GM-1020: a novel, orally bioavailable NMDA receptor antagonist with rapid and robust antidepressant-like effects at well-tolerated doses in rodents

The NMDA receptor (NMDAR) antagonist ketamine has shown great potential as a rapid-acting antidepressant; however, its use is limited by poor oral bioavailability and a side effect profile that necessitates in-clinic dosing. GM-1020 is a novel NMDAR antagonist that was developed to address these limitations of ketamine as a treatment for depression. Here, we present the preclinical characterization of GM-1020 alongside ketamine, for comparison. In vitro, we profiled GM-1020 for binding to NMDAR and functional inhibition using patch-clamp electrophysiology. In vivo, GM-1020 was assessed for antidepressant-like efficacy using the Forced Swim Test (FST) and Chronic Mild Stress (CMS), while motor side effects were assessed in spontaneous locomotor activity and on the rotarod. The pharmacokinetic properties of GM-1020 were profiled across multiple preclinical species. Electroencephalography (EEG) was performed to determine indirect target engagement and provide a potentially translational biomarker. These results demonstrate that GM-1020 is an orally bioavailable NMDAR antagonist with antidepressant-like efficacy at exposures that do not produce unwanted motor effects.

A Congenital Tongue Mass

A 13-month-old male presents with a firm left anterior tongue mass noted since birth that has increased proportionally with the child’s growth. What is your diagnosis?

CTNNB1 and APC Mutations in Sinonasal Myxoma : Expanding the Spectrum of Tumors Driven By WNT/β-catenin Pathway

Sinonasal myxoma (SNM) is a rare, benign mesenchymal neoplasm with distinct clinicopathologic features and aberrant nuclear localization of β-catenin by immunohistochemistry. The molecular underpinnings have been linked to that of a "myxoid variant" of desmoid fibromatosis. Herein, we describe a series of 8 cases of SNM and propose clinical and biologic differences compared with desmoid fibromatosis. Our patient cohort is comprised of 5 males and 3 females (age range: 10 mo to 12 y), 6 of whom are aged less than or equal to 24 months. All presented with facial swelling, reflecting lesions involving the maxillary bone, and all underwent resection. All tumors were variably cellular and comprised of bland spindled to stellate cells in a profusely myxoid background with diffuse nuclear β-catenin expression. All cases of SNM were analyzed by next-generation sequencing using the Oncopanel assay. Three cases failed sequencing, 2 of 5 successful cases exhibited exon 3 CTNNB1 alterations involving the ubiquitin recognition motif, and 3 had adenomatous polyposis coli ( APC ) deletions. One patient had APC germline testing which was negative. No germline testing was available for the remaining 7 patients. Follow-up data over a range of 1 month to 23 years was available for 7 of the 8 SNMs. One case patient had local recurrence, and all were alive without evidence of disease. This is in contrast to the high recurrence rate typically seen in desmoid fibromatosis, particularly after resection. Our findings expand the spectrum of tumors with underlying WNT/β-catenin pathway and highlight the histologic, clinical, and genetic differences of SNM compared with desmoid fibromatosis. APC deletion raises the possibility of underlying germline alteration and familial adenomatous polyposis.

Juvenile Nasopharyngeal Angiofibroma: Outcomes Analysis Based Upon Hospital Volume

OBJECTIVE

To evaluate the management of juvenile nasopharyngeal angiofibroma (JNA) from a national perspective with outcomes comparison based on hospital volume.

STUDY DESIGN

Ten-year Pediatric Health Information Systems (PHIS) data analysis.

METHODS

The PHIS database was queried for the diagnosis of JNA. Data regarding demographics, surgical approach, embolization, length of stay, charges, readmission, and revision surgery was collected and analyzed. Hospitals were classified as low volume if fewer than 10 cases and high volume if greater than or equal to 10 cases during the study period. A random effects model compared outcomes based on hospital volume.

RESULTS

A total of 287 JNA patients were identified with a mean age of 13.8 (± 2.7) years. Nine hospitals were classified as high volume, accounting for a total of 121 patients. The mean length of hospitalization, blood transfusion rate, and 30-day readmissions did not differ significantly by hospital volume. Patients cared for at high-volume institutions were less likely to require postoperative mechanical ventilation (8.3% vs. 25.0%; adjusted RR = 0.32; 95% CI 0.14-0.73; p < 0.01) or return to the operating room for residual disease than patients admitted to low-volume hospitals (7.4% vs. 20.5%; adjusted RR = 0.38; 95% CI 0.18-0.79; p = 0.01).

CONCLUSIONS

The management of JNA is complex from both an operative and perioperative management standpoint. Over the past decade, nearly half (42.2%) of JNA patients have been managed at nine institutions in the United States. These centers have significantly lower rates of postoperative mechanical ventilation and the need for revision surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3216-3220, 2023.

Pharmacological Mechanism of the Non-hallucinogenic 5-HT2A Agonist Ariadne and Analogs

