Search

Objective: The PedsQL™ (Pediatric Quality of Life Inventory™) is a modular instrument designed to measure health-related quality of life (HRQOL) and disease-specific symptoms in children and adolescents ages 2-18. The new PedsQL™ Infant Scales were designed as a generic HRQOL instrument specifically for healthy and ill infants ages 1-24 months. The objective of this study was to report on the initial feasibility, internal consistency reliability, and validity of the PedsQL™ Infant Scales in healthy, acutely ill, and chronically ill infants.Methods: The 36-item (ages 1-12 months) and 45-item (ages 13-24 months) PedsQL™ Infant Scales (Physical Functioning, Physical Symptoms, Emotional Functioning, Social Functioning, Cognitive Functioning) were completed by 683 parents of healthy, acutely ill, and chronically ill infants.Results: The PedsQL™ Infant Scales evidenced minimal missing responses, achieved excellent internal consistency reliability for the Total Scale Scores (α = 0.92), distinguished between healthy infants and acutely and chronically ill infants, and demonstrated a confirmatory factor structure largely consistent with the a priori conceptual model.Conclusions: The results demonstrate the initial measurement properties of the PedsQL™ Infant Scales in healthy and ill infants. The findings suggest that the PedsQL™ Infant Scales may be utilized in the evaluation of generic HRQOL in infants ages 1-24 months. [ABSTRACT FROM AUTHOR]

Importance: Cochlear implants can restore sound and enable speech and language development for children with severe to profound sensorineural hearing loss. Long-term outcomes of pediatric cochlear implant recipients are variable. Although the association between social determinants of health (SDH) and pediatric cochlear implant outcomes has been explored, the strength of this association has not been quantitatively synthesized in the literature., Objective: To determine the association of SDH with language and academic outcomes in pediatric cochlear implant recipients., Data Sources: In August 2023, the following databases were searched: Embase.com, Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cumulated Index to Nursing and Allied Health Literature Plus, APA PsycINFO, and ClinicalTrials.gov. Following duplicate exclusion of 8687 results, 5326 records were finalized., Study Selection: Abstract screening, full-text review, and risk of bias assessment was performed by 1 to 2 reviewers. Articles were included if an effect size for an SDH variable that was associated with measures of language, communication, reading, academics, and quality of life was reported., Main Outcomes and Measures: A random-effects meta-analysis was performed, with standardized regression coefficients measuring the relative direction and magnitude of a variable association with the outcome of interest., Results: Of 5326 articles, 40 articles that included a total of 3809 children were included in the systematic review; 20 articles that included a total of 1905 children were included in the meta-analysis. Parental involvement, education level, and low socioeconomic status were moderately to strongly associated with language outcomes (β = 0.30; 95% CI, 0.13-0.48; β = 0.45; 95% CI, 0.29-0.62; β = -0.47; 95% CI, -0.83 to -0.10, respectively). Known determinants of language outcomes, such as the age of cochlear implantation and duration of cochlear implant use, demonstrated moderate to no associations with language outcomes (β = -0.30; 95% CI, -0.43 to -0.17; β = 0.19; 95% CI, -0.26 to 0.63, respectively)., Conclusions and Relevance: The results of this systematic review and meta-analysis suggest that SDH are associated with childhood language development and academic achievement. In addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child's home, primary medical care, and school environment.

Objective: Metastasis of renal cell carcinoma to nonthyroid head and neck region is rare. Survival benefit for complete metastasectomy of more common renal cell foci has been reported in the literature. It is uncertain whether metastasectomy in nonthyroid head and neck region would provide a similar benefit., Data Sources: We conducted a retrospective review of all renal cell metastases to the head and neck region treated in the past 15 years at an academic hospital, and a systematic review of all relevant reports with survival data in the literature between 1960 and 2016., Review Methods: An analysis of pooled data was performed to estimate overall survival., Results: Six cases from our institution and 260 independent cases reported in the literature were included in the survival analyses (n = 266). The median follow-up time was 12 months (range 0-180 months). The overall median survival was 36 months (95% confidence interval [CI] 23.7-48.3). The median survival for those who underwent complete metastasectomy in the head and neck was significantly higher at 60 months (95% CI 41.1-78.9) than those who had incomplete or no metastasectomy (12 months, 95% CI 9.5-14.5). Multivariable Cox proportional hazards model estimated that, after controlling for potential confounders, complete metastasectomy remained associated with reduced risk of death (hazard ratio 0.44, 95% CI 0.29-0.69)., Conclusion: Complete metastasectomy was associated with 4-year longer median overall survival than incomplete metastasectomy or no metastasectomy. Laryngoscope, 128:889-895, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

The study objective was to develop quality measures for adult cochlear implant centers. A modified Delphi design beginning with focus groups of surgeons and audiologists was used, as adapted from the American College of Cardiology / American Heart Association method for creating quality measures. Two academic cochlear implant programs and 1 private program participated. Qualitative focus group analysis yielded 58 candidate measures. An additional 5 candidate measures were added from a systematic review of the literature. After exclusion of pediatric measures, structure measures, and process measures and discussion of details and implications of each measure, 8 measures remained as the preliminary Adult Cochlear Implant Outcome (CI-OUTCOME) Measure Set. This study provides a preliminary set of measures for evaluating the quality of adult cochlear implant centers, based on input from implant surgeons and audiologists. The next step will be to gather feedback from implant patients., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objective: To determine the impact of pediatric hearing loss (HL) on quality of life (QOL)., Data Sources: A qualified medical librarian conducted a literature search for relevant publications that evaluate QOL in school-aged children with HL., Review Methods: Studies were assessed independently by 2 reviewers for inclusion in the systematic review and meta-analysis., Results: From 979 abstracts, 69 were identified as relevant; ultimately, 40 articles were included in the systematic review. This review revealed that children with HL generally report a lower QOL than their normal-hearing peers and that QOL improves after interventions. The extent of these differences is variable among studies and depends on the QOL measure. Four studies using the Pediatric Quality of Life Inventory (PedsQL) had sufficient data for inclusion in a meta-analysis. After studies were pooled, statistically and clinically significant differences in PedsQL scores were found between children with normal hearing and those with HL, specifically in the social and school domains. Statistically significant differences were also noted in total scores for children with unilateral HL and in the physical domain for children with bilateral HL as compared with those having normal hearing; however, these differences were not clinically meaningful., Conclusions: Our analysis reveals that decreased QOL in children with HL is detected in distinct domains of the PedsQL. These domains-school activities and social interactions-are especially important for development and learning. Future work should focus on these aspects of QOL when assessing HL in the pediatric population., Competing Interests: none, (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objectives: To determine the breadth of outcome domains used in the reporting of adult cochlear implant surgery for the purpose of registry and quality measure development., Data Sources: Systematic review of randomized controlled trials., Review Methods: In consultation with a medical librarian, search strategies were constructed to identify randomized controlled trials studying adults undergoing cochlear implantation. MEDLINE, EMBASE, Scopus, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects were searched from database inception to July 2015. Studies were evaluated for level of evidence and risk of bias with the Cochrane Collaboration's Risk of Bias Tool, and outcome domains were extracted from each study., Results: Of 4473 unique citations found, 8 studies were included in this review. All 8 trials were evidence level 1B. Risk of bias was low in 2 trials and high in the other 6. Reported outcome domains included speech perception in quiet and noise, speech tracking, quality of life, timbre perception, hearing preservation, vestibular function, electrode insertion technique, functional measures, functional imaging, fitting time, and tinnitus., Conclusions: An analysis of randomized controlled trials studying cochlear implantation in adults yielded a wide spectrum of outcome domains. This is the first study to comprehensively describe the breadth of outcome domains in adult cochlear implantation. Validated instruments from these domains could be considered for potential inclusion as quality measures and registry use., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

