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To describe the impact of vestibular dysfunction on gross motor development in children with hearing loss.MEDLINE (PubMed), Embase (Elsevier), Web of Science (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (EBSCO).A systematic review was reported in concordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Articles on children with hearing loss who underwent at least 1 instrumented measure of vestibular function and had gross motor milestones assessed were included. The Downs and Black checklist was used to assess risk of bias and methodological quality.Eleven articles were included in the systematic review. Three articles stratified quantitative results of gross motor milestone acquisition by severity of vestibular impairment. Over half of studies were case series published within the last 5 years. This systematic review showed that children with hearing loss and severe, bilateral vestibular dysfunction demonstrate delayed gross motor milestones. However, it was difficult to draw conclusions on whether milder forms of vestibular dysfunction significantly affect gross motor milestone acquisition in children with hearing loss. The reason is that most studies were of low to moderate quality, used different assessment methods, and contained results that were descriptive in nature.This emerging area would benefit from future research, such as higher-quality studies to assess vestibular function and gross motor milestones. This would allow for better characterization of the impacts of vestibular impairment, especially milder forms, in children with hearing loss.

Objectives: Postoperative respiratory depression is of concern in children undergoing adenotonsillectomy receiving postoperative opioids and may be mitigated with intraoperative bupivacaine. This study aims to compare the impact of bupivacaine on postoperative pain and sedation in various pediatric age and surgical indication subgroups. Methods: This is a case series with chart review of 181 patients 2 test and analysis of variance. Subanalysis was performed after stratifying into age and surgical indication subgroups. Results: Ninety-eight patients were included in the pre-tonsillectomy group, 47 in the post-tonsillectomy group, and 36 in the none group. The number of postanesthesia care unit opioid doses ( P = .159) and pain scores at arrival ( P = .362) or discharge ( P = .255) were not significantly different between treatment groups overall. Among 0- to 5-year-olds, pre-tonsillectomy injection was associated with lowest mean (SD) discharge pain score of 0.55 (1.29) pre-tonsillectomy versus 0.71 (1.37) post-tonsillectomy versus 2 (1.63) none group ( P = .004). Among 12- to 17-year-olds, no injection was associated with lowest mean (SD) discharge pain score of 2.33 (0.52) pre-tonsillectomy versus 5 (2.65) post-tonsillectomy versus 1.63 (1.60) none group ( P = .020). Injection in patients with obstructive sleep apnea and/or sleep-disordered breathing did not improve postoperative outcomes. Conclusion: Intraoperative bupivacaine may improve pain scores in younger pediatric populations, though it may not impact the amount of postoperative opioid use. Prospective analysis with a larger sample size is warranted to better outline opioid usage and pain control in this group.

The U.S. is in an opioid epidemic with greater than 40,000 deaths annually. Pediatric adenotonsillectomy is one of the most common and painful otolaryngology surgeries performed, often associated with opioid prescriptions.To understand postoperative prescribing practices of adenotonsillectomy in a tertiary care institution and associated postoperative emergency department (ED) visits.Descriptive analysis of retrospective cohort data.Tertiary academic healthcare institution.Pediatric patients18yo undergoing adenotonsillectomy between 2013 and 2016.Postoperative analgesic regimens assessed including opioid and non-opioid analgesic prescriptions upon discharge from tonsillectomy surgery.Main outcomes included ED presentation within 30-days of surgery and reoperation. Secondary outcomes included reason for ED presentation and relation to prescribed analgesics. Data was analyzed between November 2021-February 2022.200 patients were included in the study with 69% prescribed opioids, and 51% prescribed non-opioid analgesics. Number of opioid doses ranged widely with a median of 37 (Q1, Q3: 0, 62). There were no demographic differences in patients prescribed opioids from those who were not. Of those patients who presented to the ED, 81% were not specifically prescribed acetaminophen (p 0.001). Regression analysis models were not predictive of postoperative analgesic regimen or 30-day ED presentation (p 0.05) CONCLUSIONS: Wide ranges of post tonsillectomy prescribing practices currently exist in our institution. Prescribing acetaminophen may help to reduce 30-day ED presentation rate. Larger prospective studies are needed to optimize pain control regimens and reduce variability of opioid prescribing practices. Standardization of postoperative pain medication doses may also reduce postoperative ED presentations.

