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Chiem JL, Hansen EE, Fernandez N, Merguerian PA, Parikh SR, Reece K, Low DK, Martin LD. Transforming into a Learning Health System: A Quality Improvement Initiative. Pediatr Qual Saf 2024; 9:e724. [PMID: 38751896 PMCID: PMC11093568 DOI: 10.1097/pq9.0000000000000724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/21/2024] [Indexed: 05/18/2024] Open
Abstract
Background The Institute of Medicine introduced the Learning Healthcare System concept in 2006. The system emphasizes quality, safety, and value to improve patient outcomes. The Bellevue Clinic and Surgical Center is an ambulatory surgical center that embraces continuous quality improvement to provide exceptional patient-centered care to the pediatric surgical population. Methods We used statistical process control charts to study the hospital's electronic health record data. Over the past 7 years, we have focused on the following areas: efficiency (surgical block time use), effectiveness (providing adequate analgesia after transitioning to an opioid-sparing protocol), efficacy (creating a pediatric enhanced recovery program), equity (evaluating for racial disparities in surgical readmission rates), and finally, environmental safety (tracking and reducing our facility's greenhouse gas emissions from inhaled anesthetics). Results We have seen improvement in urology surgery efficiency, resulting in a 37% increase in monthly surgical volume, continued adaptation to our opioid-sparing protocol to further reduce postanesthesia care unit opioid administration for tonsillectomy and adenoidectomy cases, successful implementation of an enhanced recovery program, continued work to ensure equitable healthcare for our patients, and more than 85% reduction in our facility's greenhouse gas emissions from inhaled anesthetics. Conclusions The Bellevue Clinic and Surgical Center facility is a living example of a learning health system, which has evolved over the years through continued patient-centered QI work. Our areas of emphasis, including efficiency, effectiveness, efficacy, equity, and environmental safety, will continue to impact the community we serve positively.
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Affiliation(s)
- Jennifer L. Chiem
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Elizabeth E. Hansen
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Nicolas Fernandez
- Department of Urology, Seattle Children’s Hospital, Seattle, Wash
- Department of Urology, University of Washington, Seattle, Wash
| | - Paul A. Merguerian
- Department of Urology, Seattle Children’s Hospital, Seattle, Wash
- Department of Urology, University of Washington, Seattle, Wash
| | - Sanjay R. Parikh
- Seattle Children’s Hospital, Seattle, Wash
- Department of Otolaryngology—Head and Neck Surgery, University of Washington, Seattle, Wash
| | - Kayla Reece
- Department of Perioperative Services, Seattle Children’s Hospital, Seattle, Wash
| | - Daniel K. Low
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Lynn D. Martin
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
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Siu JM, Amin SN, Colyer J, Horner C, Bhat A, Bohuta L, Chan T, Dahl JP, Fridgen J, Johnson K, Yip C, Parikh SR. Injection Medialization in Infants with Vocal Fold Immobility Improves Dysphagia. Laryngoscope 2024. [PMID: 38676424 DOI: 10.1002/lary.31462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/25/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Unilateral vocal fold immobility (VFI) is a known cause of morbidity amongst children following congenital heart surgery. Injection medialization (IM) provides medial distraction and improves glottic closure. Limited objective data is available for the effect of IM in young children (<2 years-old) with VFI. METHODS Retrospective case series of infants <2 who underwent IM for VFI after congenital cardiac surgery. Primary outcome was objective reduced risk of aspiration based on Dysphagia and Outcome Severity Scores (DOSS) on Video swallow study (VFSS) performed prior to and within 4 weeks following IM. Secondary analysis included perioperative complications and number of children who were able to avoid NG or G tube placement. RESULTS 17 children <2 years of age had unilateral VFI after congenital cardiac surgery and underwent IM. The median age at time of initial cardiac surgery was 6 days (IQR 3-7). There was no intraoperative or postoperative stridor or associated complications. All 17 patients had preoperative aspiration noted on VFSS. Average swallowing outcomes on VFSS improved after IM with an increase in DOSS score (preop score 3 (IQR 2-4) to postop score 6.5 (IQR 5-7) [P = 0.001]). At 2 months following IM, of the patients who had improvement in swallowing function, 50% (n = 6) were able to feed completely orally, 25% (n = 3) were fed orally with an NG wean, and 3 (25%) had a G tube placed. CONCLUSION Initial results suggest that IM is safe and improves early objective swallowing outcomes in children <2 years old with VFI after congenital cardiac surgery. LEVEL OF EVIDENCE IV Laryngoscope, 2024.
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Affiliation(s)
- Jennifer M Siu
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shaunak N Amin
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jessica Colyer
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Cassie Horner
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Aarti Bhat
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Lyubomyr Bohuta
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Titus Chan
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - John P Dahl
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jennifer Fridgen
- Division of Physical Therapy, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Kaalan Johnson
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Caitlin Yip
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
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Siu JM, Colyer J, Horner C, Bhat A, Bohuta L, Chan T, Dahl JP, Fridgen J, Johnson K, Yip C, Parikh SR. Ultrasound Screening After Cardiac Surgery Shows Vocal Fold Impairment and Predicts Aspiration. Laryngoscope 2024; 134:1939-1944. [PMID: 37615373 DOI: 10.1002/lary.31000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/09/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Vocal fold motion impairment (VFMI) is a known consequence after high-risk cardiac surgery. We implemented a universal laryngeal ultrasound (LUS) screening protocol for VFMI after the Norwood and aortic arch surgery. We hypothesized that LUS would accurately identify VFMI and predict postoperative aspiration. METHODS We implemented a screening algorithm with LUS for patients undergoing high-risk cardiac surgery at a tertiary care pediatric hospital. Positively screened patients underwent flexible nasolaryngoscopy (FNL). Patients with an abnormal FNL underwent a video-fluoroscopic swallow study (VFSS). Patient demographics, length of stay, and swallowing outcomes were assessed. Two-tailed chi square and Wilcoxon rank sum tests were used to assess for differences. RESULTS Sixty-seven patients underwent either Norwood or arch reconstruction over a 16-month period and underwent universal LUS. The average birth weight was 3.24 kg (SD 0.57). Of the 67 patients, VFMI was identified by LUS and 100% confirmed on FNL in 58.21% (n = 39/67) of patients. Aspiration and penetration on VFSS were higher in the group with VFMI as compared with those without VFMI (53.8% vs. 21.4%, p = 0.008). There was no difference in length of stay between patients who did not have a diagnosis of VFMI and those found to have VFMI (41.0 days vs 45.3 days p = 0.73). CONCLUSIONS Universal LUS screening for patients following high-risk cardiac surgery may lead to earlier identification of postoperative VFMI and aspiration. Recognition of VFMI through this universal screening program could lead to earlier interventions and possibly improved swallowing outcomes. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1939-1944, 2024.