As health care reimbursements based on pay-for-performance models become more common, there is an unprecedented demand for ways to measure health care quality and demonstrate value. Performance measures, a type of quality measure, are unique tools in a health care delivery system that allow objective monitoring of adherence to specific goals and tracking of outcomes. We sought to provide information on the development of quality measures in otolaryngology-head and neck surgery, as well as the goals of performance measurement at a national level and for our specialty. The historical development, various types, and approach to creating effective performance measures are discussed. The primary methods of developing performance measures (using clinical practice guidelines, clinical registries, and alternative methods) are also discussed. Performance measures are an important tool that can aid otolaryngologists in achieving effective, efficient, equitable, timely, safe, and patient-centered care as outlined by the Institute of Medicine.

Objective: Efficacy of insert and supra-aural earphones during visual reinforcement audiometry (VRA) was investigated for 12- to 24-month-old children., Design: VRA testing began in the soundfield and transitioned to either insert or supra-aural earphones. Audiologists recorded threshold estimates, participant behaviors, and an overall subjective rating of earphone acceptance., Study Sample: One hundred and eighty-six 12- to 24-month-old children referred to the Department of Audiology at St. Louis Children's Hospital for a variety of reasons., Results: Subjective ratings indicated high acceptance of insert earphones (84%) and supra-aural earphones (80%) despite negative behaviors. There was no significant difference in the number of threshold estimates based on earphone type for 12- to 17-month-old participants. Participants in the 18- to 24-month-old age group provided significantly more threshold estimates with insert earphones (mean = 5.3 threshold estimates, SD = 3.5) than with supra-aural earphones (mean = 2.9 threshold estimates, SD = 2.9). All seven participants who rejected earphone placement were successfully reconditioned for soundfield testing., Conclusions: Data support the use of insert earphones during VRA, especially with 18-to 24-month-old children, to obtain ear-specific information.

Children with impaired hearing in one ear (unilateral hearing loss [UHL]) and normal hearing in the other ear experience challenges in understanding speech in noisy backgrounds and localizing the source of sounds in 3-dimensional space. They are at a high risk for speech and language delay and need educational help in school. However, definitive evidence of benefit from amplification is currently lacking to recommend placement of hearing aids or cochlear implants in all young children with UHL. Management of UHL in children should be guided by the child's development, performance in school, and personal/family values and preferences., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Performance measures (PMs), or quality indicators, are metrics based on objective data that allow one to assess whether a system achieves a prespecified goal. Given the relatively high level of resource utilization and potential morbidity associated with cochlear implantation (CI), PMs could be used to evaluate quality of care provided by implant centers and, ultimately, optimize care delivery. This article discusses PMs currently in use, how PMs are developed, potential downsides of using PMs, and various examples of PMs that could be used in CI centers., (© American Academy of Otolaryngology-Head and Neck Surgery Foundation 2015.)

Asymmetric and unilateral hearing losses in children have traditionally been underappreciated, but health care practitioners are now beginning to understand their effect on development and the underlying pathophysiologic mechanisms. The common wisdom among medical and educational professionals has been that at least one normal-hearing or near-normal-hearing ear was sufficient for typical speech and language development in children. The objective of this review is to illustrate, to the non-otolaryngologist, the consequences of asymmetric and unilateral hearing loss in children on developmental and educational outcomes. Etiology, detection, and management are also discussed. Lastly, implications for further research are considered.

Purpose of Review: Quality of life (QOL) is an important patient-oriented outcome in common disorders, particularly when one management strategy is not clearly superior to an alternative. This article reviews the recently published literature that evaluated QOL in children with common pediatric otolaryngologic problems., Recent Findings: Among the 41 reviewed articles that used QOL as an outcome, 14 disease-specific QOL surveys and 12 generic QOL questionnaires were used. QOL instruments that had been validated in adults were frequently used in children without validation in pediatric populations. For children, parent-reported outcomes of caregiver concerns are often used as proxy measures of QOL for the child, and only a few QOL instruments asked the child to rate their own perception of their QOL. Several studies used nonvalidated QOL surveys as outcomes., Summary: QOL is being evaluated in an increasing number of pediatric otolaryngologic disorders. Although there are numerous surveys to measure generic pediatric QOL, validated disease-specific surveys for children are less common, especially those that utilize child self-report. The lack of disease-specific pediatric surveys for otolaryngologic disorders hampers the ability to document change or differences in patient-oriented outcomes with interventions.