OBJECTIVES: To determine the utility of diagnostic laryngoscopy and bronchoscopy in children with tracheostomies and to describe the incidence of airway findings. METHODS: Retrospective cohort study examining children with tracheostomies who underwent direct laryngoscopy and bronchoscopy (DLB) at Duke University Hospital between 2008 and 2016. RESULTS: A total of 81 patients who underwent 114 bronchoscopies met inclusion criteria. The median time between tracheostomy and first DLB was 13 months (IQR 4.25-14.75). Sixty-six patients were diagnosed with findings on DLB (81.5%). Suprastomal granulation tissue was the most common complication (59.0%), followed by increased tracheal secretions (23%), stomal and peristomal granulation (13.2%), tracheal ulcer (3.3%), and suprastomal collapse (1.6%). The proportion of patients with airway findings who underwent endoscopy >6 months post-tracheostomy was higher than those 6 months post-tracheostomy (61%) compared to 6 months after tracheostomy versus

Clinical practice guidelines synthesize and disseminate the best available evidence to guide clinical decisions and increase high-quality care. Since 2004, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published 16 guidelines. The objective of this review was to evaluate clinicians' adherence to these guidelines' recommendations as measured in the literature.We searched PubMed, Embase, and Web of Science on August 29, 2019, for studies published after June 1, 2004.We systematically identified peer-reviewed studies in English that reported clinician adherence to AAO-HNSF guideline recommendations. Two authors independently reviewed and abstracted study characteristics, including publication date, population, sample size, guideline adherence, and risk of bias.The search yielded 385 studies. We excluded 331 studies during title/abstract screening and 32 more after full-text review. The remaining 22 studies evaluated recommendations from 8 of the 16 guidelines. The Otitis Media with Effusion, Polysomnography, Tonsillectomy, and Sinusitis guidelines were studied most. Study designs included retrospective chart reviews (7, 32%), clinician surveys (7, 32%), and health care database analyses (8, 36%). Studies reported adherence ranging from 0% to 99.8% with a mean of 56%. Adherence varied depending on the recommendation evaluated, type of recommendation, clinician type, and clinical setting. Adherence to the polysomnography recommendations was low (8%-65.3%). Adherence was higher for the otitis media with effusion (76%-90%) and tonsillectomy (43%-98.9%) recommendations.Adherence to recommendations in the AAO-HNSF guidelines varies widely. These findings highlight areas for further guideline dissemination, research about guideline adoption, and quality improvement.

OBJECTIVES/HYPOTHESIS This study compares the hospital cost of osseointegrated implants for retention of an auricular prosthesis to autologous ear reconstruction. STUDY DESIGN Retrospective review. METHODS This study includes patients who underwent reconstruction for either congenital or acquired ear defects at Duke University Medical Center during 2009 to 2015. RESULTS A total of nine patients had autologous repair representing nine operative ears, and 16 patients had an osseointegrated implant representing 18 operative ears (two bilateral). The average age for the autologous repair was 11.6 years with 56% male versus 40.7 years with 56% male for the osseointegrated implant patients. For autologous patients, indications for surgery were anotia/microtia in 8/9 (89%) and trauma in 1/9 (11%) versus 6/16 (387.5%) anotia/microtia, 8/16 (50%) cancer, and 2/16 (132.5%) trauma in the osseointegrated implant group. The mean number of surgeries was 3.1 for autologous repairs and 1.0 for osseointegrated repairs (mean difference confidence interval [CI]: -2.4 to -1.8, P

Background In February 2015, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR-CPG). The objective of this study was to assess otolaryngologists' perception of the accuracy and adherence to the AR-CPG. Methods A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists' demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements. Results The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11-30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct "a great deal" (295 [69.7%]) and deviated from the guideline "only a little" (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents "always/most of the time" recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001). Conclusion Overall perception of the correctness of and adherence to the AR-CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.

Introduction Congenital CMV (cCMV) is the leading cause of non-genetic sensorineural hearing loss. Babies with cCMV can present with hearing loss any time but failing the initial hearing screen should trigger cCMV testing. cCMV must be identified within 3 weeks after birth to differentiate congenital from acquired CMV, yet follow-up hearing screens may not occur until after 21 days. A new electronic health record protocol to test cCMV in babies who fail their initial hearing screen was established at our institution in 2013. The purpose of this study is to evaluate adherence and deviations from this protocol. Methods All term infants born in 2013–2016 who failed initial hearing screen were included. The records were reviewed retrospectively. Demographic data, dates of hearing screens, CMV testing results and follow-up hearing test results were collected. Results A total of 19,069 newborn babies were screened between 2013 and 2016. Babies who were in the neonatal intensive care unit whether premature or not were excluded as these infants are often in the hospital longer than 3 weeks so audiologic diagnostic testing may be delayed. Among term newborns screened, 1358 failed initial screen and 444 failed subsequent hearing testing prior to discharge. We identified 60 babies who did not follow up and 59 underwent additional audiologic testing. Overall 38 babies were tested for cCMV with 2 positives. We found an increase in cCMV testing over time and a significant decrease between physical distance from birth hospital and outpatient audiologic follow-up testing within 21 days of birth. Discussion Our results are consistent with a 0.4% rate of cCMV in full-term babies who failed their newborn hearing screen. From 2013 to 2016, more babies received CMV tests, but post-screening follow up was still delayed. Further research is necessary to address factors affecting follow up. Use of electronic health record eased identification of results and improved tracking.