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Affiliation(s)
- Jennifer M Siu
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jessica Colyer
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Cassie Horner
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Aarti Bhat
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Lyubomyr Bohuta
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Titus Chan
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - John P Dahl
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jennifer Fridgen
- Division of Physical Therapy, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Kaalan Johnson
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Caitlin Yip
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
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Barbour MC, Amin SN, Friedman SD, Perez FA, Bly RA, Johnson KE, Parikh SR, Richardson CM, Dahl JP, Aliseda A. Surface Reconstruction of the Pediatric Larynx via Structure from Motion Photogrammetry: A Pilot Study. Otolaryngol Head Neck Surg 2024; 170:1195-1199. [PMID: 38168480 PMCID: PMC10960702 DOI: 10.1002/ohn.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/10/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
Endoscopy is the gold standard for characterizing pediatric airway disorders, however, it is limited for quantitative analysis due to lack of three-dimensional (3D) vision and poor stereotactic depth perception. We utilize structure from motion (SfM) photogrammetry, to reconstruct 3D surfaces of pathologic and healthy pediatric larynges from monocular two-dimensional (2D) endoscopy. Models of pediatric subglottic stenosis were 3D printed and airway endoscopies were simulated. 3D surfaces were successfully reconstructed from endoscopic videos of all models using an SfM analysis toolkit. Average subglottic surface error between SfM reconstructed surfaces and 3D printed models was 0.65 mm as measured by Modified Hausdorff Distance. Average volumetric similarity between SfM surfaces and printed models was 0.82 as measured by Jaccard Index. SfM can be used to accurately reconstruct 3D surface renderings of the larynx from 2D endoscopy video. This technique has immense potential for use in quantitative analysis of airway geometry and virtual surgical planning.
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Affiliation(s)
- Michael C Barbour
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Shaunak N Amin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Seth D Friedman
- Center for Respiratory Biology and Therapeutics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Francisco A Perez
- Department of Pediatric Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall A Bly
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Clare M Richardson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Alberto Aliseda
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
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Richardson CM, Walton S, Park JS, Bonilla-Velez J, Bly RA, Dahl JP, Parikh SR, Friedman S, Johnson KE. Multidisciplinary Advanced Surgical Planning for Slide Tracheoplasty Using 3D-Printed Models. Laryngoscope 2024. [PMID: 38450727 DOI: 10.1002/lary.31327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/03/2023] [Accepted: 01/23/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE The objective of this study was to develop and assess multidisciplinary advanced surgical planning (ASP) sessions using three dimensional (3D) printed models for cervicothoracic slide tracheoplasty (CST). We hypothesized that these sessions would improve surgeon confidence, streamline intraoperative planning, and highlight the utility of 3D modeling. METHODS 3D-printed patient-specific trachea models were used in pre-operative ASP sessions consisting of a multidisciplinary case discussion and hands-on slide tracheoplasty simulation. Participants completed a survey rating realism, utility, impact on the final surgical plan, and pre- and post-session confidence. Statistical analysis was performed via Wilcoxon and Kruskal-Wallis tests. RESULTS Forty-eight surveys were collected across nine sessions and 27 different physicians. On a 5-point Likert scale, models were rated as "very realistic", "very useful" (both median of 4, IQR 3-4 and 4-5, respectively). Overall confidence increased by 1.4 points (+/- 0.7, p < 0.0001), with the largest change seen in those with minimal prior slide tracheoplasty experience (p = 0.005). Participants felt that the sessions "strongly" impacted their surgical plan or anticipated performance (median 4, IQR 4-5), regardless of training level or experience. CONCLUSION 3D-printed patient-specific models were successfully implemented in ASP sessions for CST. Models were deemed very realistic and very useful by surgeons across multiple specialties and training levels. Surgical planning sessions also strongly impacted the final surgical plan and increased surgeon confidence for CST. LEVEL OF EVIDENCE IV Laryngoscope, 2024.
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Affiliation(s)
- Clare M Richardson
- Division of Pediatric Otolaryngology - Head & Neck Surgery, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - Scott Walton
- Division of Pediatric Otolaryngology - Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
- Department of Otolaryngology - Head & Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, U.S.A
| | - Jason S Park
- Department of Otolaryngology-Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology - Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
- Department of Otolaryngology - Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Randall A Bly
- Division of Pediatric Otolaryngology - Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
- Department of Otolaryngology - Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - John P Dahl
- Division of Pediatric Otolaryngology - Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
- Department of Otolaryngology - Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Division of Pediatric Otolaryngology - Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
- Department of Otolaryngology - Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Seth Friedman
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Kaalan E Johnson
- Division of Pediatric Otolaryngology - Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
- Department of Otolaryngology - Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
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Feldman RM, O'Reilly-Shah V, Dahl JP, Siu J, Newby M, Sutherland TN, Parikh SR, Jiang T, Franz A. Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single-Center Retrospective Propensity-Matched Study. Otolaryngol Head Neck Surg 2024; 170:928-936. [PMID: 37925621 DOI: 10.1002/ohn.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 09/20/2023] [Accepted: 10/07/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE To determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48 hours. STUDY DESIGN Single-center retrospective propensity-matched study. SETTING Quaternary pediatric hospital and ambulatory surgery center. METHODS Patients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K-) patients were calculated for the total cohort and a 1:1 propensity-matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers. RESULTS There were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity-matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K- patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K- patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72-1.69, P = 0.662) in the propensity-matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K- patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K- patients (OR 1.33, 95% CI 0.63-2.81, P = 0.451) in the propensity-matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses. CONCLUSION Ketorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.
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Affiliation(s)
- Rachel M Feldman
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Vikas O'Reilly-Shah
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Jennifer Siu
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Maxwell Newby
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Tori N Sutherland
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay R Parikh
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Teresa Jiang
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Amber Franz
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
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Allred CM, Nakamura R, Mull H, Wang X, Jio J, Messner J, Parikh SR, Sie K, Bonilla-Velez J. Effect of an Outbound Scheduling Team on the Timeliness of Scheduling Referrals to Pediatric Otolaryngology. Otolaryngol Head Neck Surg 2024. [PMID: 38327234 DOI: 10.1002/ohn.660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 01/08/2024] [Accepted: 01/13/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Families preferring to receive care in a language-other-than-English have disparities in access to care. We studied the effect of implementing an ambulatory outbound scheduling team on the timeliness of scheduling referrals to pediatric otolaryngology. We hypothesized this intervention could increase access to care. STUDY DESIGN Retrospective cohort analysis. SETTING Tertiary care academic center. METHODS Data were abstracted from the hospital's enterprise database for patients referred to Otolaryngology over 3 years (October 2019-August 2022; 7675 referrals). An outbound scheduling team was created April 2021 and tasked with calling out to schedule referrals within one business day of receipt. Referral lag was compared across patient cohorts before and after the scheduling intervention. Log-transformed linear regression models were used to assess the impact of the scheduling intervention on referral lag for language cohorts. RESULTS The median preintervention referral lag was 6 days (interquartile range [IQR] 2-18), which was reduced to 1 day postintervention (IQR 0-5; P < .001). Preintervention language-other-than-English families had a median referral lag of 8 days (IQR 2-23), which was 1.27 times higher than for patients speaking English (P < .001). With implementation of the scheduling intervention, language-other-than-English families were scheduled in a median of 1 day (IQR 0-6), and the disparity in timeliness of scheduling was eliminated (P = .131). Postintervention, referral lag was reduced by 58% in the English and 64% in the language other than English cohorts. CONCLUSION Implementation of an outbound ambulatory scheduling process reduces referral lag for all patients and eliminated a disparity in referral lag for language-other-than-English families.