Ariadne is a non-hallucinogenic analog in the phenylalkylamine chemical class of psychedelics that is closely related to an established synthetic hallucinogen, 2,5-dimethoxy-4-methyl-amphetamine (DOM), differing only by one methylene group in the α-position to the amine. Ariadne has been tested in humans including clinical trials at Bristol-Myers Company that indicate a lack of hallucinogenic effects and remarkable therapeutic effects, such as rapid remission of psychotic symptoms in schizophrenics, relaxation in catatonics, complete remission of symptoms in Parkinson's disease (PD), and improved cognition in geriatric subjects. Despite these provocative clinical results, the compound has been abandoned as a drug candidate and its molecular pharmacology remained unknown. Here, we report a detailed examination of the in vitro and in vivo pharmacology of Ariadne and its analogs, and propose a molecular hypothesis for the lack of hallucinogenic effects and the therapeutic potential of this compound class. We also provide a summary of previous clinical and preclinical results to contextualize the molecular signaling data. Our results show that Ariadne is a serotonin 5-HT₂ receptor agonist, exhibits modest selectivity over 5-HT₁ receptors, has no relevant activity at 5-HT_4,5,7 and other aminergic receptors, and no substantial affinity at plasma membrane monoamine transporters. Compared to DOM, Ariadne shows lower signaling potency and efficacy in multiple signaling pathways examined (G_q, G₁₁, and β-arrestin2) coupled to 5-HT_2A receptors. We confirmed the shift in signaling for an α-propyl analog and provide a molecular docking rationale for the progressive decrease in signaling potency with the growing length of the α-substituent. Ariadne versus DOM exhibits no apparent change in the relative preference between G_q/11 activation and β-arrestin2 recruitment; instead, there is a small but consistent drop in efficacy in these signaling channels. Ariadne acts as a 5-HT_2A agonist in vivo in mice and shows markedly attenuated head twitch response (HTR) in comparison to its hallucinogenic analogs, consistent with previous studies in rabbits, cats, and dogs. Hence, we propose the lower 5-HT_2A receptor signaling efficacy of this compound class as an explanatory model for the lack of hallucinogenic effects of Ariadne in humans and the dramatically attenuated hallucinosis-like effects in animals (5-HT_2A signaling efficacy hypothesis). In terms of reverse translation of the noted clinical therapeutic effects, we used an auxilin knockout model of Parkinson's disease where Ariadne rescued severe motor deficits in this mouse line, on par with the effects of l-DOPA, a notable finding considering Ariadne's lack of activity at dopamine receptors and transporters. Ariadne emerges as a prototype of a new drug class, non-hallucinogenic 5-HT_2A agonists, with considerable therapeutic potential across psychiatric and neurological indications.

Management of Intracranial Sinusitis Complications in Children and Adolescents: Similarities and Differences Among Otolaryngology Subspecialists

The purpose of this study was to compare the management of intracranial sinusitis complications in pediatric patients between members of the American Rhinologic Society (ARS) and the American Society of Pediatric Otolaryngology (ASPO). A cross-sectional web-based survey was distributed twice to the ASPO and ARS membership over an 8-month period. The overall survey response rate was 12.1% (7.5% of ARS members and 17.3% of ASPO members). Recommended management was similar with respect to the use of intravenous antibiotics, nasal saline irrigations, topical decongestants, and nasal steroid sprays. Recommendations diverged with regards to systemic steroid use and urgent/emergent endoscopic sinus surgery (ESS). ARS members were more likely to recommend systemic corticosteroids. ASPO members were more likely to recommend immediate ESS. Based on survey responses, we found differences in practice patterns among subspecialists, which indicates additional collaborative research between societies is necessary to develop and disseminate evidence-based guidelines for these patients.

Level of Evidence: 4

Charles F. Ferguson, MD: America's first full time pediatric otolaryngologist

This historical review highlights the career of Charles F. Ferguson, MD for whom the annual clinical science awards bestowed by the American Society of Pediatric Otolaryngology are named. Dr. Ferguson was the first full time pediatric otolaryngologist in the United States. His career at Boston Children's Hospital spanned almost four decades. Disorders of the larynx, trachea and bronchi were his principal professional focus, with a specific expertise in bronchoesophagology. His pioneering work in pediatric airway endoscopy and the development of techniques to diagnose congenital airway malformations led to his receipt of the Chevalier Jackson Award from the American Bronchoesophagological Association, and the James Newcomb Award from the American Laryngological Society. He notably edited the first Pediatric Otolaryngology textbook in 1972. His life's work help set the foundation for the creation of the American Society of Pediatric Otolaryngology in 1984, six years following his retirement. The Charles Ferguson Clinical Science Awards were established to sustain his legacy.

Utility of DNA barcoding in native Oreochromis species

The importance of Oreochromis in worldwide aquaculture and regional fisheries motivates the study of their genetic diversity in their native range. In this article, all mitochondrial cytochrome c oxidase subunit I gene (COI) sequences of Oreochromis species are retrieved from Barcode of Life Data system to quantify the available DNA barcoding information from wild individuals collected within the native ranges of the respective species. It is found that 70% of the known species in the genus still lack a COI barcode, and only 15% of the available sequences are from within the respective native ranges. Many of the available sequences have been produced from specimens acquired from aquaculture and introduced, naturalized populations, making the assessment of variation within the original native range challenging. Analyses of the wild-collected fraction of available sequences indicated the presence of cryptic lineages within Nile tilapia Oreochromis niloticus and O. schwebischi, the occurrence of potential introgressive hybridization between O. niloticus and blue tilapia O. aureus, and potential ancestral polymorphism between Karonga tilapia O. karongae and black tilapia O. placidus. This article also reports a case of misidentification of O. mweruensis as longfin tilapia O. macrochir. These results stress the importance of improving the knowledge of genetic variation within the native ranges of Oreochromis species for better-informed conservation of these natural resources.

Contemporary Management of Vascular Anomalies of the Head and Neck-Part 1: Vascular Malformations: A Review

Importance

Vascular anomalies of the head and neck are relatively rare lesions. Management is challenging because of the high likelihood of involvement of functionally critical structures. Multiple modalities of treatment exist for vascular anomalies of the head and neck, including medical therapies, sclerotherapy and embolization procedures, and surgery. This review focuses on the accurate diagnosis and the relative roles of the various therapeutic options.

Observations

Vascular anomalies are classified by the International Society for the Study of Vascular Anomalies into 2 major groups: vascular tumors and vascular malformations. Vascular tumors encompass proliferative lesions ranging from infantile and congenital hemangiomas to kaposiform hemangioendothelioma. Alternatively, vascular malformations are embryologic errors in vasculogenesis. This article focuses on the management of vascular malformations. The 3 primary vascular malformation subclassifications are lymphatic, venous, and arteriovenous. The burden of disease, diagnosis, and current management options are discussed in detail for each subtype.

Conclusions and Relevance

Most vascular malformations of the head and neck require a multidisciplinary approach. Available medical, interventional radiologic, and surgical interventions are constantly evolving. Optimization of function and cosmesis must be balanced with minimization of treatment-associated morbidity. Otolaryngologists-head and neck surgeons must remain up to date regarding options for diagnosis and management of these lesions.