Objective: Children with otitis media (OM) suffer sleep disturbances, loss of appetite, earache, and behavioral problems. Our objective was to quantitate the average burden of OM and to compare the associated impact of tympanostomy tubes on infant health related quality of life (HR-QoL)., Study Design: Multi-institutional prospective cross-sectional study., Setting: Otolaryngology, family practice, and pediatric clinics., Subjects and Methods: Children ages 6 to 24 months of age with or without recurrent OM. Patient history, the PedsQL Infant QoL survey, and the 6-item child with OM survey (Otitis Media 6 [OM-6]) were collected from providers and parents., Results: Data from 1208 patients were analyzed. Mean age was 14.7 months, and 54% were male. The mean OM-6 score of children with recurrent OM was 3.3, whereas similarly aged well-children had a mean OM-6 score of 2.5. The mean PedsQL Infant scores of recurrent OM patients were significantly worse than those of children from well-child visits. Worse OM-6 scores were correlated with poorer PedsQL Infant scores, Pearson r = -0.581 (1-12 months) and -0.558 (13-24 months), P < .001. Otolaryngology patients who were recommended to undergo ear tube placement had significantly poorer OM-6 scores and worse PedsQL Infant scores, whereas patients with prior tube placement had significantly better OM-6 and PedsQL Infant scores., Conclusion: Children with recurrent OM had significantly worse HR-QoL than similarly aged healthy children. Increased burden of OM strongly affected HR-QoL, and recommendation for tube placement was associated with increased disease burden and poorer HR-QoL. The presence of tympanostomy tubes was associated with better OM-6 and PedsQL Infant scores., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Objective: Otitis media (OM) in children is the most frequent reason for physician visits in developed countries and burdens caregivers, society, and the child. Our objective was to describe the impact of OM severity on parent/caregiver quality of life (QoL)., Study Design: Multi-institutional prospective cross-sectional study., Setting: Otolaryngology, family, and pediatric practices., Subjects and Methods: Children 6 to 24 months old with and without a primary diagnosis of recurrent OM and their caregivers. Physicians provided patient history, and parents/caregivers completed a Family Information Form, the PedsQL Family Impact survey, the Patient Reported Outcomes Measurement Information System (PROMIS) survey, and the OM 6-item severity survey (OM-6)., Results: A total of 2413 subjects were enrolled and data from 1208 patients and physician were analyzed. The average child age was 16 months, and 54% were male. The mean OM-6 score was 3.2. The mean PedsQL Family Impact score for parents was 66.9 from otolaryngology sites and 78.8 from pediatrics/family practice sites (P < .001). Higher (worse) OM-6 scores correlated significantly with worse PedsQL Family Impact scores (Pearson r = -0.512, P < .01). Similarly, increasing OM-6 scores strongly correlated with increased parental anxiety, depression, and fatigue, as well as decreased satisfaction (all P < .01)., Conclusions: Worse PedsQL Family Impact and PROMIS scores were highly correlated with elevated OM-6 scores, suggesting that severity of childhood OM significantly affects parent/caregiver QoL. Understanding the impact of a child's illness on parent/caregiver QoL can help physicians counsel patients and families and provide better family-centered, compassionate care., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Objective: Language acquisition was assumed to proceed normally in children with unilateral hearing loss (UHL) since they have one functioning ear. However, children with UHL score poorly on speech-language tests and have higher rates of educational problems compared to normal hearing (NH) peers. Diffusion tensor imaging (DTI) is an imaging modality used to measure microstructural integrity of brain white matter. The purpose of this pilot study was to investigate differences in fractional anisotropy (FA) and mean diffusivity (MD) in hearing- and non-hearing-related structures in the brain between children with UHL and their NH siblings., Study Design: Prospective observational cohort., Setting: Academic medical center., Subjects and Methods: Sixty one children were recruited, tested and imaged. Twenty nine children with severe-to-profound UHL were compared to 20 siblings with NH using IQ and oral language testing, and MRI with DTI. Twelve children had inadequate MRI data. Parents provided demographic data and indicated whether children had a need for an individualized educational program (IEP) or speech therapy (ST). DTI parameters were measured in auditory and non-auditory regions of interest (ROIs). Between-group comparisons were evaluated with non-parametric tests., Results: Lower FA of left lateral lemniscus was observed for children with UHL compared to their NH siblings, as well as trends toward differences in other auditory and non-auditory regions. Correlation analyses showed associations between several DTI parameters and outcomes in children with UHL. Regression analyses revealed relationships between educational outcome variables and several DTI parameters, which may provide clinically useful information for guidance of speech therapy., Discussion/conclusion: Our data suggests that white matter microstructural patterns in several brain regions are preserved despite unilateral rather than bilateral auditory input which contrasts with findings in patients with bilateral hearing loss.

Objectives/hypothesis: The prevalence of hearing loss (HL) in adolescents has grown over the past decade, but hearing-related quality of life (QOL) has not been well-measured. We sought to develop a reliable, valid measure of hearing-related QOL for adolescents and the Hearing Environments And Reflection on Quality of Life (HEAR-QL)., Study Design: Multisite observational study., Methods: Adolescents with HL and siblings without HL were recruited from five centers. Participants completed the HEAR-QL and validated questionnaires measuring generic pediatric QOL (PedsQL), depression and anxiety (RCADS-25), and hearing-related QOL for adults (HHIA) to determine construct and discriminant validity. Participants completed the HEAR-QL 2 weeks later for test-retest reliability. We used exploratory principal components analysis to determine the HEAR-QL factor structure and measured reliability. Sensitivity and specificity of the HEAR-QL, PedsQL, HHIA, and RCADS-25 were assessed. We compared scores on all surveys between those with normal hearing, unilateral, and bilateral HL., Results: A total of 233 adolescents (13-18 years old) participated: 179 with HL, 54 without HL. The original 45-item HEAR-QL was shortened to 28 items after determining factor structure. The resulting HEAR-QL-28 demonstrated excellent reliability (Cronbach's alpha = 0.95) and construct validity (HHIA: r = .845, PedsQL: r = .587; RCADS-25: r = .433). The HEAR-QL-28 displayed excellent discriminant validity, with higher area under the curve (0.932) than the PedsQL (0.597) or RCADS-25 (0.529). Teens with bilateral HL using hearing devices reported worse QOL on the HEAR-QL and HHIA than peers with HL not using devices., Conclusions: The HEAR-QL is a sensitive, reliable, and valid measure of hearing-related QOL for adolescents., Level of Evidence: 2b., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Compare the epidemiology of pediatric unilateral sensorineural hearing loss before and after implementation of universal newborn hearing screening in Missouri., Study Design: Inception cohort., Methods: Charts of 134 children born between January 1, 1990 and December 31, 2007, diagnosed with unilateral sensorineural hearing loss at a single institution in Missouri were reviewed to determine the effects of universal newborn hearing screening on age of detection and etiology of hearing loss., Results: Mean age of detection declined from 4.4 (standard deviation [SD] 1.8) to 2.6 (SD 2.6) years of age, whereas the rate of detection by 6 months of age increased from 3% to 42%. The majority (58%) of cases had normal hearing at birth. The most common etiological category was unknown (41%) before screening and congenital (45%) after screening. The use of magnetic resonance imaging has increased by 21% (2-fold), whereas use of computed tomography has declined by 8% since 2002. Yields of connexin, Pendred, electrocardiogram, and syphilis testing were 0/48 and 2/31 before and after screening, respectively., Conclusions: Implementation of universal newborn hearing screening in Missouri is associated with a decrease in age of detection of unilateral sensorineural hearing loss. The majority of cases are either not present or not detectable at birth. The combination of hearing status at birth and imaging findings suggests that the majority of cases are congenital rather than of unknown etiology., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine whether audiologic characteristics of unilateral hearing loss in children were associated with language, cognitive, or achievement scores., Study Design: Case-control study, Setting: Pediatric otolaryngology ambulatory practice, Patients: Cases (n = 109) were children aged 6 to 12 years with permanent unilateral hearing loss; controls (n = 95) were siblings with normal bilateral hearing., Interventions: Audiologic characteristics measured included side and severity of hearing loss and word recognition scores in quiet and in noise., Main Outcome Measures: Cognitive abilities were measured using the Wechsler Abbreviated Scale of Intelligence; reading, math, and writing achievement was measured with the Wechsler Individual Achievement Test - Second Edition - Abbreviated; and oral language skills were measured with the Oral Written and Language Scales., Results: Children with unilateral hearing loss had worse verbal cognitive and oral language scores than children with normal hearing, but there were no differences in achievement scores. Children with profound unilateral hearing loss tended to have worse cognitive scores and had significantly lower oral language scores. Higher word recognition scores of the normal hearing ear in quiet were associated with higher cognitive, oral language, and reading achievement scores. Higher word recognition scores in noise were slightly correlated with higher oral language scores., Conclusion: As expected, children with unilateral hearing loss had worse language scores than their siblings with normal hearing, with trends toward worse cognitive scores. Children with profound unilateral hearing loss tended to have worse outcomes than children with normal hearing or less severe unilateral loss. However, there were no differences in outcomes between children with right or left unilateral hearing loss.