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Affiliation(s)
- Caleb M Allred
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Rina Nakamura
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Helen Mull
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Xing Wang
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jason Jio
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jack Messner
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kathleen Sie
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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Amin SN, Thompson T, Wang X, Goldklang S, Martin LD, Low DKW, Parikh SR, Sie KC, Dahl JP. Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative. Otolaryngol Head Neck Surg 2024; 170:610-617. [PMID: 37747042 PMCID: PMC10841103 DOI: 10.1002/ohn.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/21/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Postoperative pain is the most common morbidity associated with tonsillectomy. Opioids are frequently used in multimodal posttonsillectomy analgesia regimens; however, concerns regarding respiratory depression, drug-drug interactions, and medication misuse necessitate responsible opioid stewardship among prescribing surgeons. It is unclear if intentionally reducing opioid prescription doses negatively affects the patient experience. METHODS A quality improvement team reviewed all posttonsillectomy opioid prescriptions at a pediatric ambulatory surgery center between January and June 2021 (preintervention, 163 patients). Following this review, we performed an opioid education session for surgeons and studied opioid prescribing habits between July and December 2021 (Plan-Do-Study-Act [PDSA] 1, 152 patients). We then implemented a standardized prescription protocol of 7 doses of oxycodone per patient and again reviewed prescriptions between January and June 2022 (PDSA 2, 178 patients). The following measures were evaluated: initial number of opioid doses prescribed, need for refills, 7-day emergency department (ED) visits, and readmissions. RESULTS Each intervention reduced the average number of initial oxycodone doses per patient (12.2 vs 9.2 vs 6.9 doses, P < .001). There were no changes in the rate of refill requests, 7-day ED visits, and readmissions, by descriptive or Statistical Process Control analyses. DISCUSSION In 2 PDSA cycles, we achieved a 43% reduction in the number of doses of oxycodone prescribed following tonsillectomy. We did not observe any increased rates in balancing measures, which are surrogates for unintentional effects of PDSA changes, including refills, ED presentations, and readmission rates. IMPLICATIONS FOR PRACTICE Directed provider education and standardized posttonsillectomy prescription protocols can safely decrease postoperative opioid prescribing. Further PDSA cycles are required to consider even fewer opioid prescription doses.
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Affiliation(s)
- Shaunak N Amin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Trey Thompson
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Xing Wang
- Department of Biostatistics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Samantha Goldklang
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel K-W Low
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Sie
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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Aldriweesh B, Alkhateeb A, Boudewyns A, Chan CY, Chun RH, El-Hakim HG, Fayoux P, Gerber ME, Kanotra S, Kaspy K, Kubba H, Lambert EM, Luscan R, Parikh SR, Rahbar R, Rickert SM, Russell J, Rutter M, Schroeder JW, Schwarz Y, Sobol SE, Thevasagayam R, Thierry B, Thompson DM, Valika T, Watters K, Wei JL, Wyatt M, Zur KB, Daniel SJ. International pediatric otolaryngology group (IPOG) consensus on approach to aspiration. Int J Pediatr Otorhinolaryngol 2024; 176:111810. [PMID: 38147730 DOI: 10.1016/j.ijporl.2023.111810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/31/2023] [Accepted: 11/25/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration. METHODS Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step. RESULTS Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children. CONCLUSION Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.
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Affiliation(s)
- Bshair Aldriweesh
- Division of Otolaryngology-Head and Neck Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada; Department of Otolaryngology-Head & Neck Surgery, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Ahmed Alkhateeb
- Department of Otolaryngology-Head & Neck Surgery, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - An Boudewyns
- Department of Otolaryngology Head and Neck Surgery, Antwerp University Hospital, University of Antwerp Faculty of Medicine and Translational Neurosciences, Antwerp, Belgium
| | - Ching Yee Chan
- Department of Otolaryngology, KK Women's and Children's Hospital, Singapore
| | - Robert H Chun
- Department of Otolaryngology, Medical College of Wisconsin, United States
| | - Hamdy G El-Hakim
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta and the Stollery Children's Hospital, Edmonton, Alberta, Canada; Division of Pediatric Surgery, Department of Pediatrics, University of Alberta and the Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Pierre Fayoux
- Department of Pediatric Otolaryngology-Head Neck Surgery, Jeanne de Flandre Hospital, CHU Lille, Université de Lille, Lille, France
| | - Mark E Gerber
- Division of Otolaryngology, Head & Neck Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Sohit Kanotra
- Department of Otolaryngology - Head & Neck Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, United States
| | - Kimberley Kaspy
- Division of Respiratory Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Haytham Kubba
- Department of Paediatric Otolaryngology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, Scotland, United Kingdom
| | - Elton M Lambert
- Division of Otolaryngology, Department of Surgery, Texas Children's Hospital, Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, 6701 Fannin Street, D.640, Houston, TX, 77030, United States
| | - Romain Luscan
- Department of Pediatric ENT, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris University, 149, rue de Sèvres, 75015, Paris, France
| | - Sanjay R Parikh
- Department of Otolaryngology Head and Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, United States
| | - Reza Rahbar
- Department of Otolaryngology & Communication Enhancement, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, United States; Department of Otolaryngology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, United States
| | - Scott M Rickert
- Department of Otolaryngology, New York University Langone Medical Center, New York, NY, 10016, United States
| | - John Russell
- Department of Pediatric Otolaryngology Children's Health Ireland (Crumlin), Dublin, Ireland
| | - Mike Rutter
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - James W Schroeder
- Division of Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Yehuda Schwarz
- Department of Otolaryngology- Head and Neck Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Steven E Sobol
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, United States
| | - Ravi Thevasagayam
- Sheffield Children's Hospital, Western Bank, Sheffield, South Yorkshire, S10 2TH, United Kingdom
| | - Briac Thierry
- Department of Pediatric ENT, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris University, 149, rue de Sèvres, 75015, Paris, France
| | - Dana M Thompson
- Division of Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Taher Valika
- Division of Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Karen Watters
- Department of Otolaryngology & Communication Enhancement, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, United States; Department of Otolaryngology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, United States
| | - Julie L Wei
- Chair, Otolaryngology Education, University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL, 32827, United States
| | - Michelle Wyatt
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, United Kingdom
| | - Karen B Zur
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, United States
| | - Sam J Daniel
- Division of Otolaryngology-Head and Neck Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada.
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10
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Parikh SR, Boudewyns A, Friedman NR, Schwartz SR, Baldassari CM, Benedek P, Carr MM, Chan DK, Chan KC, Cheng AT, Couloigner V, Diala OR, DeRowe A, El-Hakim H, Fayoux P, Hsu WC, Ishman S, Kirkham EM, Mitchell RB, Thevasagayam R, Lam D. International Pediatric Otolaryngology Group (IPOG) consensus on scoring of pediatric Drug Induced Sleep Endoscopy (DISE). Int J Pediatr Otorhinolaryngol 2023; 171:111627. [PMID: 37441992 DOI: 10.1016/j.ijporl.2023.111627] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/10/2023] [Accepted: 06/05/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea. METHODS The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus. RESULTS A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids. CONCLUSION This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients.