Postoperative Disposition Following Pediatric Sistrunk Procedures: A National Database Query

OBJECTIVE/HYPOTHESIS

Variability exists in the postoperative disposition of children following Sistrunk procedures. Management options include discharge home versus overnight observation, with the latter allowing monitoring for immediate postoperative complications, presumably reducing the need for subsequent readmission. This study investigates the association between overnight observation and ambulatory management of children undergoing Sistrunk procedures and relevant postoperative complication and revisit rates to clarify best practice for these patients.

METHODS

This was a retrospective database review using the Pediatric Health Information System database from 2007 to 2016.

RESULTS

The cited dataset identified 6,434 qualifying patients, categorized into ambulatory versus overnight observation cohorts. The overall 30-day revisit rate was 4.9%; the revisit rate with overnight observation (6.1%) was higher than for ambulatory patients (3.8%, adjusted odds ratio (OR) 1.60; 95% confidence interval (CI): 1.21, 2.12). Revisit rates were significantly higher in patients 2 years of age or younger compared to older patients (6.7% vs. 4.3%). The rates of return to the operating room for the observation versus ambulatory groups were 1.8% and 0.5%, respectively. Cervical fluid collection and neck swelling were among the most common revisit indications in both groups, with a mean time to presentation of 9 days.

CONCLUSIONS

This study demonstrates that ambulatory management following a Sistrunk procedure is not associated with increased rates of common postoperative complications, readmission, or need for secondary surgical intervention. A Sistrunk procedure may be safely performed on an ambulatory basis in select cases.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E2352-E2355, 2021.

International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA)

OBJECTIVE

To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea.

METHODS

A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG).

RESULTS

Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA.

CONCLUSION

The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA.

COVID19: a case report of thrombus in transit

BACKGROUND

The global pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused significant morbidity and mortality, not only through devastating lung injury, but also due to multiple malfunctions in the cardiovascular system. The primary aetiology is believed to be mediated through lung alveolar injury; however, a few published reports have linked SARS-CoV-2 to significant organ dysfunction, venous thrombo-embolism, and coagulopathy. In view of the fact that the utility of tissue plasminogen activator in this population is not well studied, we present this case of rapid improvement in oxygenation after successful lytic therapy for thrombus in transit in this patient with SARS-CoV-2.

CASE SUMMARY

We discuss a patient admitted with SARS-CoV-2 pneumonia. Due to the development of dramatic hypoxia, he underwent echocardiography which demonstrated extensive thrombus in transit. He received successful thrombolytic therapy with tissue plasminogen activator, with subsequent improvement in oxygenation. The patient was successfully discharged home on 2 L of oxygen via nasal cannula, and continues to improve at follow-up with his cardiologist and primary care physician.

CONCLUSION

This case not only highlights embolic causes of hypoxia in SARS-CoV-2, but demonstrates the important utility of an echocardiogram and tissue plasminogen activator in this population.

Theoretical Framework of a Polydisperse Cell Filtration Model

Filtration via a porous medium is a ubiquitous process where high-fidelity physical models are needed. The classical cell model oversimplifies the filtration medium and results in biased and inaccurate predictions of the filter performance. This paper presents the discrete framework of a polydisperse cell model that can incorporate any measured pore size distribution. A new equation connecting the polydisperse cell efficiencies and the medium efficiency is derived from first principles. For ceramic filters, the discrete model demonstrates a generic prediction capability of the filtration efficiency with a root-mean-squared difference of 5.4%, while the counterpart of the classical cell model is 26.4%. In addition, the discrete model eliminates the biased predictions of the classical cell model on sub-100 nm particles.

Pediatric Subperiosteal Abscess Secondary to Acute Sinusitis: A Systematic Review and Meta-analysis

OBJECTIVES/HYPOTHESIS

The surgical versus medical management of subperiosteal abscess can be controversial. The purpose of this study was to summarize current literature and provide pooled analyses to help direct management decisions.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Patients <18 years old with subperiosteal abscess secondary to acute sinusitis were reviewed, and a meta-analysis was conducted. Studies including five or more patients written in English were the primary search focus.

RESULTS

Thirty-eight studies met inclusion criteria for the systematic review, and seven studies contained sufficient data for the meta-analysis. A total of 1,167 patients between the ages of 10 days and 18 years were included. Eleven sign/symptom categories were identified, with restricted ocular motility (n = 289, 45.9%), proptosis (n = 277, 44%), and fever (n = 223, 35.4%) being most frequent. Staphylococcus aureus was the most common pathogen isolated from cultures. Patients with abscess volume greater than the threshold specified in each individual study were over three times more likely to require surgical intervention compared to those with smaller abscess volume (pooled risk ratio [RR] = 3.61, 95% confidence interval [CI]: 2.40-5.44). Proptosis and gaze restriction also significantly predicted surgical intervention (pooled RR = 1.65: 95% CI: 1.29-2.12 for proptosis/pooled RR = 1.90; 95% CI: 1.20-3.00 for gaze restriction).

CONCLUSIONS

Approximately half of patients with a subperiosteal abscess undergo surgical drainage. Abscess volume appears to be the most significant predictive risk factor. Detailed data from future studies regarding radiologic and ophthalmologic parameters are needed to provide more definitive values predictive of which patients are likely to fail medical therapy.

LEVEL OF EVIDENCE

2a Laryngoscope, 2020.

Advanced practice providers and children's hospital-based pediatric otolarynology practices

INTRODUCTION

Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting.

METHODS

Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice.

RESULTS

A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale.

DISCUSSION

The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

To drain or not to drain following a Sistrunk procedure: A dual institutional experience

INTRODUCTION

A Sistrunk procedure is the standard operative management of patients with thyroglossal duct cysts. Drain placement is commonly employed with the goal of reducing postoperative complications. This study investigates the association between drain use and relevant postoperative complications following pediatric Sistrunk procedures.

METHODS

Retrospective cohort study evaluating 295 pediatric patients treated between 2007 and 2016 at two tertiary care children's hospitals.