Suprastomal granulomas pose a persistent challenge for tracheostomy-dependent children. They can limit phonation, cause difficulty with tracheostomy tube changes and prevent decannulation. We describe the use of the coblator for radiofrequency plasma ablation of suprastomal granulomas in five consecutive children from September 2012 to January 2016.Retrospective case series at a tertiary medical center.The suprastomal granuloma could be removed with the coblator in all 5 cases. Three were removed entirely endoscopically and 2 required additional external approach through the tracheal stoma for complete removal. There were no intraoperative or postoperative complications. One patient was subsequently decannulated and 2 patients have improved tolerance of their speaking valves. Two patients remain ventilator dependent, but their bleeding and difficulty with tracheostomy tube changes resolved. Three of the patients have had subsequent re-evaluation with bronchoscopy, demonstrating resolution or markedly decreased size of the granuloma. This technique is time efficient, simple and minimizes risks associated with other techniques. The relatively low temperature and use of continuous saline irrigation with the coblator device minimizes the risk of airway fires. Additionally, the risk of hypoxia from keeping a low fractional inspiratory oxygen level (FIOCoblation can be used safely and effectively with an endoscopic or external approach to remove suprastomal granulomas in tracheostomy-dependent children. More studies that are larger and have longer follow-up are needed to evaluate the use of this technique.

Pediatric patient caregivers may prefer to avoid a surgical intervention and request a medical management option for eustachian tube dysfunction (ETD). However, there are limited published data evaluating the efficacy of intranasal fluticasone in the medical management of ETD as an alternative to tympanostomy tube placement. The objectives of this study were to: 1) determine if intranasal fluticasone (INF) prevented tympanostomy tube placement in children with ETD, and 2) describe differences in patient response to INF related to cleft lip and/or palate (CLP) and Down syndrome.Case series with planned chart review at a Tertiary academic hospital. We reviewed pediatric patients treated with INF for ETD. Inclusion criteria included ETD, no prior intranasal or oral steroid therapy, and no prior tympanostomy tube placement. Outcomes included time-to- tympanostomy tube placement with or without INF and therapy compliance. Kaplan-Meier survival analyses with log-rank tests and Fisher's exact tests were used to examine outcome variables.676 fulfilled inclusion criteria. 393 (58.7%) were male, and 355 (52.5%) Caucasian with mean age of 27.1 months old. 92 (13.6%) had CLP and 46 (6.8%) had Down Syndrome. 266 (39.4%) received INF, and 202 (88.2%) were compliant at their next visit. 474 (70.1%) had tympanostomy tubes placed. Children treated with INF were less likely to have tympanostomy tubes placed than children not treated (52.6% vs. 81.5%; p 0.0001). Using survival analyses, INF use was associated with significantly longer mean time-to-tympanostomy tube than no INF use (199.4 vs. 133.7 days; p 0.0001). INF did not reduce time-to-tympanostomy tube in patients with CLP (p = 0.05) or Down Syndrome (p = 0.27).INF significantly reduces the number of children requiring tympanostomy tube placement for ETD. The CLP and Down Syndrome anatomical variants may attenuate INF efficacy. Further in vivo characterization of INF action on eustachian tube tissues will help further substantiate these observations.

To analyze variation in tonsillectomy procedure rates between health care system types around the world.International database analysis.The 2015 Organization for Economic Co-operation and Development (OECD) Health Statistics surgical procedures database was used to ascertain tonsillectomy procedure volumes for 31 countries. Each country's health system type and structure were classified by overall system type, and by health care regulation, financing, and provision methods. Each system type and structure variable were compared using the rate of tonsillectomy procedures per 100,000 citizens.10.5 million tonsillectomy procedures completed between 1993 and 2014 were analyzed. Overall, social health insurance system types had higher total tonsillectomy rates versus other health care system types (p 0.05 for each comparison). Health systems with private care provision had a higher procedure rate versus state provided care (159.1 vs. 131.1 per 100,000 citizens; p = 0.002). Health care systems with societal regulation and financing had a higher procedure count versus state regulated or financed care (regulation 193.3 vs. 139.7 per 100,000 citizens, p 0.0001; financing 168.2 vs. 135.0 per 100,000 citizens, p = 0.0004).The volume of tonsillectomy procedures is associated with a health care system's overall structure, regulation, financing, and provision methods. International health care systems with state mediated provision, regulation, and financing had lower tonsillectomy rates versus systems with private provision, and societal regulation or financing. Further study is needed to determine differences in indications for tonsillectomy between countries, but these results underscore potential variation in health care delivery in different systems.

On October 1,2015, the United States required use of the Clinical Modification of the International Classification of Diseases, 10th Revision (ICD-10-CM) for diagnostic coding. This primer was written to assist the cleft care community with understanding and use of ICD-10-CM for diagnostic coding related to cleft lip and/or palate (CL/P).