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Affiliation(s)
- Sanjay R Parikh
- Department of Otolaryngology, University of Washington, Seattle Children's Hospital, USA.
| | - An Boudewyns
- Department of Otolaryngology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Norman R Friedman
- Department of Otolaryngology, University of Colorado, Children's Hospital Colorado, USA
| | - Seth Roslow Schwartz
- Department of Otolaryngology, University of Washington, Virginia Mason Hospital, Seattle, USA
| | - Cristina M Baldassari
- Department of Otolaryngology, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, USA
| | - Palma Benedek
- Department of Otolaryngology, Heim Pal National Pediatric Institute, Hungary
| | - Michele M Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, USA
| | - Dylan K Chan
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, USA
| | - Kate C Chan
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alan T Cheng
- Department of Otolaryngology, The University of Sydney, The Children's Hospital at Westmead, Australia
| | - Vincent Couloigner
- Department of Otolaryngology, Hôpital Necker-Enfants Malades, Université Paris Cité, France
| | - Obinna R Diala
- Department of Otolaryngology, University of Colorado, Children's Hospital Colorado, USA
| | - Ari DeRowe
- Department of Otolaryngology Head and Neck and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Israel
| | - Hamdy El-Hakim
- Department of Otolaryngology, University of Alberta, Stollery Children's Hospital, Canada
| | - Pierre Fayoux
- Pediatric Otolaryngology - Head Neck Surgery, Jeanne de Flandre Hospital, CHU Lille, France
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital and Children's Hospital, Taiwan
| | - Stacey Ishman
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Erin M Kirkham
- Department of Otolaryngology, University of Michigan, Mott Children's Hospital, USA
| | - Ron B Mitchell
- Department of Otolaryngology, University of Texas, Southwestern Medical Center, Children's Medical Center Dallas, USA
| | - Ravi Thevasagayam
- Department of Otolaryngology, Sheffield Children's Hospital, United Kingdom
| | - Derek Lam
- Department of Otolaryngology, Oregon Health and Science University, USA
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11
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Evans SS, Richardson C, Friedman SD, Bly RA, Johnson KE, Dahl JP, Parikh SR, Bonilla-Velez J. Virtually Assisted Personalized Tracheostomy Tube Design in Pediatric Complex Airway Anomalies. Otolaryngol Head Neck Surg 2023; 168:893-897. [PMID: 36125892 PMCID: PMC10243722 DOI: 10.1177/01945998221126180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022]
Abstract
We sought to assess the feasibility of virtually assisted personalized tracheostomy tube (vapTT) implementation for patients with congenital airway anomalies (CAAs) and persistent tracheostomy tube (TT)-related respiratory failure at a tertiary pediatric hospital. Three patients (0-18 years) with CAAs and recurrent TT-related respiratory complications were managed with vapTT over 5 years. Patients underwent airway computed tomography acquisition with 3-dimensional reconstruction and TT virtual modeling for shape customization. Models were transferred to Bivona for fabrication based on industry-standard materials and processes. Clinical information and tracheoscopies assessing position, obstruction, and granulation were reviewed. Patients demonstrated resolution of visualized TT-related obstruction, granulation, or ulceration and de-escalation of respiratory support. Clinical events requiring urgent tracheoscopy decreased in all 3 patients. Sufficient relief of critical airway obstruction allowed progression of medical care and/or discharge. VapTTs are feasible for patients with CAA. This new frontier in personalized devices may serve uniquely challenging patient populations for whom standard treatments have failed.
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Affiliation(s)
- Sean S Evans
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
- Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Clare Richardson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Seth D Friedman
- Department of Innovation Imaging and Simulation Modeling, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall A Bly
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
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12
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Horner C, Chan T, Yip C, Parikh SR, Johnson K, Fridgen J, Rudberg K, Bhat AH, Colyer J. Improving Timeliness of Vocal Fold Mechanical Injury Screening Following Norwood or Arch Reconstruction: A Quality Improvement Initiative at a Single Center. Pediatr Cardiol 2023; 44:388-395. [PMID: 36527473 DOI: 10.1007/s00246-022-03064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
Vocal fold (VF) immobility is a common complication after pediatric cardiothoracic surgeries involving the aortic arch and conotruncal region. Nasolaryngoscopy is considered the standard for diagnosis but is invasive and requires expertise and special resources. VF ultrasound (VF US) is an efficient, non-invasive alternative for VF evaluation in the post-cardiac surgical setting. Our aim was to improve screening rates for vocal fold motion impairment (VFMI) by implementing VF US in a group of pre-identified high-risk patients after index cardiac surgeries using Quality Improvement (QI) methodology. The QI project included formation of a widely representative stakeholder team, collaborative development of a screening protocol for the cohort of patients in our tertiary center. Baseline data were derived by retrospective review of screening and incidence of VFMI in a similar post-surgical cohort in 2 years prior to this intervention. We implemented an US screening algorithm with multidisciplinary care coordination. We evaluated feeding practices and length of stay (LOS) related to our screening interventions and documented follow up practices. Screening for VFMI by ultrasound increased from 59 to 92% after implementation of the VF screening protocol. Additionally, time between extubation and VF US decreased from 7.7 to 2.3 days. The positive predictive value of VF US was 96%. Patients with VFMI had a longer LOS and greater dependence on tube feeds at discharge after index surgery. We successfully implemented an ultrasound-based screening protocol for VFMI and demonstrated improved screening, timeliness and high positive predictive value of ultrasound.
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Affiliation(s)
- Cassie Horner
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, USA.
| | - Titus Chan
- Division of Cardiology, Seattle Children's Hospital, Seattle, USA.,Division of Pediatric Critical Care, Seattle Children's Hospital, Seattle, USA.,University of Washington School of Medicine, Seattle, USA
| | - Caitlin Yip
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, USA
| | - Sanjay R Parikh
- Department of Physical Therapy, Seattle Children's Hospital, Seattle, USA.,Department of Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, USA.,University of Washington School of Medicine, Seattle, USA
| | - Kaalan Johnson
- Department of Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, USA.,University of Washington School of Medicine, Seattle, USA
| | - Jennifer Fridgen
- Department of Physical Therapy, Seattle Children's Hospital, Seattle, USA
| | - Kenneth Rudberg
- Division of Cardiology, Seattle Children's Hospital, Seattle, USA
| | - Aarti H Bhat
- Division of Cardiology, Seattle Children's Hospital, Seattle, USA.,University of Washington School of Medicine, Seattle, USA
| | - Jessica Colyer
- Division of Cardiology, Seattle Children's Hospital, Seattle, USA.,University of Washington School of Medicine, Seattle, USA
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13
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Martin LD, Chiem JL, Hansen EE, Low DK, Reece K, Casey C, Wingate CS, Bezzo LK, Merguerian PA, Parikh SR, Susarla SM, O'Reilly-Shah VN. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg 2022; 135:1271-1281. [PMID: 36384014 DOI: 10.1213/ane.0000000000006256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. METHODS A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. RESULTS The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. CONCLUSIONS This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.
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Affiliation(s)
- Lynn D Martin
- From the Departments of Anesthesiology & Pain Medicine and Pediatrics
| | - Jennifer L Chiem
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth E Hansen
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Daniel K Low
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Kayla Reece
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Corrie Casey
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Christina S Wingate
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Leah K Bezzo
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | | | - Sanjay R Parikh
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Srinivas M Susarla
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Vikas N O'Reilly-Shah
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
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14
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Jáuregui EJ, Abts MF, Dahl JP, Parikh SR, Horn DL, Pickens M, Park JS, DeMarre K, Hoang J, Johnson K. Beyond Laryngeal Clefts: Interarytenoid Injection Augmentation to Predict Success of Suture Augmentation in Children. Laryngoscope 2022. [PMID: 36069277 DOI: 10.1002/lary.30374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/26/2022] [Accepted: 08/09/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the efficacy of interarytenoid injection augmentation (IAIA) and the ability of IAIA to predict response to interarytenoid suture augmentation (IASA) based on diet advancement on video fluoroscopic swallow studies (VFSS). METHODS Retrospective cohort analysis of patients with persistent pharyngeal dysphagia at a tertiary children's hospital with VFSS pre- and post-IAIA were included between March 2011 and June 2019. RESULTS Median age of the 229 patients was 2.2 years (5.8 months-19 years). Interarytenoid mucosal height (IAMH) was found to be above the false vocal folds in 112 patients (53.4%) and at true vocal folds in 10 (4.9%) patients. On VFSS post-IAIA, 95 (41.5%) patients were successfully advanced in recommended diet consistency, 115 (50.2%) were stable, and 19 (8.3%) needed thicker consistency. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% confidence interval (CI; 0.50-0.85). Poisson regression found no covariates with significant association with improvement on IAIA. For IASA patients, 35/60 (58.3%) improved on post-op VFSS. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% CI (0.63-1.33). Positive predictive value for IAIA predicting response to IASA was 77% with positive likelihood ratio of 2.3. The response to IAIA versus no response to IAIA likelihood ratios were found to have a statistically significant difference (p < 0.05). CONCLUSIONS Our study suggests IAIA yields objective improvement in swallow function on VFSS in nearly half of our patients and may be a reliable diagnostic tool to predict response to IASA in patients with persistent pharyngeal dysphagia with or without a laryngeal cleft. LEVEL OF EVIDENCE Level 3 Laryngoscope, 2022.