RESULTS

The mean age of the study population was 5.6 years (SD 4.0). A drain was utilized in 234 cases (79.3%). The mean procedural duration was 108 min (SD 48), and significantly longer in patients receiving a drain. Early postoperative complications included seroma (5.8%), secondary infection (3.4%), wound breakdown (2.0%) and hematoma (0.3%). The risk of such complications did not significantly differ between patients without drain placement (9.8%) versus those who underwent surgical drain placement (12.0%) after accounting for age and history of preoperative infection (adjusted RR = 0.86; 95% CI: 0.37, 1.98; p = 0.72). In the subgroup analysis, findings were consistent across institutions, age category, history of infection, and primary versus secondary procedure.

CONCLUSION

This dual institutional study found drain placement during a Sistrunk procedure may not reduce rates of common postoperative complications, even in longer duration cases in which a drain is more frequently placed. This data suggests a Sistrunk procedure may be safely performed without drain placement in select cases.

Otolaryngologic Manifestations of Klippel-Feil Syndrome in Children

Importance

Children with Klippel-Feil syndrome (KFS), characterized principally by abnormal fusion of 2 or more cervical vertebrae, may have many additional congenital anomalies. The overall prevalence of otolaryngologic manifestations among patients with KFS has not been previously characterized.

Objective

To define the otolaryngologic diagnoses made and procedures performed in 95 patients with KFS, which, to our knowledge, is the largest series of this challenging patient population published to date.

Design, Setting, and Participants

For this retrospective review, all patients with KFS who underwent otolaryngology consultation at our institution over a 26-year period (January 1989 to December 2015) were included. Patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and were confirmed through individual medical record review. Relevant otolaryngologic diagnoses and procedures were extracted using ICD-9 and Current Procedural Terminology codes, respectively. Selected demographics included age, sex, number of clinic visits, and number of procedures.

Main Outcomes and Measures

The primary outcomes were the otolaryngologic diagnoses and procedures associated with the KFS patient population; the secondary outcome was Cormack-Lehane classification documented during airway procedures.

Results

Overall, 95 patients with KFS were included in this study (55 males [58%] and 40 females [42%]); mean (range) age at time of presentation to the otorhinolaryngology clinic was 5.8 (birth-23.0) years. Each patient with KFS averaged 8 visits to the otorhinolaryngology office and 5 otolaryngologic diagnoses. The most common diagnosis was conductive hearing loss (n = 49 [52%]), followed by sensorineural hearing loss (n = 38 [40%]), and dysphagia (n = 37 [39%]). Sixty-two (65%) patients underwent otolaryngologic procedures, with 44 (46%) undergoing multiple procedures. The most common procedure was tympanostomy tube placement (n = 36 [38%]), followed by office flexible endoscopy (n = 23 [24%]). Twelve of the 20 patients who underwent direct laryngoscopy had documented Cormack-Lehane classification; 5 of 12 patients (42%) had a compromised view (grade 2, 3, or 4) of the larynx. Three patients required tracheotomies at this institution for airway stabilization purposes; each had severe upper airway obstruction leading to respiratory failure.

Conclusions and Relevance

Patients with KFS require consultation for a variety of otolaryngologic conditions. Among these, hearing loss is the most common, but airway issues related to cervical spine fusion are the most challenging. Formulating an appropriate care plan in advance is paramount, even for routine otolaryngology procedures.

Balloon Sinuplasty Utilization in the Pediatric Population: A National Database Perspective

OBJECTIVE

Balloon sinuplasty (BS) is a surgical management option in the treatment of chronic rhinosinusitis. The purpose of this study was to examine BS utilization among children with a national database.

STUDY DESIGN

Retrospective review.

SETTING

National pediatric database.

SUBJECTS AND METHODS

All cases of children aged ≤18 years who underwent BS or traditional endoscopic sinus surgery (ESS) 5 years before and after the introduction of BS billing codes were studied with the Pediatric Health Information System database. We evaluated overall trends, demographics, performing physicians, readmissions, and cost data.

RESULTS

A total of 14,079 patients met inclusion criteria: 13,555 underwent traditional ESS and 524 had a BS procedure. There was no significant increase in BS rates between 2011 and 2016. BS was more commonly performed among younger children than ESS (median age [interquartile range], 6 years [4-10] vs 9 years [6-13]; P < .001). There were 23 (4.4%) readmissions within 30 days in the balloon cohort versus 474 (3.5%) in the ESS cohort. The median cost of balloon maxillary antrostomy (US $6560 [$5420-$8250]) was higher than that of traditional maxillary antrostomy (US $5630 [$4130-$7700], P < .001). Physicians who performed BS had a larger volume of ESS procedures when compared with those who did not perform BS.

CONCLUSION

Rates of BS performance in the pediatric population have not increased over time. Results showed no difference in readmission rates between BS and ESS. BS was associated with higher costs as compared with ESS. The role of BS in the pediatric chronic rhinosinusitis population remains unclear.

The Genetic and Molecular Determinants of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review

Objective:

Juvenile nasopharyngeal angiofibroma (JNA) is a rare vascular tumor of unknown etiology. Studies investigating the molecular and genetic determinants of JNA are limited by small sample size and inconsistent approaches. The purpose of this study is to examine all eligible JNA studies in aggregate, applying qualitative analysis to highlight areas of particular relevance, including potential targets for therapeutic intervention.

Methods:

The PubMed, MEDLINE, Embase, Web of Science, Cochrane, and CINAHL databases were screened with inclusion and exclusion criteria applied to all citations. Manuscripts investigating the genetic determinants, histopathogenesis, and heritability of juvenile nasopharyngeal angiofibroma were included. Non-English studies, case reports, and articles focusing on clinical management without original data were excluded. Full text articles were obtained. A qualitative synthesis of data was performed.

Results:

A total of 59 articles met criteria for inclusion. These were divided into 6 categories based on the primary topic or target discussed, (1) steroid hormone receptors, (2) chromosomal abnormalities, (3) growth factors, (4) genetic targets, (5) molecular targets, (6) Wnt cell signaling, and (7) studies that overlapped multiple of the aforementioned categories. Although relatively low n values prevent definitive conclusions to be drawn, a predominance of certain molecular targets such as vascular endothelial growth factor (VEGF) and Wnt/β-catenin pathway intermediaries is apparent.