Objective Approximately 1 to 2 of every 1000 American newborns has hearing loss identified by newborn screening. This study was designed to determine if infant hearing loss is more common in socioeconomically disadvantaged communities. Study Design In this retrospective study, we analyzed electronic medical record data using geostatistical models. Setting Infants were residents of Durham County, North Carolina, born in 2 hospitals of the Duke University Health System. This county includes the city of Durham and surrounding suburban and rural communities. Subjects and Methods Subjects were hearing-screened newborns, born between 2005 and 2016, whose residential address was in Durham County, North Carolina. This was a retrospective study using medical record data. We used Bayesian regression models with smoothing of coordinate date to identify both spatial and nonspatial predictors of infant hearing loss. Results We identified 19,348 infants from Durham County, of whom 675 had failed initial hearing screening and 191 had hearing loss confirmed on follow-up. Hearing loss was significantly associated with minority race (odds ratio [OR], 2.45; 95% confidence interval, 1.97-3.06), as well as lower gestational age and maternal sexually transmitted infections. We identified significant geographic heterogeneity, with a higher probability of hearing loss in poorer urban neighborhoods (local OR range, 0.59-1.39). Neighborhood disadvantage was a significant predictor of hearing loss, as was high local seroprevalence of cytomegalovirus (CMV) among pregnant women. Conclusions Urban, low-income neighborhoods have a high prevalence of infant hearing loss compared with more affluent surrounding communities, particularly among minorities. This distribution may be attributable to congenital CMV infection.

Objectives: To present a novel pediatric airway anomaly encountered on direct laryngoscopy and bronchoscopy, further characterized with computed tomography imaging of the chest. Study Design: Case report and literature review. Methods: Review of the clinical presentation, operative findings, and imaging findings of an infant who presented with respiratory distress in the setting of multiple congenital abnormalities. A brief literature review supplements the case presentation. Results: While multiple tracheobronchial anomalies have long been reported, this is the first report of a double or false carina: a system of symmetric paired upper and lower bronchi connected by a central conduit. Operative evaluation was limited given the narrow lumen, and postoperative imaging aided in further characterization of the pediatric airway. Conclusions: This is the first report of a novel tracheobronchial anomaly presenting as a double carina. Tracheobronchial anomalies are diverse and should be considered when performing operative airway evaluations. Imaging can be a helpful adjunct with anatomic characterization.

As there is a national and global trend to encourage and promote the benefits of breastfeeding in newborns, there has been a rise in the discussion and controversy around the impact of congenital ankyloglossia on breastfeeding for mothers. Ever since the public health message promoting the significant health, social, economic, and other benefits of breastfeeding, there seems to be an increase in the last decade regarding the diagnosis and utilization of frenotomy for ankyloglossia in newborns. We present some of the clinical considerations, evidence, and controversy surrounding ankyloglossia, more commonly referred to as a tongue-tie and dysphagia in newborns and children.

This study compares the hospital cost of osseointegrated implants for retention of an auricular prosthesis to autologous ear reconstruction.Retrospective review.This study includes patients who underwent reconstruction for either congenital or acquired ear defects at Duke University Medical Center during 2009 to 2015.A total of nine patients had autologous repair representing nine operative ears, and 16 patients had an osseointegrated implant representing 18 operative ears (two bilateral). The average age for the autologous repair was 11.6 years with 56% male versus 40.7 years with 56% male for the osseointegrated implant patients. For autologous patients, indications for surgery were anotia/microtia in 8/9 (89%) and trauma in 1/9 (11%) versus 6/16 (387.5%) anotia/microtia, 8/16 (50%) cancer, and 2/16 (132.5%) trauma in the osseointegrated implant group. The mean number of surgeries was 3.1 for autologous repairs and 1.0 for osseointegrated repairs (mean difference confidence interval [CI]: -2.4 to -1.8, P .001). The average cost to the hospital for an osseointegrated repair was $6,491.39 versus $10,047.93 for autologous repairs (CI: $6,496.38 to $-616.68, P = .02) CONCLUSIONS: Osseointegrated implants for retaining an auricular prosthesis has a similar cost to autologous repair of ear defects, but patients underwent an average of two more surgeries with autologous repair. Patients should be able to choose the reconstruction option that best suits their condition and preferences.4. Laryngoscope, 128:2153-2156, 2018.