Objectives/hypothesis: The objective of this study was to determine whether a prognostic model using risk factors for hearing loss could predict the chance that infants who failed a newborn hearing screen would subsequently be found to have hearing loss diagnosed by auditory brainstem response testing., Study Design: Individual retrospective case-control study., Methods: We studied 229 infants with hearing loss compared with 458 infants with normal hearing. All infants had undergone natural sleep or sedated auditory brainstem response, predominantly for not passing a newborn hearing screen. Risk factors, birth history, and other information were extracted via medical record review. Multiple logistic regression analyses identified independent predictors of hearing loss., Results: Four risk factors were independently predictive of hearing loss diagnosed by sleep or sedated auditory brainstem response: prematurity, 5-minute APGAR score ≤ 6, intracranial complication, and craniofacial abnormality. A prognostic model developed from these risk factors was associated with a 15% rate of hearing loss in stage I, 52% rate of hearing loss in stage II, and 96% rate of hearing loss in stage III., Conclusions: The presence of any one of four independently predictive risk factors in infants who did not pass newborn hearing screen was associated with a 50% rate of hearing loss; having three or more was associated with a 90% rate of hearing loss. Knowing that an infant is at high risk of hearing loss can motivate parents to follow up with diagnostic auditory brainstem response testing so that early identification can lead to early intervention., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The objective of this study was to obtain preliminary data on the cognitive function of children with unilateral hearing loss in order to identify, quantify, and interpret differences in cognitive and language functions between children with unilateral hearing loss and with normal hearing., Methods: Fourteen children ages 9-14 years old (7 with severe-to-profound sensorineural unilateral hearing loss and 7 sibling controls with normal hearing) were administered five tests that assessed cognitive functions of working memory, processing speed, attention, and phonological processing., Results: Mean composite scores for phonological processing were significantly lower for the group with unilateral hearing loss than for controls on one composite and four subtests. The unilateral hearing loss group trended toward worse performance on one additional composite and on two additional phonological processing subtests. The unilateral hearing loss group also performed worse than the control group on the complex letter span task. Analysis examining performance on the two levels of task difficulty revealed a significant main effect of task difficulty and an interaction between task difficulty and group., Conclusions: Cognitive function and phonological processing test results suggest two related deficits associated with unilateral hearing loss: (1) reduced accuracy and efficiency associated with phonological processing, and (2) impaired executive control function when engaged in maintaining verbal information in the face of processing incoming, irrelevant verbal information. These results provide a possible explanation for the educational difficulties experienced by children with unilateral hearing loss., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

IMPORTANCE Aural atresia (AA) is associated with maximal conductive hearing loss in affected ears, and children with bilateral AA require amplification. Some recent research has suggested an increased risk for speech and learning problems among children with unilateral sensorineural hearing loss. OBJECTIVE To investigate whether increased risk for speech and learning problems exists among children with AA. DESIGN Retrospective medical record review. SETTING Multidisciplinary craniofacial clinic. PARTICIPANTS Children with unilateral or bilateral AA. INTERVENTIONS Records review, including evaluations by audiologists, speech pathologists, and psychologists. MAIN OUTCOME MEASURES Rates of speech and/or language delay, prevalence of speech therapy and educational interventions, and parental report of psychosocial problems. RESULTS A total of 74 patients were identified who met inclusion and exclusion criteria: 48 with right-sided AA, 19 with left-sided AA, and 7 with bilateral AA. Children with AA demonstrated high rates of speech therapy (86% among bilateral, 43% among unilateral). Reports of school problems were more common among children with right-sided AA (31%) than those with left-sided AA (11%) or bilateral AA (0%) (P = .06). Educational interventions were common in all groups (33% right, 21% left, 43% bilateral). In the case of bilateral AA, all children who received additional interventions were enrolled in schools for the hearing impaired, without any identified learning deficiencies. CONCLUSIONS AND RELEVANCE Children with unilateral AA may be at greater risk of speech and learning difficulties than previously appreciated, similar to children with unilateral sensorineural hearing loss. Whether amplification may alleviate this risk is unclear and warrants further study.

Conjunctive consolidation, one method of multivariable analysis by arranging data into clusters, is intuitive and transparent. An unexpected consequence in writing this article was the discovery of just how useful it is in critically analyzing articles and in designing new projects. It has stimulated a fresh understanding as to the value of multivariable thinking in all clinical research. This article is organized into the sequential steps for performing conjunctive consolidation for critically analyzing an article of interest and for completing the process, pending all required data are available. Investigators, particularly those who perform clinical research, should consider conjunctive consolidation as a valuable method of multivariable analysis with which to report data.

Multivariable analyses are complex statistical methods to evaluate the impact of multiple variables on outcomes of interest. Books have been written on each of these methods detailing the mathematical and statistical objectives and processes. However, we have found very little in the way of brief reports that help the nonstatistically trained physician obtain a basic understanding of multivariable analyses in order to have some understanding of the increasing literature using these methods. This work is organized in 2 parts. This article, Part A, addresses the "big 4" algebraic methods of multivariable analysis. The primary focus of Part A is to present a brief "primer" to help the reader understand the methods and uses; it expressly avoids the many details of statistical assumptions, calculations, and myriad branching alternatives. Part B will concentrate on conjunctive consolidation and will focus on enough information to allow the interested reader to actually perform the analysis. For the statistical scholar, we have included references to several voluminous serious works.

Unlabelled: PROBLEM/OBJECTIVES: Unilateral hearing loss (UHL) in children is a relatively common problem often identified by newborn screening or school screening. This review summarizes the outcomes of a large study of children with UHL which identified risk factors for educational problems, describes the results of pilot studies of intervention, and proposes guidelines for interventions and future studies., Methods: Cohort of children age 6-12 years with UHL was compared to their siblings with normal hearing on the primary outcomes of cognition, achievement, and language. Secondary outcomes examined included behavioral, speech, and educational problems. A subgroup of children with UHL was followed longitudinally to examine change over time., Results: Children with UHL had lower language and verbal IQ scores than their siblings with normal hearing. They required individualized education plans (a measure of educational difficulty) at three times the rate and speech therapy at twice the rate of their siblings. The additional educational concerns did not ameliorate over time. Low maternal education levels and lower baseline cognitive skills were independent risk factors for school problems. Pilot studies suggest that children with UHL might benefit from amplification, but may need attention to cognitive or executive function skills as well., Conclusions: Children with UHL are at risk for delays in speech-language development, cognition, and behavioral problems that can affect functioning at school. Controlled studies are urgently needed to determine whether amplification, auditory rehabilitation, school-provided educational assistance, or other interventions are able to reduce or eliminate this risk.