Conclusions:

Although the etiology of JNA remains elusive, contemporary molecular genetic investigation holds promise for risk stratification and could form the basis of a modernized staging system. A multicenter clinical registry and linked tissue bank would further promote the search for JNA specific biomarkers.

Mucoepidermoid carcinoma of the head and neck in children

INTRODUCTION

Mucoepidermoid carcinoma is a rare malignant salivary gland neoplasm in the pediatric population. Few studies have discussed best practice with respect to diagnosis and treatment in children.

OBJECTIVE

To present our institution's experience with the evaluation and management of pediatric mucoepidermoid carcinoma of the head and neck.

METHODS

Retrospective chart review of patients under 20 years of age diagnosed with mucoepidermoid carcinoma of the head and neck between 1998 and 2017. Data assessed includes demographics, clinical presentation, imaging examinations, histopathology, treatment, complications, local recurrence, distant metastasis, and follow-up.

RESULTS

Sixteen patients (10 female, 6 male) were identified with a median age of 12.9 (IQR: 10.9-15.0) years. Tumors were located within the parotid gland (n = 11, 68.8%), accessory lobe of the parotid gland (n = 2, 12.5%), palate (n = 2, 12.5%), and submandibular region (n = 1, 6.3%). In 9 patients (56.3%) a neoplastic etiology was suspected based on the clinical and/or radiographic findings and confirmed pathologically on biopsy or excision. All patients were treated surgically and five patients required adjuvant radiotherapy. One patient had recurrence requiring re-excision. Seven patients (43.8%) had transient facial paresis post-operatively and one had Frey syndrome. Median follow-up time was 59.7 months (IQR: 18.9-99.3).

CONCLUSION

The malignant nature of mucoepidermoid carcinoma requires comprehensive, multidisciplinary management. Imaging and tissue sampling by fine needle aspiration give clinicians the best insight into location and nature of the mass. Complete surgical excision with attention to preservation of facial nerve and achieving negative margins is desired.

Population diversity and relatedness in Sugarbirds (Promeropidae: Promerops spp.)

Sugarbirds are a family of two socially-monogamous passerine species endemic to southern Africa. Cape and Gurney’s Sugarbird (Promerops cafer and P. gurneyi) differ in abundance, dispersion across their range and in the degree of sexual dimorphism in tail length, factors that affect breeding systems and potentially genetic diversity. According to recent data, P. gurneyi are in decline and revision of the species’ IUCN conservation status to a threatened category may be warranted. It is therefore necessary to understand genetic diversity and risk of inbreeding in this species. We used six polymorphic microsatellite markers and one mitochondrial gene (ND2) to compare genetic diversity in P. cafer from Helderberg Nature Reserve and P. gurneyi from Golden Gate Highlands National Park, sites at the core of each species distribution. We describe novel universal avian primers which amplify the entire ND2 coding sequence across a broad range of bird orders. We observed high mitochondrial and microsatellite diversity in both sugarbird populations, with no detectable inbreeding and large effective population sizes.

Trends in Pediatric Otolaryngology Disparities Research

Objectives To describe trends in disparities research within pediatric otolaryngology as evidenced by major meeting presentations and to compare observed trends with those in the realm of patient safety and quality improvement (PSQI). Study Design Retrospective review of presentations at national otolaryngology meetings. Setting Online review of meeting programs. Subjects and Methods Meeting programs from the American Society of Pediatric Otolaryngology, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery Foundation, and Society for Ear, Nose and Throat Advances in Children from 2003 to 2016 were manually searched for pediatric oral and poster presentations addressing disparities and socioeconomic determinants of health, as well as PSQI. Presentation frequency was compared between categories and within each category over time. Results Of 11,311 total presentations, 3078 were related to the pediatric population, and 1945 (63.2%) of those were oral presentations. Disparities-related presentations increased from 0 in 2003 to 17 in 2016. From 2003 to 2009, 9 of 656 (1.4%) presentations involved disparities, as opposed to 70 of 2422 (2.9%) from 2010 to 2016 ( P = .03). The proportion of presentations regarding PSQI also increased: from 42 of 656 (6.4%) in 2003-2009 to 221 of 2422 (9.1%) in 2010-2016 ( P = .01). PSQI presentations remain more common than disparities presentations (9.1% vs 2.9%, P < .001). Conclusion Health care disparities are increasingly addressed in pediatric otolaryngology meeting presentations. Compared with the well-established realm of PSQI, disparities research remains nascent but is gaining attention. Health care reform and quality improvement efforts should recognize the role of socioeconomic factors and include strategies for addressing disparities.

Changes in Scope of Procedures Performed by Pediatric Otolaryngologists in the Past Decade

Importance

Monitoring current trends in pediatric otolaryngology will help adjust our training and practice paradigms in a way that ensures the long-term viability of the specialty.

Objectives

To gauge the current scope of pediatric otolaryngology (ORL) practice within and outside of the United States and to identify changes in caseload over the past decade.

Design, Setting, and Participants

An online survey was sent to pediatric ORL chairs and/or fellowship directors at 42 institutions in the United States and abroad. For 59 procedures, respondents were asked to estimate the percentage of cases performed by their department, determine whether this percentage has changed over the past 10 years (2006-2016), and identify any other specialties performing the procedure. Data were collected during a 2-week period in October 2016, from October 7 through 21, and analyzed from November 2016 through February 2017.

Main Outcomes and Measures

Main outcomes included the percentage of operations currently performed by the respondent's department for each procedure; whether this percentage has decreased, increased, or remained the same over the past decade; other specialties that perform each procedure; and any procedures added to or eliminated from the respondent's practice over the past decade.

Results

Respondents from 33 of the 42 academic institutions completed the survey (23 in the United States and 10 international; 79% response rate). Respondents reported the least involvement in procedures pertaining to facial plastic and reconstructive surgery, aerodigestive endoscopy, and congenital anomalies. Conversely, a mean (SD) of 91% (7%) reported performing 90% to 100% of otology, airway, rhinology, and general procedures. A mean (SD) of 82% (11%) reported that their department's involvement in each procedure has remained the same from 2006 to 2016.