Purpose: We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia. Using remifentanil along with spinal anesthesia eliminates the fetal and maternal risks associated with inhalational general anesthesia, allows the mother to be awake, and obviates the need for and costs associated with general anesthesia and a second anesthesia team. Materials and Methods: We performed a retrospective review of all sequential patients undergoing ex utero intrapartum treatment procedure at our hospital from 1/1/2009 to 11/1/2010. All procedures were performed under regional neuraxial analgesia, using nitroglycerine as a tocolytic agent and remifentanil for analgesia. Variables included indication, time to secured fetal airway, complications, estimated blood loss, need for additional anesthetics, participating personnel, and survival. Results: All five of our ex utero intrapartum treatment procedures were successfully completed with combined spinal epidural remifentanil anesthetic. No patient was required additional alternative anesthetic. There were no complications with mother or fetus. Indications for procedure were arthyrogryposis (n = 3), fetal goiter, and micrognathia. Average time to secured airway was 10.25 minutes. Average estimated blood loss was 1010 ml. All five mothers were conscious during their procedure. Conclusions: We report the largest series of ex utero intrapartum treatment procedures performed with remifentanil regional anesthesia. We found that the combined use of nitroglycerin and regional remifentanil anesthesia is a safe alternative to the pediatric otolaryngologist for performing ex utero intrapartum treatment procedures without the risks of general anesthesia, allowing the mother to be awake for the delivery, and reducing the cost of providing care.

The aesthetic aspects of the cleft lip nasal deformity have been appreciated for over a century, but the functional implications have remained largely underappreciated or misunderstood. This study describes the frequency and severity of nasal obstructive symptoms among children with cleft lip and/or cleft palate, addressing the hypotheses that age, cleft type, and severity are associated with the development of nasal obstructive symptoms. Children with nonsyndromic cleft lip and/or cleft palate and a comparison group of unaffected children born from 1997 to 2003 were identified through the North Carolina Birth Defects Monitoring Program and birth certificates. Nasal airway obstruction was measured using the validated Nasal Obstruction Symptom Evaluation scale. The survey was completed by parental proxy for 176 children with cleft lip and/or cleft palate and 333 unaffected children. Nasal obstructive symptoms were more frequently reported in cleft lip with cleft palate compared with unaffected children (p < 0.0001); children who had isolated cleft lip with or without alveolus and isolated cleft palate were not statistically different from unaffected children. Patients with unilateral cleft lip with cleft palate were found to be more severely affected than bilateral cases. Nasal obstruction was observed in early childhood, although severity worsened in adolescence. This population-based study reports a high prevalence of nasal obstructive symptoms in children with cleft lip and/or cleft palate based on type and severity of the cleft. The authors encourage cleft teams to consider using this or similar screening methods to identify which children may benefit from functional rhinoplasty. Risk, I.

Supraglottoplasty is the first-line surgical treatment for severe laryngomalacia. The purpose of this study is to determine the current trends of practice patterns in managing children who require supraglottoplasty.A 25-question survey regarding supraglottoplasty techniques and perioperative management was sent by e-mail to 274 physician members of the Society for Ear, Nose and Throat Advances in Children (SENTAC).101 surgeons responded and 72% of respondents were in academic practice (p 0.0001). All four United States regions, Canada and the United Kingdom were represented. The most commonly reported age of patients undergoing supraglottoplasty was 1-3 months (62% of respondents). Indications include worsening airway symptoms (43%), failure to thrive (41%) and worsening feeding (10%). The majority of respondents (89%) treat these patients for reflux with 54% prescribing PPIs and 41% prescribing H2 blockers. Cold steel is the most popular surgical technique (73%) followed by laser (14%), microdebrider (10%) and coblator (3%) (p 0.0001). Most respondents (92%) administer intraoperative steroids with the majority of them choosing dexamethasone (99%). Perioperative antibiotics are administered by 23% of respondents. Almost all respondents admit their patients for post-operative observation (99%) and 53% of these admit to PICU rather than step-down or floor status. The level of care is associated with the number of supraglottoplasties performed per year (p = 0.009) and with the geographic region (p = 0.02). Surgeons who perform fewer supraglottoplasties tend to admit to a higher level of care. Those in the South and Northeast regions tend to admit more to floor status. Only 13% routinely keep patients intubated post-operatively.This provider survey study highlights some significant variations and trends in practice patterns of otolaryngologists who perform supraglottoplasty. The majority utilizes anti-reflux pharmacotherapy; however, there is no consensus in which type. The method for supraglottoplasty also varies with cold steel being the most popular, although no single method has been shown to be superior. There is variation in post-operative care with trends for keeping patients extubated and admitting them to an intensive care. With the importance of safe, effective, and also cost-conscious care, further studies are needed to understand the optimal management of those who undergo supraglottoplasty.