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Affiliation(s)
- Emmanuel J Jáuregui
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Matthew F Abts
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - David L Horn
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Michael Pickens
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jason S Park
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, U.S.A
| | - Kim DeMarre
- Speech and Language Services, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jennifer Hoang
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Kaalan Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
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15
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Maksimoski M, Bauer AJ, Kazahaya K, Manning SC, Parikh SR, Simons JP, D'Souza J, Maddalozzo J, Purkey MR, Rychlik K, Ho B, Rutter MJ, Jiang W, Prager JD, Diercks G, Propst EJ, Miyamoto RC, Stack BC, Randolph GW, Rastatter JC. Outcomes in Pediatric Thyroidectomy: Results From a Multinational, Multi-institutional Database. Otolaryngol Head Neck Surg 2022; 167:869-876. [PMID: 35133903 DOI: 10.1177/01945998221076065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. STUDY DESIGN Retrospective multi-institutional cohort study. SETTING Tertiary care pediatric hospital systems throughout North America. METHODS Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models. RESULTS In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism. CONCLUSION These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.
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Affiliation(s)
- Matthew Maksimoski
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrew J Bauer
- The Thyroid Center, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott C Manning
- Department of Otolaryngology, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jeffrey P Simons
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jill D'Souza
- Division of Pediatric Otolaryngology, Children's Hospital of New Orleans and Louisiana State University, New Orleans, Louisiana, USA
| | - John Maddalozzo
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Pediatric Otolaryngology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Matthew R Purkey
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Karen Rychlik
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brian Ho
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael J Rutter
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Wen Jiang
- Department of Surgery, University of California, San Diego, Division of Otolaryngology, Rady Children's Hospital, San Diego, California, USA
| | - Jeremy D Prager
- Division of Pediatric Otolaryngology, University of Colorado School of Medicine, Children's Hospital of Colorado, Denver, Colorado, USA
| | - Gillian Diercks
- Division of Pediatric Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Evan J Propst
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - R Christopher Miyamoto
- Division of Pediatric Otolaryngology, Peyton Manning Children's Hospital at Ascension St. Vincent, Indianapolis, Indiana, USA
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, SIU School of Medicine, Springfield, Illinois, USA
| | - Gregory W Randolph
- Division of Pediatric Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Jeffrey C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Pediatric Otolaryngology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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16
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Brady C, Manning SC, Rudzinski E, Paulson V, Wang X, Liu YJ, Parikh SR, Bonilla-Velez J, Hawkins DS, Dahl J. Clinical Outcomes of Diffuse Sclerosing Variant Papillary Thyroid Carcinoma in Pediatric Patients. Laryngoscope 2021; 132:1132-1138. [PMID: 34713899 DOI: 10.1002/lary.29926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVES/HYPOTHESIS The diffuse sclerosing variant of papillary thyroid carcinoma (DSV) may be more aggressive than conventional well-differentiated non-DSV related papillary thyroid carcinomas (N-PTC). STUDY DESIGN Retrospective chart review. METHODS Retrospective review of clinical outcomes for patients 21 years of age or younger who underwent initial surgery for PTC at a single institution from January 1, 2005 to April 1, 2020. Genomic analysis was performed using targeted next-generation sequencing. Data were analyzed using Fischer's exact test and Kaplan-Meier curve log-rank test. RESULTS Our cohort consisted of 72 patients, nine with DSV and 63 with N-PTC. Age at diagnosis was comparable (15.4 vs. 16.2 years, respectively, P = .46). DSV were more likely to be in the high-risk American Thyroid Academy pediatric risk group (100% vs. 41.3%, P = .004), to present with regional cervical lymph node metastases (100% vs. 60.3%, P = .036), and to present with distant metastases (67% vs. 22%, P = .005). No mortality seen in either group over 27.5 (interquartile range 14.8, 46.00) months average follow-up. Throughout the follow-up period, DSV were more likely to experience progression than N-PTC (hazard ratio = 5.7 [95% confidence interval 1.7-20.0; P = .0056]). In a subset of 19 patients with aggressive disease who had molecular testing as part of clinical care we detected RET fusions in nearly all DSV compared to a minority of N-PTC (83% vs. 15.4%, P = .0095). CONCLUSIONS Pediatric patients with DSV have more advanced disease at diagnosis and are more likely to experience progression of disease compared to patients with N-PTC. The prevalence of RET fusions in our cohort recapitulates the frequency of this alteration described in prior studies. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Charles Brady
- UW Medicine, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Scott C Manning
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Erin Rudzinski
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Vera Paulson
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Xing Wang
- Seattle Children's Research Division, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Yajuan J Liu
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Julianna Bonilla-Velez
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Douglas S Hawkins
- Division of Pediatrics, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - John Dahl
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
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17
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Richardson C, Friedman SD, Park JS, Bonilla-Velez J, Dahl JP, Parikh SR, Perkins J, Johnson K. Comparison of Slide Tracheoplasty Technique on Postoperative Anatomic Outcomes in Three-Dimensional Printed Models. Laryngoscope 2021; 132:1306-1312. [PMID: 34606107 DOI: 10.1002/lary.29874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/31/2021] [Accepted: 09/11/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS We hypothesized that the use of three-dimensional (3D) printed tracheal models to reproducibly simulate surgical technique variations in slide tracheoplasty would demonstrate the quantitative impact of surgical variables on postoperative tracheal dimensions. STUDY DESIGN Prospective analysis of three-dimensional printed surgical simulation models. METHODS Slide tracheoplasty was performed on 3D printed long segment tracheal stenosis models with combinations of tracheal transection incision angle (90°, 45° beveled superior to inferior, 45° beveled inferior to superior) and tracheal transection location relative to the stenosis (at midpoint, 2 mm each superior and inferior to midpoint). Postoperative computed tomography (CT) scans measured changes in tracheal length, volume, and cross-sectional area compared to controls. Statistical analysis was performed using one-way analysis of variance and unpaired two-tailed t-tests. RESULTS Slide tracheoplasty yielded 27 reconstructed tracheas. On average, slide tracheoplasty reduced total tracheal length by 36%. Beveled tracheal incisions yielded 9.5% longer final tracheas than straight transection incisions (P < .0001). Cross-sectional area at the stenosis midpoint increased from 9.0 mm2 to 45 mm2 but did not vary with technique (P > .05). Total tracheal luminal volume increased from 900 mm3 to 1378 mm3 overall and was largest with beveled incisions (P = .03). More material was discarded with straight incisions compared to beveled (89 mg vs. 19 mg, P < .0001). CONCLUSIONS Beveled tracheal transection incisions resulted in increased tracheal length, longer anastomotic segments, increased volume, and reduced tissue waste as compared to straight incisions. Offsetting the incision from the midpoint of stenosis did not significantly affect reconstructed tracheal morphology. Using 3D printed models for surgical simulation can be helpful for the quantitative study of the effect isolated surgical variables on technical outcomes. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Clare Richardson
- Department of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Washington, District of Columbia, U.S.A
| | - Seth D Friedman
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jason S Park
- Department of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Washington, District of Columbia, U.S.A
| | - Juliana Bonilla-Velez
- Department of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Washington, District of Columbia, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - John P Dahl
- Department of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Washington, District of Columbia, U.S.A
| | - Sanjay R Parikh
- Department of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Washington, District of Columbia, U.S.A
| | - Jonathan Perkins
- Department of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Washington, District of Columbia, U.S.A
| | - Kaalan Johnson
- Department of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Washington, District of Columbia, U.S.A
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18
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Pattisapu P, Abts MF, Bly RA, Bonilla-Velez J, Dahl JP, DeYoung SCH, Horn DL, Johnson KE, Parikh SR. Validation of the Seattle Suprastomal Safety Score (5S): A Novel Measure in Pediatric Tracheostomy-Dependent Patients. Otolaryngol Head Neck Surg 2021; 166:970-975. [PMID: 34488510 DOI: 10.1177/01945998211037254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an instrument with 2 domains: collapse and granulation. STUDY DESIGN Cross-sectional repeated testing survey. SETTING Electronic survey. METHODS A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains. RESULTS ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation. CONCLUSION The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients.