Objectives/hypothesis: Children with unilateral hearing loss (UHL) have been found to have lower language scores, and increased rate of speech therapy, grade failures, or needing Individualized Education Plans (IEPs). The objective of this study was to determine whether language skills and educational performance improved or worsened over time in a cohort of children with UHL., Study Design: Prospective longitudinal cohort study., Methods: Forty-six children with permanent UHL, ages 6 to 12 years, were studied using standardized cognitive, achievement, and language testing at yearly intervals for 3 years. Using standardized test scores allowed implicit comparison to norms established by national cross-sectional samples. Secondary outcomes included behavioral issues, IEPs, receipt of speech therapy, or teacher report of problems at school. Analysis utilized repeated measures analysis of variance and multilevel random regression modeling., Results: Several cognitive and language mean standardized scores increased over time. Possible predictors of increase with time included higher baseline cognitive levels and receipt of interventions through an IEP. However, standardized achievement scores and indicators of school performance did not show concomitant improvements. Rates of IEPs remained >50% throughout, and rates of speech therapy were consistently about 20%., Conclusions: Children with UHL demonstrated improvement in oral language and verbal intelligence quota scores over time, but not improvements in school performance. Parents and teachers reported persistent behavioral problems and academic weaknesses or areas of concern in about 25%. The provision of IEPs for children with UHL, and acknowledging UHL as a hearing disability, may be an effective intervention to improve language skills over time., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Few quality of life (QOL) assessment tools are available for children with specific chronic conditions, and none have been designed specifically for children with hearing loss (HL). A validated hearing-related QOL questionnaire could help clinicians determine whether an intervention is beneficial and whether one intervention is better than another., Purpose: To examine QOL in children with HL and assess the validity, reliability, and factor structure of a new measure, the Hearing Environments and Reflection on Quality of Life (HEAR-QL) questionnaire., Research Design: A descriptive and correlational study of a convenience sample of children., Study Sample: Participants included 35 children with unilateral HL, 45 with bilateral HL, and 35 siblings with normal hearing., Data Collection and Analysis: Children 7-12 yr old were recruited by mail from a tertiary-care pediatric otolaryngology practice and the local county's Special School District. With parent consent, children completed the validated Pediatric Quality of Life Inventory™ (PedsQL) 4.0 and a 35-item HEAR-QL questionnaire. The factor structure of the HEAR-QL was determined through principal components analysis (PCA), and mean scores were computed for each subscale and the total HEAR-QL. Three weeks following the return of the initial questionnaires, a second HEAR-QL questionnaire was sent to participants to assess test-retest reliability. Both PedsQL and HEAR-QL scores were compared between children with and without HL, between children with unilateral and bilateral HL, and between children who used and did not use a hearing device using analysis of variance. Sensitivity and specificity were calculated for both the HEAR-QL and the PedsQL. A multivariable, hierarchical linear regression analysis was conducted with independent variables associated with the HEAR-QL in unadjusted tests., Results: Using exploratory PCA, the 35-item HEAR-QL was reduced to 26 items (Cronbach's α = 0.97, sensitivity of 91% and specificity of 92% at a cutoff score of 93.5) loading on three factors: difficulty hearing in certain environments/situations (Environments α = 0.97), impact of HL on social/sports activities (Activities α = 0.92), and impact of HL on child's feelings (Feelings α = 0.88). Sensitivity of 78.8% and specificity of 30.9% at a cutoff score of 69.6 on the PedsQL (at risk for impaired QOL) were lower than for the HEAR-QL. Participants with HL reported significantly lower mean total HEAR-QL scores (71 [SD 18] vs. 98 [SD 5], p < .001), but not mean total PedsQL scores (77 [SD 14] vs. 83 [SD 15], p = .47), than participants with normal hearing. Among children with bilateral HL, children who used a hearing device reported lower mean total HEAR-QL scores (p = .01), but not mean total PedsQL scores (p = .55), than children who did not use a hearing device. The intraclass correlation coefficient for test-retest reliability for the 26-item HEAR-QL total score was 0.83. Hearing status and use of a device were independently associated with the HEAR-QL, and the variables in the model accounted for 46% of the HEAR-QL total score variance., Conclusions: The HEAR-QL appears to be a valid, reliable, and sensitive questionnaire for children with HL. The HEAR-QL was better able than the PedsQL to distinguish between children with and without HL and can help evaluate interventions for children with HL., (American Academy of Audiology.)

Objectives: Although children with unilateral hearing loss (UHL) are at risk for educational difficulties and behavioral problems, the research on treatment outcomes is limited. Previous studies suggested that children with UHL would benefit from frequency-modulated assistive devices only. The objective of this study was to examine whether children with UHL would benefit from using a conventional hearing aid in the poorer-hearing ear., Methods: Eight children, 7 to 12 years of age, with mild to moderately severe UHL and their parents and teachers participated in this study. The participants were fitted with digital hearing aids by use of pediatric prescriptive targets. The primary outcome measures were speech perception tests in quiet and noise and subjective assessments from participants, parents, and teachers, administered before hearing aid fitting and after 3 months of hearing aid use., Results: The group average speech perception scores showed no significant aided benefit or detriment in any of the conditions tested. However, subjective assessments showed large significant aided benefits at home and school according to the children and their parents, and in quality of life as reported by the children with UHL., Conclusions: Overall, the results suggest that a hearing aid trial should be considered for children with mild to moderately severe UHL, with individual monitoring for benefit.

Objective: To determine whether patterns of functional connectivity of cortical regions responsible for auditory processing and executive functions differ in children with unilateral hearing loss (UHL) versus their normal-hearing (NH) siblings., Study Design: Prospective observational study., Setting: Academic medical center., Subjects and Methods: Children with severe-to-profound UHL (9 right UHL, 7 left UHL) and 10 NH sibling controls were imaged using resting state functional connectivity magnetic resonance imaging (rs-fcMRI). All MRI images were transformed to a single common atlas; regions of interest (ROI) were chosen based on previous literature and unpublished results. Mean regionwise correlations and conjunction analyses were performed across 34 seed ROIs to identify temporally synchronized, low-frequency spontaneous fluctuations in the resting state blood oxygenation level-dependent signal that reveal functionally related regions., Results: Mean regionwise Student t tests found a left posterior opercular region with more correlated resting state activity with the inferior parietal lobule seed in the children with both left and right UHL than NH. In conjunction analysis, 4 regions showed different resting-state functional interactions between the NH and both UHL groups. These differences were in left medial globus pallidus, left middle temporal gyrus, right parahippocampal gyrus, and mid-cingulate cortex. These regions include areas associated with auditory processing, executive function, and memory formation., Conclusions: Resting state fcMRI identified differences in brain network interconnections between children with UHL and NH and may inform further investigation into the educational and behavioral difficulties experienced by children with UHL.

