil hydrochloride is a reversible acetyl cholinesterase inhibitor approved for Alzheimer disease treatment. As an alternate therapy, a donepezil hydrochloride transdermal patch is in development. Recommended nonclinical safety studies include a 3-month Good Laboratory Practice (GLP) dose-range finding (DRF) study prior to conducting the 2-year dermal carcinogenicity study in rats. Demonstration of systemic exposure is necessary to interpret the in vivo data. Previous nonclinical reports supporting oral dosing have utilized liquid chromatography tandem mass spectrometry (LC/MS/MS) to quantify donepezil concentrations in plasma. Smaller species with limited blood volumes do not allow serial sampling to derive the full pharmacokinetic profile from a single animal. Therefore, the option of another analytical method requiring decreased sample volumes is desirable as it would decrease the required number of animals while obtaining the complete profile. The dried blood spot (DBS) technique allows drug level measurement from a few microliters; however, the method is still not widely utilized in GLP studies. Because donepezil plasma levels are known by the oral route, DBS was used to bridge the previous oral data and to support a 13-week GLP DRF study for repeated topical application in rats, comparing oral administration with 4 topical formulations. The DBS method was validated and demonstrated robustness and reproducibility for application to the DRF study. The assay results were comparable to a previously reported plasma LC/MS/MS assay-derived pharmacokinetic profile and provided justification for selection of the topical formulation and dose levels for the subsequent dermal carcinogenicity study.

Objective Temporal bone imaging in children has several inherent limitations. Computed tomography has the disadvantage of ionizing radiation, possible sedation, cost and accessibility. Magnetic resonance imaging has most of these disadvantages, with the exception of radiation, and provides bone images of limited resolution. Recent advances in ultrasound have led to its increased application in numerous medical fields. The purpose of this study was to investigate the ability of four-dimensional ultrasound (4DUS) to image middle ear ossicles in vitro and determine if this technology should be adapted for future clinical use. Methods Thirty cadaveric ossicles (10 malleus, 10 incus, and 10 stapes) were randomized and measured by two evaluators under a microscope. The ossicles were then immersed in a cold water bath and imaged, randomized, and measured using four-dimensional ultrasound by the same two evaluators. A separate cadaveric temporal bone, modified to allow the ultrasound probe to rest on the tympanic membrane, was imaged to visualize the ossicles in situ and evaluate whether or not the tympanic membrane and malleus would impede visualization of more medial structures. Results Microscopic measurements were: malleus (h = 8.0 mm ± 0.32, w = 2.7 mm ± 0.20 ), incus (h = 6.8 mm ± 0.41, w = 5.3 mm ± 0.46 ), stapes (h = 3.5 mm ± 0.34, w = 2.4 mm ± 0.17 ). Inter-rater reliability was 0.8. Measurements were in agreement with previously published values. Ultrasound measurements were: malleus (h = 8.0 mm ± 0.51, w = 2.9 mm ± 0.27 ), incus (h = 6.8 mm ± 0.49, w = 5.5 mm ± 0.42 ), stapes (h = 3.6 mm ± 0.41, w = 2.5 mm ± 0.19 ). Inter-rater reliability was 0.7. Mean intra-class correlation coefficient for microscopic and ultrasound measurements was 0.7. Images of the ossicular chain in continuity in the temporal bone specimen were not as clear as images of individual ossicles that were disarticulated and imaged under water. Conclusions 4DUS provides reasonable images of ossicles disarticulated and mounted in underwater medium. However, images of the intact ossicular chain in a modified cadaveric temporal bone were not as clear, making interpretation difficult. Further investigation into the development of a thinner ultrasound probe that can pass through the external auditory canal and into overcoming limitations of air in the middle ear cleft are warranted. This could allow for a clinically relevant, faster, lower cost and lower risk alternative to current imaging techniques.

Objective To measure the quality of outpatient surgery in an ambulatory surgery center (ASC) compared to a hospital-based facility (HBF) in a multidimensional manner. Study Design Cross-sectional survey based on chart review. Setting Pediatric academic health center. Subjects and Methods A total of 486 cases were reviewed. Procedures were performed at either an ASC (n = 275) or an HBF (n = 211). Cases comprised four procedure types: ventilation tube insertion (ASC, n = 126; HBF, n = 108), dental rehabilitation (ASC, n = 89; HBF, n = 58), adenotonsillectomy (ASC, n = 37; HBF, n = 34), and ventilation tube insertion/adenoidectomy (ASC, n = 23; HBF, n = 11). Measures were developed for five categories: safety, patient-centeredness, timeliness, efficiency, and equitability. Performance was compared between facilities. Results The ASC had no unexpected safety events (0/275) compared to nine events (9/211) at the HBF. Tonsil bleed rates were 0 percent (0/37) at the ASC compared to 5.9 percent (2/34) at the HBF. Patient satisfaction was similar between facilities (ASC, n = 64; HBF, n = 35). Differences in timeliness approached 30 percent. A total of 77 percent of ASC cases finished within the scheduled time compared to 38 percent at the HBF. Total charges were 12 to 23 percent less at the ASC. Patients treated at the ASC generally lived in wealthier neighborhoods. Conclusion Performance at the ASC generally exceeded that at the HBF. Future research should investigate how perioperative processes result in these quality differences. Health policy implications are discussed.