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Affiliation(s)
- Prasanth Pattisapu
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew F Abts
- Department of Pulmonology, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall A Bly
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Juliana Bonilla-Velez
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sarah C Hofman DeYoung
- Department of Pulmonology, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - David L Horn
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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19
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Kazahaya K, Prickett KK, Paulson VA, Dahl JP, Manning SC, Rudzinski ER, Rastatter JC, Parikh SR, Hawkins DS, Brose MS, Bauer AJ. Targeted Oncogene Therapy Before Surgery in Pediatric Patients With Advanced Invasive Thyroid Cancer at Initial Presentation: Is It Time for a Paradigm Shift? JAMA Otolaryngol Head Neck Surg 2021; 146:748-753. [PMID: 32614439 DOI: 10.1001/jamaoto.2020.1340] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Initial data suggest the effectiveness of oncogene-specific targeted therapies in inducing tumor regression of diverse cancers in children and adults, with minimal adverse effects. Observations In this review, preliminary data suggest that systemic therapy may be effective in inducing tumor regression in pediatric patients with unresectable invasive thyroid cancer. Although most pediatric patients with thyroid cancer initially present with operable disease, some children have extensive disease that poses substantial surgical challenges and exposes them to higher than usual risk of operative complications. Extensive disease includes thyroid cancer that invades the trachea or esophagus or encases vascular or neural structures. Previous efforts to manage extensive thyroid cancer focused on surgery with near-curative intent. With the recent development of oncogene-specific targeted therapies that are effective in inducing tumor regression, with minimal drug-associated adverse effects, there is an opportunity to consider incorporating these agents as neoadjuvant therapy. In patients with morbidly invasive regional metastasis or with hypoxia associated with extensive pulmonary metastasis, neoadjuvant therapy can be incorporated to induce tumor regression before surgery and radioactive iodine therapy. For patients with widely invasive medullary thyroid cancer, in whom the risk of surgical complications is high and the likelihood of surgical remission is low, these agents may replace surgery depending on the response to therapy and long-term tolerance. Conclusions and Relevance With oncogene-specific targeted therapy that is associated with substantial tumor regression and low risk of adverse reactions, there appears to be an opportunity to include children with advanced invasive thyroid cancer in clinical trials exploring neoadjuvant targeted oncogene therapy before or instead of surgery.
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Affiliation(s)
- Ken Kazahaya
- Department of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia
| | - Kara K Prickett
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Vera A Paulson
- Department of Laboratory Medicine, University of Washington (UW) Medical Center, Seattle
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle
| | - Scott C Manning
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle
| | - Erin R Rudzinski
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington
| | - Jeffrey C Rastatter
- Otorhinolaryngology-Head & Neck Surgery, Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle
| | - Douglas S Hawkins
- Division of Hematology/Oncology, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, University of Washington, Seattle
| | - Marcia S Brose
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia.,Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Andrew J Bauer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania, Philadelphia
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20
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Loy KA, Lam AS, Franz AM, Martin LD, Manning SC, Ou HC, Perkins JA, Parikh SR, Low DKW, Dahl JP. Impact of Eliminating Local Anesthesia on Immediate Postoperative Analgesia in Pediatric Ambulatory Adenotonsillectomy. Pediatr Qual Saf 2021; 6:e405. [PMID: 33977193 PMCID: PMC8104218 DOI: 10.1097/pq9.0000000000000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/31/2020] [Indexed: 11/26/2022] Open
Abstract
Our goal was to standardize intraoperative analgesic regimens for pediatric ambulatory tonsillectomy by eliminating local anesthetic use and to determine its impact on postoperative pain measures, while controlling for other factors. METHODS We assembled a quality improvement team at an ambulatory surgery center. They introduced a standardized anesthetic protocol, involving American Society of Anesthesiologists Classification 1 and 2 patients undergoing adenotonsillectomy. Local anesthesia elimination was the project's single intervention. We collected pre-intervention data (79 cases) from July 5 to September 17, 2019 and post-intervention data (59 cases) from September 25 to December 17, 2019. The intervention requested that surgeons eliminate the use of local anesthetics. The following outcomes measures were evaluated using statistical process control charts and Shewhart's theory of variation: (1) maximum pain score in the post-anesthesia care unit, (2) total post-anesthesia care unit minutes, and (3) postoperative opioid rescue rate. RESULTS No special cause variation signal was detected in any of the measures following the intervention. CONCLUSIONS Our data suggest that eliminating intraoperative local anesthetic use does not worsen postoperative pain control at our facility. The intervention eliminated the added expenses and possible risks associated with local anesthetic use. This series is unique in its standardization of anesthetic regimen in a high-volume ambulatory surgery center with the exception of local anesthesia practices. The study results may impact the standardized clinical protocol for pediatric ambulatory adenotonsillectomy at our institution and may hold relevance for other centers.
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Affiliation(s)
- Kelsey A Loy
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Austin S Lam
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Amber M Franz
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Scott C Manning
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Henry C Ou
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Jonathan A Perkins
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Sanjay R Parikh
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Daniel K-W Low
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Wash
| | - John P Dahl
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
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21
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Filipek N, Kirkham E, Chen M, Ma CC, Horn DL, Johnson KE, Parikh SR. Drug-induced sleep endoscopy directed surgery improves polysomnography measures in overweight and obese children with obstructive sleep apnea. Acta Otolaryngol 2021; 141:397-402. [PMID: 33372808 DOI: 10.1080/00016489.2020.1863465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Obstructive sleep apnea affects approximately 1-4% of all children, with increased prevalence amongst overweight and obese children. OBJECTIVE To assess the effects of drug-induced sleep endoscopy (DISE)-directed surgery on polysomnography parameters in obese and overweight children. MATERIAL/METHODS A retrospective case-series was performed on obese and overweight pediatric patients who underwent clinically indicated DISE-directed surgery. Forty children met the inclusion criteria, including: body mass index ≥85%, DISE-study, and pre- and post-DISE polysomnography. Patients were divided into surgically naïve (n = 23) and prior adenotonsillectomy (n = 17) groups. Demographic and clinical characteristics were examined with chi-square and Wilcoxon rank-sum test. Polysomnography parameters were compared with Wilcoxon signed rank test. RESULTS Of 40 children with mean BMI 94% and mean age 8 ± 6 years old, 17 (43%) underwent a previous adenotonsillectomy. Overall, significant improvements were observed in the apnea-hypopnea index (AHI; 25.0 to 9.9 events/hour, p < .01) and oxygen nadir (82.7% to 88.5%, p < .01). A similar pattern was observed among the surgically naïve (AHI: 35.9 to 12.7 events/hour, p = .04; oxygen nadir: 79.7% to 86.4%, p = .2) and post-adenotonsillectomy groups (AHI: 10.4 to 6.2 events/hour, p = .02; oxygen nadir: 86.7% to 91.2%, p < .01). CONCLUSIONS/SIGNIFICANCE Polysomnography parameters significantly improved following DISE-directed interventions in obese and overweight children with obstructive sleep apnea.