Objective: To determine whether children with unilateral hearing loss (UHL) demonstrate worse language skills than their siblings with normal hearing, and whether children with UHL are more likely to receive extra assistance at school., Patients and Methods: We conducted a case-control study of 6- to 12-year-old children with UHL compared with sibling controls (74 pairs, n = 148). Scores on the oral portion of the Oral and Written Language Scales (OWLS) were the primary outcome measure. Multivariable analysis was used to determine whether UHL independently predicted OWLS scores after we controlled for potential confounding variables., Results: Children with UHL had worse scores than their siblings on language comprehension (91 vs 98; P = .003), oral expression (94 vs 101; P = .007), and oral composite (90 vs 99; P < .001). UHL independently predicted these OWLS scores when multivariable regression was used with moderate effect sizes of 0.3 to 0.7. Family income and maternal education were also independent predictors of oral expression and oral composite scores. No differences were found between children with right- or left-ear UHL or with varying severity of hearing loss. Children with UHL were more likely to have an individualized education plan (odds ratio: 4.4 [95% confidence interval: 2.0-9.5]) and to have received speech-language therapy (odds ratio: 2.6 [95% confidence interval: 1.3-5.4])., Conclusions: School-aged children with UHL demonstrated worse oral language scores than did their siblings with normal hearing. These findings suggest that the common practice of withholding hearing-related accommodations from children with UHL should be reconsidered and studied, and that parents and educators should be informed about the deleterious effects of UHL on oral language skills.

Purpose: The objective of this pilot study was to investigate the health-related quality of life (HRQOL) of children with unilateral hearing loss (UHL)., Method: The study was conducted in 2 stages among children age 6-17 years. In Stage 1, the authors conducted focus groups of children with UHL and their parents to elicit perceptions of how UHL affected the lives of these children. In Stage 2, a generic pediatric quality of life survey was used to measure HRQOL quantitatively in children with normal hearing, UHL, and bilateral hearing loss. Participants were recruited from the clinical and research populations of an academic otolaryngology department., Results: The focus groups revealed that the children with UHL experienced barriers due to their hearing loss but learned to adapt. Quantitatively, statistically significant differences between groups were not observed on the 3 main HRQOL scales (Total, Psychosocial, and Physical). Children with UHL had a significantly larger variance on the social functioning score than children with normal hearing and bilateral hearing loss., Conclusions: UHL may affect the HRQOL of children; this possibility should be included when counseling parents. However, further research is warranted to determine whether the authors' findings are generalizable to other children with UHL.

Objective: To examine the differences between participants and nonparticipants in a study of children with unilateral hearing loss that might contribute to selection bias., Study Design: Case-control study., Setting: Academic pediatric otolaryngology practice., Subjects and Methods: Comparison of clinical and sociodemographic characteristics between the 81 participants and 78 nonparticipants with unilateral hearing loss in a case-control study., Results: Compared with nonparticipants, the study participants were younger but were diagnosed at an older age. Participants were more likely to have been diagnosed through a primary care screen and have normal ear anatomy, and less likely to have an attributed etiology for their unilateral hearing loss or tried assistive hearing devices. No other significant demographic, socioeconomic, or clinical differences were identified., Conclusion: Self-selection bias may jeopardize both internal and external validity of study results and should be evaluated whenever possible. Methods to minimize self-selection bias should be considered and implemented during the planning stages of clinical studies., (Copyright 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Objective: Comparison of the Cincinnati criteria (midpoint >0.9 mm or operculum >1.9 mm) to the Valvassori criterion (midpoint > or =1.5 mm) for enlarged vestibular aqueduct (EVA) in pediatric cochlear implant patients., Study Design: Cohort study., Subjects: One hundred thirty pediatric cochlear implant recipients., Methods: We reviewed temporal bone CT scans to measure the vestibular aqueduct midpoint and opercular width., Results: The Cincinnati criteria identified 44 percent of patients with EVA versus 16 percent with the Valvassori criterion (P < 0.01). Of those with EVA, 45 percent were unilateral and 55 percent were bilateral using Cincinnati criteria; 64 percent were unilateral and 36 percent bilateral using Valvassori criterion (P < 0.01). The Cincinnati criteria diagnosed 70 ears with EVA classified as normal using the Valvassori criterion (P < 0.01); 59 lacked another medical explanation for their hearing loss., Conclusion: The Cincinnati criteria identified a large percentage of pediatric cochlear implant patients with EVA who might otherwise have no known etiology for their deafness.

Objective: To characterize presentation, treatment, and outcomes of pediatric retropharyngeal abscess (RPA) and determine optimal treatment., Study Design: Retrospective cohort., Subjects and Methods: Chart review of 162 pediatric patients with RPA., Results: Initial treatment was surgery in 126 and intravenous antibiotics in 36, of which 17 required surgery. Findings were negative in 30, murky fluid in 34, and pus in 79. Factors predicting positive surgical drainage were duration of symptoms for more than 2 days, prior antibiotic treatment, and CT lesion cross-sectional area >2.0 cm(2). A history of rash was a negative predictor. The mean length of stay (LOS) was 4.8 vs 3.6 days (P = 0.14), and duration of fever (DOF) was 2.5 vs 1.4 days (P = 0.01) for patients with no fluid and fluid at surgery, respectively. For antibiotic vs surgery groups, LOS was 4.4 vs 3.6 days (P = 0.14) and DOF was 2.4 versus 1.5 days (P = 0.0061)., Conclusions: These predictive factors may be useful in selecting patients with retropharyngeal abscesses who might be treated with intravenous antibiotics alone.

Purpose: The purpose of the study was to evaluate the effectiveness of a 2-hr initial audiologic assessment appointment for infants referred from area universal newborn hearing screening (UNHS) programs to a clinical audiology department in an urban hospital., Method: A prospective auditory brainstem response (ABR)-based protocol, including clicks, frequency-specific tone bursts, and bone-conducted stimuli, was administered by 10 audiologists to 375 infants. Depending on the ABR findings, additional test options included distortion product otoacoustic emissions (DPOAEs), high-frequency tympanometry, and/or otologic examination., Results: In 88% of the 2-hr test sessions, at least 4 ABR threshold estimates were obtained (i.e., bilateral clicks and either a 500- or 1000-Hz tone burst and a 4000-Hz frequency tone burst for the better ear). The incidence of hearing loss was significantly different across nursery levels: 18% for Level I (well baby), 29% for Level II (special care), and 52% for Level III (neonatal intensive care unit). Hearing loss type was defined at the initial assessment for 35 of the 51 infants with bilateral hearing loss based on bone-conduction ABR, latency measures, DPOAEs, high-frequency tympanometry, and/or otologic examination., Conclusions: Our findings indicate that a 2-hr test appointment is appropriate for all nursery levels to diagnose severity and type of hearing loss in the majority of infants referred from UNHS. Examination by an otolaryngologist within 24-48 hr further defines the hearing loss and facilitates treatment plans.

Purpose: The goal of this study was to examine the rate of diagnostic testing after newborn hearing screening (NHS) referral, evaluate timeliness of follow-up, and evaluate the use of multilevel auditory brainstem response (ABR) in screening of high-risk infants., Method: Telephone interviews were conducted with parents of infants who had been admitted to a neonatal intensive care unit from 1999 to 2002 and referred on NHS. An ABR screen was combined with a multilevel ABR (40, 70, and 90 dB nHL) for referrals., Results: Parents of 206 infants participated; 69% of the infants underwent diagnostic follow-up. Of those with follow-up, 37% had normal hearing, 38% had hearing loss, and parents were unsure of hearing test results for 25%. Follow-up by 6 months of age occurred for 13% in 1999, increasing to 31% by 2002. Infants who did not pass their screening in both ears had confirmed hearing loss in 56% vs. 25% in those who passed in 1 ear. Also, 67% of infants with bilateral pass levels of 90 dB nHL or more had confirmed hearing loss, vs. 32% in all others., Conclusions: Timely follow-up after NHS referral in our program has improved over time. Multilevel ABR may facilitate allocation of appropriate resources to track and ensure follow-up in infants at high risk for hearing loss.