To correlate genetic and audiometric findings with a detailed radiologic analysis of the temporal bone in patients with enlarged vestibular aqueduct (EVA) to ascertain the contribution of SLC26A4 gene mutations to this phenotype.A retrospective review of patients with EVA identified in a database of pediatric hearing-impaired patients.A tertiary care pediatric referral center.Seventy-one children with EVA and screening results for SLC26A4 mutations.Genetic screening results, audiometric thresholds, and radiographic temporal bone measurements.Seventy-one children with EVA were screened for SLC26A4 mutations. Mutations were found in 27% of children overall, while only 8% had biallelic mutations. The mean initial pure-tone average (PTA) was 59 dB; the mean final PTA was 67 dB. A bilateral EVA was found in 48 (67%) of the children; a unilateral EVA was found in 23 (33%). Progressive hearing loss (in at least 1 ear) was seen in 29 (41%) of the patients. The strongest genotype-phenotype interaction was seen in children with a bilateral EVA. Among children with SLC26A4 mutations, there was a significantly wider vestibular aqueduct at the midpoint and a wider vestibule width (P.05) than in children without the mutation. Among patients with a bilateral EVA, children with any SLC26A4 mutation were more likely to have a more severe final PTA (64 dB vs 32 dB), larger midpoint measurement (2.1 vs 1.1 mm), and larger operculum measurement (3.0 vs 2.0 mm) than those without the mutation in their better-hearing ear (P.05).In a population of pediatric patients with an EVA and hearing loss, SLC26A4 mutations are a contributor to the phenotype. Our data suggest that other genetic factors also have important contributions to this phenotype. The presence of an abnormal SLC26A4 allele, even in the heterozygous state, was associated with greater enlargement of the vestibular aqueduct, abnormal development of the vestibule, and possibly a stable hearing outcome.

Objective The study goal was to determine the prevalence and clinical significance of a large vestibular aqueduct (LVA) in children with sensorineural hearing loss (SNHL). Study Design and Setting We conducted a retrospective review of a pediatric SNHL database. One hundred seven children with SNHL were selected and their radiographic and audiometric studies were evaluated. Radiographic comparisons were made to a group of children without SNHL. Results A vestibular aqueduct (VA) larger than the 95th percentile of controls was present in 32% of children with SNHL. Progressive SNHL was more likely to occur in ears with an LVA and the rate of progressive hearing loss was greater than in ears without an LVA. The risk of progressive SNHL increased with increasing VA size as determined by logistic regression analysis. Conclusions An LVA is defined as one that is ≥2 mm at the operculum and/or ≥1 mm at the midpoint in children with nonsyndromic SNHL. An LVA appears to be more common than previously reported in children with SNHL. A linear relationship is observed between VA width and progressive SNHL. Significance The finding of an LVA in children with SNHL provides diagnostic as well as prognostic information.

This paper describes a real-time implementation of a variable rate baseband speech coding algorithm. The implementation is achieved using the Speech Command System (SCS) option available with the Texas Instruments Professional Computer (TIPC). The SCS consists of a peripheral speech board and related interface software. The central processor on the peripheral speech board is TI's new signal processing microcomputer TMS32010. The implementation works real-time with an average bit rate of the 9600 bits/sec.

Good digital filter realizations for hardware implementation in narrowband filtering applications should have low roundoff noise, low coefficient sensitivity, and freedom from overflow oscillations. The hardware implementations presented here incorporate the above properties into a highly modular structure which can perform computations in pipeline fashion. That is, after an initial delay an output sample is obtained for each input sample. The realization and implementations discussed here contain more multipliers than direct form realizations. However, by using shorter word lengths because of their increased performance and distributed arithmetic implementations (instead of multiplier structures) these implementations can have less total hardware complexity.