The aim of this study was to better characterize the impact of pre-transplant adenotonsillectomy in the development of graft-versus-host disease in pediatric patients undergoing allogeneic stem cell transplantation.This retrospective study involved 211 children undergoing stem cell transplantation at Duke University. Patients who had undergone transplant were characterized by age at transplant, age at adenotonsillectomy (if applicable), age at graft-versus-host disease (if applicable), average length of follow up and other factors. Statistical analyses were performed to determine the relative risks associated with each variable.A total of 136 patients developed graft-versus-host disease and 75 did not. Average length of follow up was 2 years for GVHD and 1.7 years for non-GVHD patients. The relative risk (RR) of graft-versus-host disease was significantly increased under univariate analysis if the donor and recipient were unrelated (RR=2.1, p0.0001) and if the HLA match was not identical (RR=1.6, p0.001). A history of adenotonsillectomy prior to transplant did not affect the risk of developing graft-versus-host disease (RR=1.1, p=0.70).Adenotonsillectomy prior to bone marrow transplant has no significant impact either protectively or adversely on the risk of developing graft-versus-host disease after transplantation in pediatric patients. Future studies are needed to further examine the impact of otolaryngologic surgery on pediatric patients in terms of immune system modification. Research should specifically focus on the immunological effects of surgery on patients who will be undergoing bone marrow transplant.

Although the American Academy of Otolaryngology–Head and Neck Surgery conducts a workforce survey annually, no study has been conducted to examine practice patterns as they pertain specifically to academic otolaryngology. Therefore, I developed the Academic Otolaryngologist Survey for this purpose. This survey, conducted in 2006, was mailed to 856 practicing otolaryngologists in the United States; 230 responded, for a return rate of 26.9%. Of the 230 respondents, 94% practiced full-time, 97% worked with otolaryngology residents and were hoard certified, and 67% had fellowship trainingin one or more subspecialties. The most commonly reported fellowships were in pediatric otolaryngology, facial plastic surgery, head and neck, and otology/neurotology. Respondents answered that they felt practice patterns had changed. Unlike the private-practice sector, academic otolaryngology is seeing a shift from generalists to subspecialists. The subspecialization becoming prevalent in academic otolaryngology may ultimately alter resident training. Therefore, academic programs need a balance of general and subspecialized otolaryngologists in order to train residents for practice.

Objective. Identify concerns in non-English-speaking patients to improve patient care and communication. Misunderstandings due to language barriers can impose undue hardship possibly leading to adverse outcomes. Information from this study may identify ways of improving care. Methods. A 31-question survey was administered in the patients’ native language using certified medical interpreters. Surveys were collected anonymously during clinic visits. Results. Thirty-eight surveys were completed and compiled. Most were happy with their provider. Half indicated that they did not know why they were seeing that provider, did not understand the tests, or had difficulty with interpreters. Many indicated they would like medical information written in their native language. Conclusion. Barriers to communication can lead to adverse medical outcomes, poor compliance with therapy, and poor understanding of medical conditions. Providing written information in the patient’s native language has the potential to complement the verbal discussion and enhance patient care.

Sensorineural hearing loss has been identified in several types of muscular dystrophy, but few studies have investigated any relationship between Duchenne muscular dystrophy and hearing. An animal model of Duchenne muscular dystrophy, the mdx mouse, exhibits the same genetic defect as humans. We performed brainstem auditory evoked responses on mdx and control mice in order to assess sensorineural hearing loss. The amplitude and latency of wave I for each animal were measured at increasing sound pressure levels. A significant increase in threshold and a decrease in wave I amplitude were found in the mdx mice. These results indicate that significant sensorineural hearing loss is associated with muscular dystrophy in the mdx mouse. Possible cellular mechanisms contributing to the hearing deficit are presented.

Septoplasty is commonly performed for nasal airway obstruction or rhinologic headache due to contact irritation, often in conjunction with other nasal procedures, including cosmetic rhinoplasty and endoscopic sinus surgery.Traditionally, it is performed before these procedures via a "headlight" technique. This article describes the use of the microdebrider in 29 cases of endoscopic septoplasty. Many of the procedures were performed in conjunction with functional endoscopic sinus surgery; however, several were performed as an isolated procedure or with inferior turbinoplasty. The technique is described in detail. All 29 patients had significant improvement in their symptoms, and no patient developed a perforation or postoperative hematoma. Conversion to a traditional septoplasty was required in 1 case because of the severity of the deviation. Power-assisted endoscopic septoplasty is a useful adjunct in cases involving isolated septal spurs or moderate septal deviations. Patients with severe nasal obstruction due to caudal deflection of the septum off the nasal spine are better served with traditional headlight septoplasty.