Conclusions and Relevance

The specialty of pediatric ORL has evolved over the past decade. There has been a notable decline in involvement in facial plastic and reconstructive surgery and treatment of vascular malformations and esophageal disorders. The management of thyroid disease is in flux. Monitoring current trends to adjust training and practice paradigms will ensure the long-term viability of the specialty.

Exploring the phylogeography of a hexaploid freshwater fish by RAD sequencing

The KwaZulu‐Natal yellowfish (Labeobarbus natalensis) is an abundant cyprinid, endemic to KwaZulu‐Natal Province, South Africa. In this study, we developed a single‐nucleotide polymorphism (SNP) dataset from double‐digest restriction site‐associated DNA (ddRAD) sequencing of samples across the distribution. We addressed several hidden challenges, primarily focusing on proper filtering of RAD data and selecting optimal parameters for data processing in polyploid lineages. We used the resulting high‐quality SNP dataset to investigate the population genetic structure of L. natalensis. A small number of mitochondrial markers present in these data had disproportionate influence on the recovered genetic structure. The presence of singleton SNPs also confounded genetic structure. We found a well‐supported division into northern and southern lineages, with further subdivision into five populations, one of which reflects north–south admixture. Approximate Bayesian Computation scenario testing supported a scenario where an ancestral population diverged into northern and southern lineages, which then diverged to yield the current five populations. All river systems showed similar levels of genetic diversity, which appears unrelated to drainage system size. Nucleotide diversity was highest in the smallest river system, the Mbokodweni, which, together with adjacent small coastal systems, should be considered as a key catchment for conservation.

Resident responses to after-hours otolaryngology patient phone calls: An overlooked aspect of residency training?

OBJECTIVES/HYPOTHESIS

Otolaryngology residents are often responsible for triaging after-hours patient calls. However, residents receive little training on this topic. Data are limited on the clinical content, reporting, and management of otolaryngology patient calls. This study aimed to characterize the patient concerns residents handle by phone and their subsequent management and reporting.

STUDY DESIGN

Retrospective review.

METHODS

Five hundred consecutive after-hours patient calls in a tertiary pediatric hospital were reviewed. Data collected included patient and caller demographics, clinical concerns, surgical history, recommendations, and subsequent emergency department (ED) visits.

RESULTS

On average, 3.7 calls occurred per shift, 2.8 on weekday and 5.9 on weekend shifts. Mean patient age was 6.6 years. Mothers (71%) called most frequently. The majority of calls were postoperative (64.2%). Of postoperative calls, most occurred within 3 days of surgery (52.3%). Most calls were for surgical site bleeding (19.9%). Residents recommended ED evaluation for 17.2% of calls, of which 20.9% returned to the primary institution ED. ED evaluation was recommended more frequently for postoperative patients (P = .040), particularly following adenotonsillectomy (51.2%) or surgical site bleeding (18.6%). With respect to documentation, 32.8% of medical record numbers were absent, 11.8% had name errors, and 2.2% of patients could not be identified.

CONCLUSIONS

This is the first study to analyze the management and reporting of patient calls by otolaryngology residents. A wide array of clinical concerns are triaged by phone conversations. The study has implications for both resident and patient education.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:E163-E170, 2018.

Emergency department use for acute rhinosinusitis: Insurance dependent for children and adults

OBJECTIVES/HYPOTHESIS

Patients with Medicaid or self-pay insurance status are more likely to present to the emergency department (ED) for uncomplicated acute rhinosinusitis (ARS). Our aim was to determine if this pattern holds true for both pediatric and adult visits.

STUDY DESIGN

Cross-sectional study using the 2005 to 2012 National Hospital Ambulatory Medical Care Surveys and National Ambulatory Medical Care Surveys.

METHODS

We included all visits with International Classification of Diseases, Ninth Revision codes for ARS and without codes for ARS complications. We tested for associations between insurance type and presentation to an ED versus a primary care physician (PCP), stratifying children versus adults. We used univariate and multivariable logistic regression modeling, controlling for clinical and demographic characteristics for analysis.

RESULTS

There were 51,579,977 uncomplicated ARS visits to PCPs (48,213,335 visits) and EDs (3,366,642 visits). Medicaid and uninsured patients were under-represented for ARS visits. Medicaid insurance was significantly associated with ED presentation for ARS for both children (adjusted odds ratio [OR] = 7.0, P < 0.001) and adults (adjusted OR = 6.8, P < 0.001). Children with ARS and self-pay insurance status were much more likely to present to the ED (adjusted OR = 48.8, P < 0.001) than adults (adjusted OR = 5.2, P < 0.001); this difference between children and adults with self-pay insurance was significant (P = 0.001).

CONCLUSION

With respect to absolute numbers of visits, patients with Medicaid or no insurance use less care overall for uncomplicated ARS than do privately insured patients. Medicaid is associated with ED presentation for ARS for pediatric and adult visits. Self-pay insurance status is strongly associated with ED presentation for adult and pediatric visits, and is significantly more common for children. These results suggest limitations in primary care access for uncomplicated ARS based on insurance status, particularly for uninsured pediatric patients.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:299-303, 2018.

Isotretinoin Monitoring Trends: A National Survey of Dermatologists

<p>BACKGROUND: Isotretinoin is an effective treatment for nodulocystic acne. Outside of required pregnancy testing, laboratory monitoring suggested by the manufacturers is vague. Dermatologists, therefore, monitor a variety of tests with variable frequency. Despite intense monitoring, the majority of patients do not have gross laboratory abnormalities that warrant changes in management.</p> <p>OBJECTIVE: To survey US dermatologists regarding laboratory monitoring practices while prescribing isotretinoin.</p> <p>METHODS: An online survey sent via e-mail to members of the American Academy of Dermatology.</p> <p>RESULTS: 12,396 surveys were sent with a response rate of ~19%. At baseline >60% of responders check a CBC, LFTs, and a lipid panel. 74% check a monthly lipid panel and LFTs, while 57% check a monthly CBC. 75% report stopping isotretinoin when AST or ALT values reach 3 times normal; 89% report stopping at 4 times normal. When triglycerides reach 4 times normal, 72% stop the medication.</p> <p>CONCLUSIONS: There is no consensus on isotretinoin monitoring tests and frequency, though the majority of dermatologists surveyed monitor a lipid panel and LFTs.</p> <p><em>J Drugs Dermatol. 2017;16(6):557-564.</em></p>.