Objective: To identify the otolaryngological manifestations of posttransplant lymphoproliferative disorder (PTLD) in pediatric heart and lung transplant recipients., Methods: A 14-year retrospective case series review (1990-2003) of children less than 18 years of age presenting with PTLD after receiving orthotopic heart and lung transplants at St. Louis Children's hospital (St. Louis, MO, USA)., Results: One hundred ninety seven cardiac and 246 pulmonary transplant patients were included in this review. Thirteen heart transplant patients developed PTLD with 39% (5/13) presenting in the head and neck. Thirty-two lung transplant patients developed PTLD with 25% (8/32) presenting in the head and neck. PTLD in cardiac transplants most often presented as adenotonsillar hypertrophy or cervical lymphadenopathy. The sinonasal cavity was the most common site of head and neck PTLD in pulmonary transplants patients., Conclusions: This study suggests that head and neck involvement is more common than currently reported in the literature. As thoracic organ transplants become more frequent in children, otolaryngologists caring for this population should maintain a high index of suspicion for any suggestive findings. Evaluation must include tissue biopsy, as histopathologic examination is required for diagnosis.

Objectives/hypothesis: The objectives of this study were to 1) quantify the relative importance of established risk factors for congenital hearing loss (HL), 2) identify other risk factors for congenital HL, and 3) create a prognostic system that can predict the chance of an infant having HL., Methods: The authors conducted a retrospective cohort study with validation of a prognostic system. The authors used a medical record review on 1,863 infants admitted to level II and level III nurseries who underwent auditory brainstem reflex (ABR) hearing screening from 1998 to 1999 (derivation cohort). The primary outcome was hearing screening referral (i.e., hearing screening failure) classified as mild to moderate, moderate to severe, and severe to profound loss. To validate the prognostic system, a medical record review of a separate cohort of 437 infants admitted to a level III nursery who underwent ABR hearing screening in 2002 (validation cohort) was performed., Results: In the derivation cohort, 1,513 infants (81%) passed the ABR screen at 30 dB, 77 (4%) had a unilateral referral, 243 (13%) had a bilateral referral, and 30 (1.6%) did not have a complete screening. In multivariable analysis, the following risk factors were clinically and statistically significant: craniofacial abnormalities, cytomegalovirus infection, bronchopulmonary dysplasia (BPD), maternal ethanol use, syndromes, hydrocephalus, and hyperbilirubinemia., Conclusions: Our results reaffirm the importance of several established risk factors for congenital HL, but suggest that BPD is an important predictor in high-risk populations. Whether these risk factors are causal or merely associated in congenital HL remains to be determined.

Objectives: To confirm the finding of pepsin/pepsinogen in middle ear fluid of children with chronic or recurrent otitis media (OME or ROM), and to ask parents about symptoms associated with gastroesophageal reflux (GER)., Methods: Middle ear fluid was collected from children undergoing tympanostomy tube placement. We tested this fluid for pepsin/pepsinogen using a proteolytic enzyme assay and an ELISA. Parents completed questionnaires about symptoms of GER in their children., Results: We collected 36 samples from 22 children; 16 of 22 children (73%) were positive with the proteolytic assay; 17 (77%) were positive with ELISA. Questionnaires did not show increased GER symptoms., Conclusions: We replicated the finding of pepsin/pepsinogen in middle ear fluid of children with OME or ROM, but did not find any increase in GER symptoms. Further research is needed to establish a causative link between GER and OM.

Objective: To understand the clinical presentation and management of salivary gland anlage tumor (SGAT)., Design and Methods: This case series includes a report of a newborn male who presented with acute airway obstruction secondary to a nasopharyngeal mass which was discovered in the course of the clinical evaluation. Six additional cases of SGAT from the pathology consultation files of one of the authors (LPD) presenting in similar fashion are also included. The relevant literature from 1966 to the present has been reviewed through a Medline keyword search utilizing terms "salivary gland anlage tumor", "neonatal", and "nasopharynx.", Results: Endoscopic evaluation identified a nasopharyngeal mass tethered to the posterior septum. Although CT and MRI were helpful in identifying the mass and excluding involvement of the surrounding structures, the imaging characteristics of the mass itself were nonspecific. The patient was taken to the operating room and the polypoid mass was removed transorally after lysis of its septal attachment. Pathologic examination revealed a SGAT, a recently described entity in neonates and young infants, who present with early onset respiratory distress. Since the initial report of nine cases by one of the co-authors (LPD), seven additional cases including the present one have been seen in consultation., Conclusions: Salivary gland anlage tumor of the nasopharynx is a rare cause of neonatal airway obstruction. Endoscopic evaluation and imaging studies are helpful in the exclusion of other etiologies, some of which may have intracranial extension. Simple excision has been curative to date. There have been no reported recurrences in any of the previously studied cases with clinical follow-up dating more than 5 years.

Physicians communicate with each other on a daily basis using staging and stratification systems, whether they recognize this or not. At a minimum, they help convey a wealth of information in communicating about patients and their disease; more sophisticated staging systems help physicians recommend therapy and prevention strategies for patients, or predict functional and survival prognoses in concordance with the current scientific evidence. The goal of this article is to discuss the purpose and rationale of staging or stratification systems, and to introduce the clinical and statistical development and evaluation of these systems. The practicing physician should be aware of basic methodologic principles in the development of staging systems that help ensure their quality and applicability, so that staging systems can help improve patient care.

Background: In the past, unilateral hearing loss (UHL) in children was thought to have little consequence because speech and language presumably developed appropriately with one normal-hearing ear. Some studies from the 1980s and 1990s have suggested that a significantly increased proportion of children with UHL may have educational and/or behavioral problems, compared with their normal-hearing peers. Limited data exist about the effect of UHL on acquisition of speech and language skills., Objective: To review the current literature about the impact UHL has on the development of speech and language and educational achievement., Data Source: MEDLINE search between 1966 and June 1, 2003, using the medical subject heading "hearing loss," combined with the textword "unilateral.", Study Selection: Studies were limited to those written in English, reporting speech-language and/or educational results in children., Data Extraction: Articles were read with attention to study design, population, recruitment of subjects, and outcomes measured., Data Synthesis: Problems in school included a 22% to 35% rate of repeating at least one grade, and 12% to 41% receiving additional educational assistance. Speech and language delays have been reported in some but not all studies., Conclusions: School-age children with UHL appear to have increased rates of grade failures, need for additional educational assistance, and perceived behavioral issues in the classroom. Speech and language delays may occur in some children with UHL, but it is unclear if children "catch up" as they grow older. Research into this area is necessary to clarify these issues and to determine whether interventions may prevent potential problems.