Respiratory failure in infants and children is a common cause of ICU admission, and diseases that jeopardize the airway are the most frequent cause of cardiac arrest in neonatal and pediatric patients.[1][1],[2][2] In neonates specifically, there are numerous causes for respiratory distress, with

Diabetes mellitus is a disease that affects multiple organ systems. In our laboratory it has been shown that there is a significant loss of outer hair cells in genetically diabetic rats. Galactosemia can also produce diabetic-like changes. This study was performed to demonstrate whether these changes also occur in the cochlea. Three groups of Sprague-Dawley rats were used and fed either a control diet, a 50% galactose diet, or a 50% galactose diet with the addition of an aldose reductase inhibitor. After 6 months the animals were killed, and the cochleas were removed, fixed, and stained. Diabetes-induced damage was assessed by counting the hair cells and calculating the neuroganglion cell density. The histopathologic changes induced by galactose were manifested as outer hair cell loss and a decrease in neuroganglion cell density. Control animals had the least amount of hair cell loss and the greatest neuroganglion cell density of all three groups. Galactose-only animals demonstrated the most pronounced changes in both hair cell loss and neuroganglion cell degeneration; however, only changes of neuroganglion cell density in the basal turn were significant. The addition of an aldose reductase inhibitor provided inconclusive results in both hair cell determination and neuroganglion cell density; however, generally the inhibitor partially prevented the damage produced by galactose. These results suggest that a high-galactose diet can induce diabetic-like changes in the cochlea. (OTOLARYNGOL HEAD NECK SURG 1995;113:748-54.)

Objective: The purpose of this study was to investigate if insulin-dependent diabetes mellitus causes degenerative changes in the inner ear and whether these changes are exacerbated by noise exposure. Methods: Insulin-dependent diabetes mellitus was induced in male rats using streptozotocin (65 mg/kg of body weight, intravenously). Half the animals were exposed to 95 dB of random noise for 12 hours per day over a period of 6 months. The cochleae were removed, fixed, decalcified, dissected, and the hair cells counted. Results: A significant loss of outer hair cells was exhibited in both noise-exposed groups; however, although there was no significant difference between these two groups, the noise-exposed diabetic animals had significant loss in more turns than did the noise-exposed control animals. The diabetic animals were not statistically different from the control animals. Conclusion: These results suggest that insulin-dependent diabetes mellitus may increase the hair-cell loss caused by noise overstimulation. (Arch Otolaryngol Head Neck Surg. 1995;121:452-456)

Thickening of the basement membrane in capillaries is implicated in the microangiopathic complications of diabetes mellitus. This study was designed to evaluate microangiopathic changes of the inner ear associated with insulin-dependent diabetes mellitus (IDDM) and concurrent moderate-intensity noise exposure. Male Sprague-Dawley rats were injected with streptozotocin (65 mg/kg) to induce IDDM. Half of the control and diabetic animals were exposed to chronic noise of 95 dB over the 6-month study period. Photomicrographs of the capillaries in the stria vascularis were obtained by transmission electron microscopy, and basement-membrane thickness was measured with an image processing system. This study quantitatively demonstrates basement-membrane thickening consistent with diabetic microangiopathy in the inner ear of IDDM rats. Noise exposure did not significantly change basement-membrane thickness in either diabetic or control animals.

To objectively determine changes in sensorineural hearing in children with mucopolysaccharidosis (MPS) by comparing audiological data before and after hematopoietic stem cell transplantation (HSCT).Retrospective medical chart analysis.Tertiary referral hospital.Thirty pediatric patients with the diagnosis of MPS who underwent HSCT and had audiological data before and after HSCT. Data were extracted from medical charts for patients seen at our institution from January 1, 1999, to December 1, 2009.Hearing was assessed using behavioral audiometry testing and auditory brainstem responses (ABR) before and after HSCT. Patient demographics, diagnosis, and age at HSCT were also evaluated.Thirty patients with MPS were included. Four (13%) had MPS type 3a, 2 (7%) had MPS type 2, and 24 (80%) had MPS type 1. The average age at HSCT was 19 months (range, 5-44 months). Hearing improvement was evaluated by audiogram (20 patients), ABR (8 patients), and qualitative measures (30 patients). On average, patients did not show improvement on audiogram (P = .28; paired t test). The ABR click threshold improved 19 dB on average (P.001). Qualitatively, 3 patients had normal hearing before and after HSCT. Of the remaining 27 patients, 20 (67%) showed improvement in sensorineural hearing (P.001). Five (17%) had hearing loss and did not improve. Two (7%) had worsening hearing. Hematopoietic stem cell transplantation at the age of 25 months or younger was significantly correlated with hearing improvement (P = .03).Hematopoietic stem cell transplantation may provide improvement in MPS-associated sensorineural hearing loss. Hearing improvement is more likely to occur in patients who undergo transplantation at 25 months or younger.

Importance In the limited number of Crohn disease cases involving the head and neck, there is a predilection for mucosal surfaces and rare reports of involvement in the postauricular region. To our knowledge, in all previously reported cases involving the head and neck, the patients had a known diagnosis of Crohn disease. Observations This case describes a 10-year-old boy with a history of psoriasis and psoriasiform dermatitis who presented with bilateral chronic granulomatous otitis externa, obliteration of the external auditory canal, and fissuring, resulting in separation of the lobule from the preauricular skin. Conclusions and Relevance Pathologic examination results were consistent with granulomatous dermatitis concerning for cutaneous Crohn disease, and a subsequent gastroenterologic workup confirmed the diagnosis of Crohn disease. This is a report of chronic granulomatous otitis as the initial presentation of cutaneous Crohn disease in a child.