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Affiliation(s)
- Natalia Filipek
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Erin Kirkham
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Maida Chen
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, WA, USA
| | - Cheng Cheng Ma
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - David L. Horn
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Kaalan E. Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Sanjay R. Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
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22
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 357] [Impact Index Per Article: 119.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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23
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Benedek P, Balakrishnan K, Cunningham MJ, Friedman NR, Goudy SL, Ishman SL, Katona G, Kirkham EM, Lam DJ, Leboulanger N, Lee GS, Le Treut C, Mitchell RB, Muntz HR, Musso MF, Parikh SR, Rahbar R, Roy S, Russell J, Sidell DR, Sie KCY, Smith RJ, Soma MA, Wyatt ME, Zalzal G, Zur KB, Boudewyns A. International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA). Int J Pediatr Otorhinolaryngol 2020; 138:110276. [PMID: 32810686 DOI: 10.1016/j.ijporl.2020.110276] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Pálma Benedek
- Heim Pal National Pediatric Institute, Ear Nose Throat Department, Budapest, Hungary
| | - Karthik Balakrishnan
- Stanford University, Department of Otolaryngology Head and Neck Surgery, Lucile Packard Children's Hospital Aerodigestive and Airway Reconstruction Center, Stanford, CA, USA
| | - Michael J Cunningham
- Boston Children's Hospital, Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, MA, USA
| | - Norman R Friedman
- Children's Hospital Colorado, Department of Pediatric Otolaryngology, University of Colorado Anschutz Medical Campus, Colorado, Canada
| | - Steven L Goudy
- Emory University and Children's Healthcare of Atlanta, Department of Otolaryngology Head and Neck Surgery, Atlanta, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gábor Katona
- Heim Pal National Pediatric Institute, Ear Nose Throat Department, Budapest, Hungary
| | - Erin M Kirkham
- Michigan Medicine, Pediatric Otolaryngology, Ann Harbor, MI, USA
| | - Derek J Lam
- Oregon Health and Science University, Department of Otolaryngology Head and Neck Surgery, Portland, OR, USA
| | - Nicolas Leboulanger
- Necker Enfants Malade Hospital, Pediatric Otolaryngology Head and Neck Department, Université de Paris, Paris, France
| | - Gi Soo Lee
- Boston Children's Hospital, Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, MA, USA
| | - Claire Le Treut
- Pediatric Otolaryngology Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, Marseille, France
| | - Ron B Mitchell
- UT Southwestern and Children's Medical Center Dallas, Department of Otolaryngology Head and Neck Surgery, Dallas, USA
| | - Harlan R Muntz
- University of Utah and Primary Children's Hospital, Department of Otorhinolaryngology Head and Neck Surgery, Salt Lake City, UT, USA
| | - Mary Fances Musso
- Texas Children's Hospital, Division of Pediatric Otolaryngology, Bobby R Alford Department of Otolaryngology, Baylor College of Medicine, Houston, TX, USA
| | - Sanjay R Parikh
- Seattle Children's Hospital, Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, USA
| | - Reza Rahbar
- Boston Children's Hospital, Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, MA, USA
| | - Soham Roy
- University of Texas, Houston McGovern Medical School, Department of Otolaryngology, Division of Pediatric Otolaryngology, Houston, TX, USA
| | - John Russell
- Department of Pediatric Otolaryngology Children's Health Ireland (Crumlin), Dublin, Ireland
| | - Douglas R Sidell
- Stanford University, Department of Otolaryngology Head and Neck Surgery, Lucile Packard Children's Hospital Aerodigestive and Airway Reconstruction Center, Stanford, CA, USA
| | - Kathleen C Y Sie
- Seattle Children's Hospital, Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, USA
| | - Richard Jh Smith
- Carver College of Medicine, Department of Otolaryngology Head and Neck Surgery, University of Iowa, Iowa City, IA, USA
| | - Marlene A Soma
- Sydney Children's Hospital, Pediatric Otolaryngology, Sydney, Australia
| | - Michelle E Wyatt
- Great Ormond Street Hospital, Department of Paediatric Otolaryngology, London, UK
| | - George Zalzal
- Children's National Medical Center, Department of Otolaryngology Head and Neck Surgery, George Washington University, Washington DC, USA
| | - Karen B Zur
- Children's Hospital Philadelphia, Department of Otolaryngology Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - An Boudewyns
- Antwerp University of Antwerp, Department of Otolaryngology Head and Neck Surgery, University of Antwerp, Antwerp, Belgium.
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24
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Abstract
Robotic surgery has been shown to be feasible and successful in several areas of pediatric head and neck surgery. However, adoption has been limited. Robotic surgery may be better integrated into practice with advanced preoperative surgical planning and the design of new robotic platforms with instrumentation specific for the application. With continued investigations, computer-aided surgical planning techniques including three-dimensional printing, virtual reality, multiobjective cost function for optimization of approach, mirror image overlay, and flexible robotic instruments may demonstrate value and utility over current practice.
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Affiliation(s)
- Neeraja Konuthula
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Washington, Seattle Children's Hospital, 1959 Northeast Pacific Street, Box 356515, Seattle, WA 98195, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Randall A Bly
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Washington, Seattle Children's Hospital, 1959 Northeast Pacific Street, Box 356515, Seattle, WA 98195, USA.