Objective To compare disease response among children with recurrent respiratory papillomatosis (RRP) who underwent combined surgical debulking and intralesional cidofovir injections vs repeated surgical debulking only. Design Retrospective medical record review; follow-up range: 16 to 56 months. Setting Tertiary care children’s hospital. Patients Seven children with RRP, including 4 subjects treated with cidofovir and 3 controls matched for age and initial papilloma staging score. Interventions Subjects treated with cidofovir underwent combined surgical debulking and intralesional cidofovir injection every 2 months until disease remission. Control subjects underwent repeated surgical debulking at individually determined intervals. Main Outcome Measures Intraoperative endoscopic photographs were retrospectively assigned papilloma staging scores. Cidofovir and control group comparisons were made using nonparametric 2-sample Wilcoxon rank-sum (Mann-Whitney) testing, and comparisons of initial and final papilloma staging scores were made using nonparametric matched-pair Wilcoxon signed-rank testing. Results The final cidofovir group scores were significantly lower than the control group scores ( P P = .07; control group, P = .29). Conclusions Four children with RRP were safely and successfully treated with intralesional cidofovir injection. Consideration should be given to using cidofovir more widely for treatment of pediatric RRP. Larger numbers in the cidofovir and control groups are needed in future studies to determine the true impact of cidofovir on management of this disease.

Objective To characterize audiometric findings in children with a large vestibular aqueduct (LVA). Design Retrospective review. Methods Audiometric records of children with an isolated LVA, diagnosed by computed tomography of the temporal bone, from 1995 through 1998 were reviewed. Results Nineteen children had an isolated LVA in one or both ears. In all, 26 ears with an isolated LVA were identified. An LVA was seen in association with another inner ear anomaly in an additional 7 ears. The hearing impairment was sensorineural in 22 ears (85%) with an isolated LVA and mixed in 3 (12%). The hearing was normal in 1 ear. The sensorineural hearing impairment (SNHI) was moderate-severe in 12 ears (46%) and severe-profound in 10 ears (38%). Thirteen (50%) of 26 ears had a downsloping or high-frequency SNHI, and 8 (31%) of 26 ears had a midfrequency-peaked audiogram. Bilateral LVAs were seen in 7 children, 6 of whom had bilateral and asymmetrical SNHI. Of 12 patients with a unilateral LVA, 5 had bilateral SNHI. Conclusions In this series, the children with LVAs typically had moderate-severe or worse SNHI. An unusual midfrequency-peaked audiogram was present in approximately one third of the study patients. The majority of the patients had a unilateral LVA; however, nearly 50% of the patients with a unilateral LVA had bilateral SNHI. The patients with bilateral LVAs generally had asymmetrical SNHI.

Summary Objective: The purpose of this research was to compare the signal-to-noise ratio required for equal performance for children (aged 6–14 years) with normal hearing (N = 17) versus those with severe-to-profound unilateral hearing impairment (N = 20) who can be at a disadvantage, particularly when sounds are presented to the impaired ear. The listening environment is designed to approximate that which is encountered in a typical classroom. Methods: All signals (Hearing in Noise Test-Children and Nonsense Syllable Test) were presented in the sound field from various azimuths with continuous noise presented from all quadrants. The children were required to repeat twenty items, from each test, in each listening condition. The intensity of the presentations was varied based on the accuracy of previous items. Average signal-to-noise ratios are compared between and within groups. Results: (1) In most listening conditions, significantly greater signal-to-noise ratios were needed by those with unilateral hearing impairment than those with normal hearing, on both speech tests. (2) In every listening condition, both groups required significantly greater signal-to-noise ratios to perform equally well on the Nonsense Syllable Test as on the Hearing-In-Noise Test-Children. (3) For the Hearing-In-Noise Test-Children, children with normal hearing required significantly greater signal-to-noise ratios when facing the signal than when the signal was presented to a normally hearing ear (monaural direct). (4) On both tests, the children with unilateral hearing impairment required significantly greater signal-to-noise ratios when facing the signal than in the monaural direct condition. (5) On both tests, the children with unilateral hearing impairment required significantly greater signal-to-noise ratios when the signal was presented to the impaired ear (monaural indirect) than when facing the signal. Conclusions: (1) The children with unilateral hearing impairment require a more advantageous listening condition to perform equally as well as their normally hearing counterparts. (2) All of the children benefited from signals delivered in a monaural direct condition. (3) The children with unilateral hearing impairment performed best in the monaural direct condition or when facing the signal at zero degrees. (4) Significantly greater signal-to-noise ratios were needed for both groups when restricted contextual cues were available versus when sentential cues were available.

Objective: To illustrate that a patient with a cochlear implant may be at increased risk of meningitis secondary to developmental anatomic abnormality associated with the underlying sensorineural hearing loss, as opposed to the implant itself. Methods: Case report. Results: Our 12-year-old patient has bilateral cochlear dysplasia, profound sensorineural hearing loss and no prior history of recurrent acute otitis media or meningitis. He underwent a left cochlear implant at 8 years of age and subsequently experienced three episodes of right acute otitis media and meningitis over the next 4 years. Middle ear exploration revealed a cerebrospinal fluid leak. A right radical mastoidectomy with closure of the external auditory canal, removal of the tympanic membrane, malleus, and incus, closure of the Eustachian tube, and obliteration of the mastoid and middle ear with abdominal fat has prevented further episodes. Conclusion: Meningitis in a patient with a cochlear implant is not necessarily related to the implant.