Life on the rocks: Multilocus phylogeography of rock hyrax (Procavia capensis) from southern Africa

Understanding the role of geography and climatic cycles in determining patterns of biodiversity is important in comparative and evolutionary biology and conservation. We studied the phylogeographic pattern and historical demography of a rock-dwelling small mammal species from southern Africa, the rock hyrax Procavia capensis capensis. Using a multilocus coalescent approach, we assessed the influence of strong habitat dependence and fluctuating regional climates on genetic diversity. We sequenced a mitochondrial gene (cytochrome b) and two nuclear introns (AP5, PRKC1) supplemented with microsatellite genotyping, in order to assess evolutionary processes over multiple temporal scales. In addition, distribution modelling was used to investigate the current and predicted distribution of the species under different climatic scenarios. Collectively, the data reveal a complex history of isolation followed by secondary contact shaping the current intraspecific diversity. The cyt b sequences confirmed the presence of two previously proposed geographically and genetically distinct lineages distributed across the southern African Great Escarpment and north-western mountain ranges. Molecular dating suggests Miocene divergence of the lineages, yet there are no discernible extrinsic barriers to gene flow. The nuclear markers reveal incomplete lineage sorting or ongoing mixing of the two lineages. Although the microsatellite data lend some support to the presence of two subpopulations, there is weak structuring within and between lineages. These data indicate the presence of gene flow from the northern into the southern parts of the southern African sub-region likely following the secondary contact. The distribution modelling predictably reveal the species' preference for rocky areas, with stable refugia through time in the northern mountain ranges, the Great Escarpment, as well as restricted areas of the Northern Cape Province and the Cape Fold Mountains of South Africa. Different microclimatic variables appear to determine the distributional range of the species. Despite strong habitat preference, the micro-habitat offered by rocky crevices and unique life history traits likely promoted the adaptability of P. capensis, resulting in the widespread distribution and persistence of the species over a long evolutionary period. Spatio-temporal comparison of the evolutionary histories of other co-distributed species across the rocky landscapes of southern Africa will improve our understanding of the regional patterns of biodiversity and local endemism.

Cystic cervical teratoma: A diagnostic and management challenge

Cervical teratomas are relatively rare congenital tumors pathologically defined by their three germ cell layer composition. Classically they manifest as solid or mixed solid-cystic lesions. Purely cystic teratomas pose a diagnostic challenge due to their clinical and radiologic similarity to lymphatic vascular malformations. Sclerotherapy, rather than operative excision, may be offered as therapy. We present an unusual cystic neck mass to highlight this dilemma.

Surgical scheduling categorization system (SSCS): A novel classification system to improve coordination and scheduling of operative cases in a tertiary pediatric medical system

OBJECTIVE

To describe a surgical categorization system to create a universal nomenclature, delineating patient complexity as a first step toward developing a true risk stratification system.

METHODS

Retrospective database review of all otolaryngology surgical procedures performed in a tertiary pediatric hospital system over one academic year (July 2012-June 2013). All otolaryngology surgical procedures were reviewed, encompassing 8478 procedures on 5711 patients. The attending otolaryngologist assigned surgical scheduling category (SSCS) at the time of case booking based on an institution specific guidelines. The guidelines are as follow: Category I was assigned to American Society of Anesthesiologists physical status classification (ASA) I/II patients, designating them appropriate for institution's suburban ambulatory surgery centers; Category II was ASA I/II patients with social or transportation issues; Category III was ASA I/II patients who required case coordination with other medical or surgical departments; Category IV was reserved for patients of any ASA class whom the surgeon designated to be of a higher complexity.

RESULTS

8478 total procedures analyzed with 7198 having complete records. 48% were Category I, 13.6% were Category II, 1.9% were Category III and 36.5% were Category IV. The ASA were 34.7% ASA I, 50% ASA II, 13.39% ASA III, and 1.9% ASA IV. Although the largest proportion of patients were ASA II (50%), 39.6% of all ASA II were Category IV. Category IV was split into 54.2% ASA II and 34% ASA III and shows that peri-operative surgical concerns were not encompassed by the ASA system.

CONCLUSION

This surgical categorization system streamlines surgical scheduling in a tertiary pediatric hospital system, particularly with respect to the designation of cases as ambulatory surgery center or main operating room appropriate. The case mix complexity is also readily apparent, enhancing recognition of the coordination and attention required for the perioperative management of high complexity patients. The SSCS helps convey concerns not addressed by ASA physical status alone.

Nasal versus tracheobronchial biopsies to diagnose primary ciliary dyskinesia: A meta-analysis

OBJECTIVES/HYPOTHESIS

To systematically review the literature regarding the efficacy of different biopsy sites and methods to obtain an adequate ciliary sample for ultrastructural examination with electron microscopy (EM) for the diagnosis of primary ciliary dyskinesia (PCD).

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A literature search was conducted with respect to the diagnosis of PCD. English studies with five or more subjects were included. Successful biopsy was defined as an adequate ciliary sample to make or exclude the diagnosis of PCD.

RESULTS

Eight studies met inclusion criteria. These studies included 1,993 patients who underwent 2,299 ciliary biopsies. Included studies were level 3 or 4 evidence. The weighted pooled proportion of obtaining an adequate specimen from a nasal biopsy was 76% (95% confidence interval [CI], 64%-86%) versus 66% (95% CI, 62%-69%) for a tracheobronchial site (P = 0.10). The pooled proportion of obtaining an adequate sample was 68% for both brush and forceps biopsy groups (95% CI, 58%-77% and 54%-81%, respectively). Nasal scraping yielded a higher proportion of adequate specimens (pooled proportion of 92%; 95% CI, 82%-99%) than other techniques (P = 0.002).