The purpose of this study was to describe 2 unique cases of ocular motility dysfunction after powered endoscopic sinus surgery and identify potential risk factors for extraocular muscle injury.Interventional case series.Patient 1 developed a restrictive global ophthalmoplegia after inadvertent entry into the medial orbit during powered endoscopic sinus surgery. Patient 2 had complete loss of adduction of the left eye as a result of transection of the medial rectus muscle by a powered cutting instrument.Despite advances in endoscopic sinus surgery technique and instrumentation, serious ophthalmic complications may still occur. Inadvertent entry into the medial orbital wall can result in ocular motility complications. Furthermore, it is possible that attraction of orbital contents into the tip of a powered cutting instrument may occur without significant entry into the orbital cavity.It is important for endoscopic sinus surgeons to be aware of the intimate anatomical relationship between the orbit and sinuses, as well as the potential risks of the current instruments used in endoscopic sinus surgery.

Objective To determine the benefit of nasally inhaled dornase alfa in cystic fibrosis (CF) sinusitis. Design Retrospective chart review comparing postsurgical course, radiographic studies, and pulmonary function test results in patients who were treated with nasally inhaled dornase alfa with those in patients who were not treated with dornase alfa. Patients Twenty consecutive patients with CF who underwent functional endoscopic sinus surgery from 1993 to 1997 were included in the study. Treatment with nasally inhaled dornase alfa was initiated in 5 of the 20 patients after they underwent functional endoscopic sinus surgery. Setting Tertiary care academic center. Results The dornase alfa–treated patients had less mucosal edema and no polyps at serial endoscopy over 3 years compared with the non–dornase alfa–treated patients. The patients who received nasally inhaled dornase alfa also underwent fewer revision functional endoscopic sinus surgical procedures (1.6 vs 3.2), even though there was essentially no change in pulmonary function test results in these patients. Conclusions Sinusitis continues to be a major cause of morbidity in patients with CF. Symptomatic patients frequently require multiple drug regimens, including long-term systemic antibiotic therapy, topical and systemic steroid therapy, and antibiotic nasal irrigations. This preliminary study indicates the potential impact of nasally inhaled dornase alfa in controlling postoperative symptoms in CF sinusitis.

Hearing loss has long been associated with diabetes mellitus. Microangiopathy, associated with thickening of the basement membranes of small vessels, has been implicated as a major source of multiple system organ disease.Objective This study was designed to evaluate changes in basement membrane thickness in the inner ear of laboratory animals suffering from non-insulin-dependent diabetes mellitus (NIDDM) with, and without, exposure to moderate intensity noise exposure in an attempt to extrapolate the same disease process in humans.Design Spontaneously hypertensive-corpulent non-insulin-dependent rats (SHR/N-cp) were selected as a genetic model for the above study. Both lean and obese rats were used in this study. A genetically similar control group of animals (LA/N-cp) were used as controls. These animals express both the lean and obese phenotypes, but they lack the NIDDM gene. Forty-eight animals in each group were sacrificed at the end of the study. The cochleas were dissected and fixed. The basement membrane of the stria vascularis was examined using transmission electron microscopy.Setting This study was a laboratory-based, standard animal study.Main outcome This study was designed to show microangiography of the inner ear as related to NIDDM with, and without, obesity and noise exposure.Results/Conclusions NIDDM alone does not cause statistically significant basement membrane thickening; however, NIDDM in combination with obesity and/or noise exposure did show significant thickening and the combination of all three showed the greatest thickening. NIDDM appeared to be the greatest contributing factor.

Nitric oxide (NO) mediates the effects of the excitatory amino acids in the central nervous system. Excitatory amino acids, in particular l -glutamate, are thought to be the neurotransmitter(s) present at the cochlear hair cell-afferent nerve synapse. To our knowledge, no studies to date have documented the presence of NO in the cochlea nor attempted to elucidate the role of NO in hearing. Rat cochlea frozen sections were examined for the presence of nitric oxide synthase (NOS) by NADPH diaphorase histochemistry. Vibratome sections of rat cochlea were examined by immunocytochemistry with an antibody to citrulline, an indication of NOS activity. Spiral ganglion cells in the rat cochlea were positive by NADPH diaphorase histochemistry and by anti-citrulline immunocytochemistry. These results indicate that NOS is present and that the enzyme actively produces nitric oxide in the spiral ganglion cells of the rat cochlea. Given our current understanding of neurotransmission in the cochlea, it is reasonable to postulate that the actions of NO in cochlear neuronal tissue are similar to the actions of NO in the CNS and that NO acts as a neurotransmitter/neuromodulator in the cochlea. In addition, because NO has been implicated as a mediator of excitotoxicity in the CNS, NO may play a role in neurotoxicity in the cochlea.