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.

Hemorrhagic thyroid nodules are rare in the pediatric age group. They present as rapidly enlarging neck masses. Diagnostic modalities available are laboratory evaluation, ultrasound, radionuclide imaging, and fine needle aspiration. Depending on the pattern of growth of the lesion, one may observe or proceed with surgery. A rapidly enlarging thyroid mass raises the suspicion of malignancy, and hemorrhagic nodules, though rare, must be considered in the differential diagnosis.

Objective: To determine whether the lack of private health insurance places children at increased risk for foreign body ingestion or aspiration. Design: Retrospective review. Setting: St. Louis Children's Hospital, a tertiary care center. Patients: Consecutive sample of 125 patients with esophageal or airway foreign bodies. Results: Fifty percent of all patients had private health insurance. Fifty-six percent of all preschool patients and 20% of all school-age patients were uninsured (P < 0.01, Fisher's exact test). Eighty-five percent of patients with airway foreign bodies, and 84% of patients with esophageal foreign bodies were in the preschool group. Sixty-one percent of preschool patients and 21% of school-age patients with esophageal foreign bodies were uninsured (P < 0.05). Forty-six percent of preschool patients with food aspiration lacked health insurance (88% of these children were fed the aspirated item). No school-age group was available for comparison. Fifty percent of preschool children with aspiration of non food items were uninsured, as were 16% of their school-age counterparts. Conclusions: Insurance status must be considered as a risk factor for foreign body aspiration and ingestion. Preschool children are more likely to lack private health insurance than school-age children with the same diagnosis. In a majority of aspiration events, the child was being fed the inappropriate food item, perhaps indicating a lack of caretaker education and anticipatory guidance. A direct focus on ‘passive protection’, anticipatory guidance in clinics for all patients, and public education with emphasis on preventive care are proposed as means to decrease the incidence of airway and esophageal foreign bodies in children.

Twenty-two children with subperiosteal orbital abscesses were treated at St. Louis Children's Hospital between 1983 and 1992. Eighteen patients were otherwise in good health; four patients had cystic fibrosis, mucoceles, or were immunocompromised. All patients were treated with intravenous antibiotics and abscess drainage. CT scans were obtained preoperatively in each case. Ten patients were treated with endoscopic ethmoidectomy and abscess drainage, and 11 were treated with external ethmoidectomy and abscess drainage. One child was initially treated with abscess drainage and an elective endoscopic ethmoidectomy was performed later. There were no cases of permanent visual loss or neurologic sequelae. Culture results were positive in 14 cases and mixed infections were common. Complications included recurrent abscess, cerebritis, and empyema. We recommend combined medical and surgical treatment for all children with subperiosteal orbital abscess. We feel that endoscopic ethmoidectomy and abscess drainage offers some advantages over external ethmoidectomy and abscess drainage.

Objective To compare temporal bone computed tomography (CT) with temporal bone and central nervous system magnetic resonance (MR) imaging in children with unilateral or asymmetric sensorineural hearing loss (SNHL). Design Retrospective chart study. Setting Tertiary-care children's hospital. Patients A total of 131 children with unilateral or asymmetric SNHL, seen consecutively by a single practitioner over 36 months. Intervention Imaging studies were read by a pediatric neuroradiologist and reviewed by the evaluating otolaryngologist. Main Outcome Measure Prevalence of clinically significant CT or MR imaging findings. Results The prevalence of CT abnormalities was 35% for unilateral SNHL, 52% for asymmetric SNHL, and 41% for all patients together. The prevalence of MR imaging abnormalities was 25% for unilateral SNHL, 50% for asymmetric SNHL, and 30% for all patients together. Among 42 subjects who underwent both studies, there were 4 cases in which abnormalities were seen only on MR images and 9 cases in which abnormalities were seen only on CT scans. Conclusions Temporal bone and/or central nervous system abnormalities were detected in 42% of 131 patients. When both CT scans and MR images were obtained (n = 42), results were concordant in 69% of cases, and one imaging modality detected clinically significant abnormalities not identified by the other in 31% of cases. The ideal imaging algorithm for children with unilateral or asymmetric SNHL is controversial. We suggest that all children with unilateral or asymmetric SNHL have a high-resolution temporal bone CT scan and that brain and temporal bone MR imaging be obtained in select cases.