CONCLUSION

Tissue biopsy is one component of diagnosing PCD. We found no significant difference between biopsy sites in terms of obtaining an adequate ciliary sample for EM evaluation. This suggests that nasal biopsy should be preferred for patients old enough to tolerate an office biopsy without the need for general anesthesia. The merits of nasal versus tracheobronchial biopsy in the operating room depend more on the risks and benefits of the procedure being performed.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:6-13, 2017.

Measuring Nontechnical Aspects of Surgical Clinician Development in an Otolaryngology Residency Training Program

IMPORTANCE

Surgical competency requires sound clinical judgment, a systematic diagnostic approach, and integration of a wide variety of nontechnical skills. This more complex aspect of clinician development has traditionally been difficult to measure through standard assessment methods.

OBJECTIVE

This study was conducted to use the Clinical Practice Instrument (CPI) to measure nontechnical diagnostic and management skills during otolaryngology residency training; to determine whether there is demonstrable change in these skills between residents who are in postgraduate years (PGYs) 2, 4, and 5; and to evaluate whether results vary according to subspecialty topic or method of administration.

DESIGN, SETTING, AND PARTICIPANTS

Prospective study using the CPI, an instrument with previously established internal consistency, reproducibility, interrater reliability, discriminant validity, and responsiveness to change, in an otolaryngology residency training program. The CPI was used to evaluate progression in residents' ability to evaluate, diagnose, and manage case-based clinical scenarios. A total of 248 evaluations were performed in 45 otolaryngology resident trainees at regular intervals. Analysis of variance with nesting and postestimation pairwise comparisons were used to evaluate total and domain scores according to training level, subspecialty topic, and method of administration.

INTERVENTIONS

Longitudinal residency educational initiative.

MAIN OUTCOMES AND MEASURES

Assessment with the CPI during PGYs 2, 4, and 5 of residency.

RESULTS

Among the 45 otolaryngology residents (248 CPI administrations), there were a mean (SD) of 5 (3) administrations (range, 1-4) during their training. Total scores were significantly different among PGY levels of training, with lower scores seen in the PGY-2 level (44 [16]) compared with the PGY-4 (64 [13]) or PGY-5 level (69 [13]) (P < .001). Domain scores related to information gathering and organizational skills were acquired earlier in training, while knowledge base and clinical judgment improved later in residency. Trainees scored higher in general otolaryngology (mean [SD], 72 [14]) than in subspecialties (range, 55 [12], P = .003, to 56 [19], P < .001). Neither administering the examination with an electronic scoring system, rather than a paper-based scoring system, nor the calendar year of administration affected these results.

CONCLUSIONS AND RELEVANCE

Standardized interval evaluation with the CPI demonstrates improvement in qualitative diagnostic and management capabilities as PGY levels advance.

Endoscopic Radiofrequency Ablation–Assisted Resection of Juvenile Nasopharyngeal Angiofibroma

Objectives

To evaluate the feasibility of radiofrequency surgical instrumentation for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and to test the hypothesis that endoscopic radiofrequency ablation–assisted (RFA) resection will have superior intraoperative and/or postoperative outcomes as compared with traditional endoscopic (TE) resection techniques.

Study Design

Case series with chart review.

Setting

Two tertiary care pediatric hospitals.

Subjects and Methods

Twenty-nine pediatric patients who underwent endoscopic transnasal resection of JNA from January 2000 to December 2014.

Results

Twenty-nine patients underwent RFA (n = 13) or TE (n = 16) JNA resection over the 15-year study period. Mean patient age was not statistically different between the 2 groups ( P = .41); neither was their University of Pittsburgh Medical Center classification stage ( P = .79). All patients underwent preoperative embolization. Mean operative times were not statistically different ( P = .29). Mean intraoperative blood loss and the need for a transfusion were also not statistically different ( P = .27 and .47, respectively). Length of hospital stay was not statistically different ( P = .46). Recurrence rates did not differ between groups ( P = .99) over a mean follow-up period of 2.3 years.

Conclusion

There were no significant differences between RFA and TE resection in intraoperative or postoperative outcome parameters.

Disorders and tumors of the salivary glands in children

Salivary gland neoplasms are rare in children. In infants most tumors are benign hemangiomas, with some notable exceptions, such as sialoblastomas. An asymptomatic swelling in the periauricular region is the most common presenting complaint in older children. Approximately 50% of these lesions are malignant, which dictates a thorough diagnostic evaluation by a head and neck surgeon. Surgical excision is the primary treatment modality. Prognosis is primarily determined by histopathologic findings. This review discusses neoplastic lesions of the salivary glands in children, and malignant epithelial tumors in particular.

Regional and socioeconomic disparities in emergency department use of radiographic imaging for acute pediatric sinusitis

BACKGROUND

Acute pediatric sinusitis (APS) is a common complication of pediatric upper respiratory tract infections. Children with all degrees of APS severity may present to emergency departments (EDs) for evaluation and management. This study was designed to analyze the use of imaging in APS presenting to U.S. EDs.

METHODS

A cross-sectional analysis of the 2008 National Emergency Department Sample database was performed. One hundred one thousand six hundred sixty children, aged ≤18 years, assigned at least one ICD9 code for APS were identified. Current procedural terminology codes for sinus plain film radiographs, computed tomography (CT), and magnetic resonance imaging identified children who underwent sinus imaging. Association of performance of sinus imaging was sought with multiple predictor variables including clinicodemographic and hospital characteristics.

RESULTS

The use of any imaging was associated with older age (odds ratio [OR] = 1.07; p < 0.001), male gender (OR = 1.57; p < 0.001), and diagnosis of chronic rhinosinusitis (OR = 2.46; p < 0.001). Imaging was more common in metropolitan teaching (OR = 1.40;0 p < 0.001) and nonteaching (OR = 5.64; p < 0.001) hospitals. Markers of higher socioeconomic status--private health insurance (OR = 1.37; p < 0.001) and higher income level (OR = 1.96; p < 0.001)--were associated with greater use of imaging, especially CT scans.

CONCLUSION

The use of ED imaging in APS is appropriately associated with factors known to be associated with APS complications. However, additional disparities with respect to regional and socioeconomic factors exist. Interventions to eliminate these health care disparities in use of imaging resources may lead to quality improvement in care and outcomes for APS.