Background: Functional endoscopic sinus surgery (ESS) has become the procedure of choice for surgical treatment of chronic rhinosinusitis. Does the published literature support the claims of greater efficacy than medical treatment alone or older sinus procedures?, Objective: To analyze the methodology of the published literature regarding the efficacy of ESS., Data Sources: MEDLINE search for primary studies published in 1987 through 2001, written in the English language, reporting results on more than 100 patients, using the MeSH (medical subject headings) terms sinusitis [subheadings surgery or therapy] and endoscopy., Study Selection: Of 512 studies initially identified, 29 studies met the inclusion and exclusion criteria for further assessment of methodologic criteria. An additional 6 studies were found when the reference lists of reviews or included studies were searched., Data Extraction: Articles were evaluated for 4 core (inclusion/exclusion criteria, control group, intervention, and clear outcome measure) methodologic criteria essential to the determination of efficacy of ESS. Eight additional methodologic criteria were also used to rate the articles., Data Synthesis: Three studies met all 4 core methodologic criteria. Only 4 of 35 studies used a control group to evaluate efficacy of ESS to treat chronic sinusitis. Mean number of criteria met was 7.2, with a range of 2 to 11., Conclusions: Absence of a control group is the most important reason that studies are unable to scientifically assess the comparative efficacy of ESS to medical therapy or other sinus procedures. The methodologic criteria described here can be used to evaluate studies of interventions for other disorders.

Objective: We sought to assess the clinical status of pediatric sinusitis patients after a minimum of 2 years follow-up and to evaluate relative treatment effectiveness. Study design We conducted a medical record review of 308 patients, with a 2-year follow-up questionnaire., Results: Overall, 55% of children were "much improved." A 4-stage prognostic system was developed and used to compare results in 133 patients who had not responded to medical treatment and who had positive sinus computed tomography scans. Endoscopic sinus surgery (ESS) had no apparent advantages in stages I and IV, but in stages II and III, rates of "much improved" for ESS versus medical therapy were 79% versus 54% and 68% versus 42%, respectively., Conclusion: These results suggest that ESS may be particularly effective for patients from intermediate prognostic stages., Significance: This type of prognostic staging and evaluation of treatment effectiveness is necessary and important in chronic sinusitis, where randomized trials are unlikely to be performed.

Objective: To estimate the relative risk for otitis media (OM) in children from environmental tobacco smoke (passive exposure), maternal smoking during pregnancy (gestational exposure), or both., Design: Analysis of data from a national cross-sectional health survey, utilizing questionnaire information and serum cotinine measurements., Participants: Children younger than 12 years (N = 11 728) in the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988-1994., Main Outcome Measures: Occurrence and recurrence of ear infections., Results: The cumulative incidence of ear infections was 69%. Of all participants, 38% were exposed to passive smoke, 23% were exposed to gestational smoke, and 19% were exposed to combined passive and gestational smoke. The occurrence of any ear infection was not increased by passive smoke exposure (adjusted risk ratio [RR], 1.01; 95% confidence interval [CI], 0.95-1.06), but was slightly increased by gestational (adjusted RR, 1.08; 95% CI, 1.01-1.14) and combined (adjusted RR, 1.07; 95% CI, 1.00-1.14) smoke exposures. The risk of recurrent ear infections (> or = 6 lifetime episodes) was significantly increased with combined smoke exposure (adjusted RR, 1.44; 95% CI, 1.11-1.81). Other risk factors for ear infection identified in multivariable analysis were race/ethnicity, poverty-income ratio of 2.00 or more, attendance in day care, history of asthma, and presence of allergic symptoms., Conclusions: Passive smoke exposure was not associated with an increased risk of ever developing an ear infection in this study. The increased risk found with gestational and combined smoke exposures has marginal clinical significance. For recurrent ear infections, however, combined smoke exposure had a clinically and statistically significant effect.

Objective: To demonstrate the safety of conscious sedation in draining peritonsillar abscesses (PTAs)., Design: Children diagnosed as having a PTA in the pediatric emergency department were identified, and their medical records were retrospectively reviewed. Results of the present study were compared with those of a previous report., Setting: A tertiary referral children's hospital pediatric emergency department., Participants: Ninety-one consecutive children initially evaluated in the emergency department and managed for a PTA., Interventions: Peritonsillar abscess incision and drainage with or without sedation. A team of physicians whose activities were documented on a formal conscious-sedation record was present. Patients were monitored for major and minor complications., Outcome Measures: The primary outcome measures were major and minor complications. Secondary outcome measures were recurrence of PTA and the need for admission., Results: There were 62 episodes of conscious sedation for drainage of a PTA. Among the 91 patients, 3 had a recurrence and 24 were admitted after the procedure. A previous study evaluated 30 episodes of conscious sedation for drainage of a PTA. No major complications occurred in either series. Combining the previous data with the present data produced 92 episodes of conscious sedation for drainage of a PTA. The 1-sided upper 95% confidence limit for the rate of major complications is 3.2%., Conclusion: Our series, when combined with previously published data, demonstrates that conscious sedation can be safely used when draining a PTA in pediatric patients.

Objective: To generate estimates of sinusitis prevalence for adults in association with the use of tobacco or passive smoke exposure., Design: Analysis of data from the Third National Health and Nutrition Examination Survey, 1988-1994., Setting: Sample of the noninstitutionalized civilian population of the United States., Participants: A total of 20,050 adults aged 17 years or older., Main Outcome Measure: Presence of self-reported sinusitis or sinus problems., Results: In the United States, 66 million adults, constituting 35% of the adult population, reported having sinusitis or sinus problems at least once during the previous 12 months. Female sex, non-Hispanic white or non-Hispanic black race, higher income levels, and progressively higher educational levels were associated with increased prevalence of sinusitis. The prevalence of both acute and recurrent or chronic sinusitis increased with direct cigarette and other tobacco use but did not rise with passive exposure to cigarette smoke., Conclusions: Consistent with data for other respiratory ailments, the direct use of tobacco confers a small increased risk of developing sinusitis in the adult population, but contrary to expectation, passive smoke does not. The demographic variables of sex, race/ethnicity, and educational level demonstrated unexpectedly strong associations with the prevalence of sinusitis and should be analyzed and controlled for in future studies of sinusitis.

Introduction: Early vocalization and speech production remains a goal in children who require tracheotomy for airway obstruction or chronic ventilation. Although studies document the efficacy of the Passy-Muir valve (PMV) in adults, none have reviewed its efficacy in children. We performed this study to better understand the clinical complexity of its use in children., Materials and Methods: Retrospective evaluation of 55 consecutive cases of children with tracheotomy using the PMV., Results: The children ranged in age from 3 days to 18 years at the time of their tracheotomies, and nearly half were 12 months old or younger. Successful use often requires patient and family conditioning. Overall, 52 children out of the 55 who were evaluated as candidates for the PMV tolerated its use. Many required two or more trials prior to the patient and family being comfortable with its use., Conclusions: The PMV may be used successfully in children with a variety of airway pathologies as well as diverse medical problems. Discussed is the current protocol for the evaluation of the patient and the introduction of the valve.