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25
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Simon F, Peer S, Michel J, Bruce IA, Cherkes M, Denoyelle F, Fagan JJ, Harish M, Hong P, James A, Jia H, Krishnan PV, Maunsell R, Modi VK, Nguyen Y, Parikh SR, Patel N, Pullens B, Russo G, Rutter MJ, Sargi Z, Shaye D, Sowerby LJ, Yung M, Zdanski CJ, Teissier N, Fakhry N. IVORY Guidelines (Instructional Videos in Otorhinolaryngology by YO-IFOS): A Consensus on Surgical Videos in Ear, Nose, and Throat. Laryngoscope 2020; 131:E732-E737. [PMID: 33270236 PMCID: PMC7891442 DOI: 10.1002/lary.29020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/10/2020] [Accepted: 07/20/2020] [Indexed: 11/16/2022]
Abstract
Objectives/Hypothesis Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology. Study Design DELPHI survey. Methods Twenty‐seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained. Results The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high‐definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ‐specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre‐ and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery. Conclusions International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery. Level of Evidence 5 Laryngoscope, 131:E732–E737, 2021
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Affiliation(s)
- François Simon
- Department of Pediatric Otolaryngology, Necker-Sick Children's Hospital, AP-HP-University of Paris, Paris, France
| | - Shazia Peer
- Division of Otolaryngology, University of Cape Town and Red Cross Children's Hospital, Rondebosch, South Africa
| | - Justin Michel
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Aix Marseille University, APHM, University Institute of Industrial Thermal Systems, La Conception University Hospital, Marseille, France
| | - Iain A Bruce
- Division of Infection, Immunity, and Respiratory Medicine, Royal Manchester Children's Hospital, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Maryana Cherkes
- Departement of Otolaryngology, Lviv City Children's Clinical Hospital, Lviv National Medical University, Lviv, Ukraine
| | - Françoise Denoyelle
- Department of Pediatric Otolaryngology, Necker-Sick Children's Hospital, AP-HP-University of Paris, Paris, France
| | - Johannes J Fagan
- Division of Otolaryngology, University of Cape Town and Red Cross Children's Hospital, Rondebosch, South Africa
| | | | - Paul Hong
- Department of Surgery, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Adrian James
- Department of Otolaryngology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Huan Jia
- Department of Otolaryngology-Head Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - P Vijaya Krishnan
- Department of Otorhinolaryngology, Madras Ear Nose and Throat Research Foundation, Chennai, Tamil Nadu, India
| | - Rebecca Maunsell
- Department of Otorhinolaryngology, Faculty of Medical Sciences, State University of Campinas UNICAMP, Campinas, Brazil
| | - Vikash K Modi
- Pediatric Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, New York, U.S.A
| | - Yann Nguyen
- Department of Otorhinolaryngology, Pitié-Salpêtrière Hospital, Robotic and surgical innovation research group, Inserm, Pasteur, "Innovative Technologies and Translational Therapeutics for Deafness," Hearing Institute, Sorbonne University, AP-HP, Paris, France
| | - Sanjay R Parikh
- Seattle Children's Hospital, University of Washington, Seattle, Washington, U.S.A
| | - Nirmal Patel
- Department of Otolaryngology-Head and Neck Surgery, University of Sydney and Macquarie University, Sydney, New South Wales, Australia
| | - Bas Pullens
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Gennaro Russo
- Department of Otorhinolaryngology, Monaldi Hospital, Naples, Italy
| | - Michael J Rutter
- Division of Pediatric Otolaryngology, Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Zoukaa Sargi
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, U.S.A
| | - David Shaye
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Leigh J Sowerby
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Matthew Yung
- Department of Otolaryngology, Ipswich Hospital, Colchester, United Kingdom
| | - Carlton J Zdanski
- Division of Pediatric Otolaryngology/Head and Neck Surgery, Department of Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Natacha Teissier
- Department of Pediatric Otolaryngology, Robert-Debré Hospital, AP-HP-University of Paris, Paris, France
| | - Nicolas Fakhry
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Aix Marseille University, APHM, Language and Speech Laboratory, La Conception University Hospital, Marseille, France
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26
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Evans SS, Pattisapu P, Parikh SR. Persistent OSA After Adenotonsillectomy in CPAP-Intolerant Children: What To Do Next? Laryngoscope 2020; 131:950-951. [PMID: 32668018 DOI: 10.1002/lary.28839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Sean S Evans
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Prasanth Pattisapu
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Seattle Children's Hospital, Seattle, Washington, U.S.A
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27
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Parikh SR, Bly RA, Bonilla-Velez J, Dahl JP, Evans SS, Horn DL, Johnson KE, Manning SC, Ou HC, Pattisapu P, Perkins JA, Sie KCY. Pediatric Otolaryngology Divisional and Institutional Preparatory Response at Seattle Children's Hospital after COVID-19 Regional Exposure. Otolaryngol Head Neck Surg 2020; 162:800-803. [PMID: 32286910 DOI: 10.1177/0194599820919748] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is a novel coronavirus resulting in high mortality in the adult population but low mortality in the pediatric population. The role children and adolescents play in COVID-19 transmission is unclear, and it is possible that healthy pediatric patients serve as a reservoir for the virus. This article serves as a summary of a single pediatric institution's response to COVID-19 with the goal of protecting both patients and health care providers while providing ongoing care to critically ill patients who require urgent interventions. A significant limitation of this commentary is that it reflects a single institution's joint effort at a moment in time but does not take into consideration future circumstances that could change practice patterns. We still hope dissemination of our overall response at this moment, approximately 8 weeks after our region's first adult case, may benefit other pediatric institutions preparing for COVID-19.
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Affiliation(s)
- Sanjay R Parikh
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall A Bly
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Juliana Bonilla-Velez
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sean S Evans
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - David L Horn
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Scott C Manning
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Henry C Ou
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Prasanth Pattisapu
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jonathan A Perkins
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Y Sie
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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28
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Parikh SR, Avansino JR, Dick AA, Enriquez BK, Geiduschek JM, Martin LD, McDonald RA, Yandow SM, Zerr DM, Ojemann JG. Collaborative Multidisciplinary Incident Command at Seattle Children's Hospital for Rapid Preparatory Pediatric Surgery Countermeasures to the COVID-19 Pandemic. J Am Coll Surg 2020; 231:269-274.e1. [PMID: 32289376 PMCID: PMC7151263 DOI: 10.1016/j.jamcollsurg.2020.04.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 01/22/2023]
Abstract
Washington was the first US state to have a patient test positive for COVID-19. Before this, our children’s hospital proactively implemented an incident command structure that allowed for collaborative creation of safety measures, policies, and procedures for patients, families, staff, and providers. Although the treatment and protective standards are continuously evolving, this commentary shares our thoughts on how an institution, and specifically, surgical services, may develop collaborative process improvement to accommodate for rapid and ongoing change. Specific changes outlined include early establishment of incident command; personal protective equipment conservation; workforce safety; surgical and ambulatory patient triage; and optimization of trainee education. Please note that the contents of this manuscript are shared in the interest of providing collaborative information and are under continuous development as our regional situation changes. We recognize the limitations of this commentary and do not suggest that our approaches represent validated best practices.
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Affiliation(s)
- Sanjay R Parikh
- Departments of Surgery, Seattle Children's Hospital, Seattle, WA; Departments of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA.
| | - Jeffrey R Avansino
- Departments of Surgery, Seattle Children's Hospital, Seattle, WA; Surgery, University of Washington, Seattle, WA
| | - Andre As Dick
- Departments of Surgery, Seattle Children's Hospital, Seattle, WA; Surgery, University of Washington, Seattle, WA
| | - Brianna K Enriquez
- Divisions of Emergency Medicine, Seattle Children's Hospital, Seattle, WA; Pediatrics, University of Washington, Seattle, WA
| | - Jeremy M Geiduschek
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA; Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Lynn D Martin
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA; Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Ruth A McDonald
- Nephrology, Seattle Children's Hospital, Seattle, WA; Pediatrics, University of Washington, Seattle, WA
| | - Suzanne M Yandow
- Departments of Surgery, Seattle Children's Hospital, Seattle, WA; Orthopedic Surgery, University of Washington, Seattle, WA
| | - Danielle M Zerr
- Infectious Diseases, Seattle Children's Hospital, Seattle, WA; Pediatrics, University of Washington, Seattle, WA
| | - Jeffrey G Ojemann
- Departments of Surgery, Seattle Children's Hospital, Seattle, WA; Neurosurgery, University of Washington, Seattle, WA
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29
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Ong T, Liu CC, Elder L, Hill L, Abts M, Dahl JP, Evans KN, Parikh SR, Soares JJ, Striegl AM, Whitlock KB, Johnson KE. The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients. Otolaryngol Head Neck Surg 2020; 163:221-231. [PMID: 32204663 DOI: 10.1177/0194599820911728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC). METHODS An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative. RESULTS In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality. DISCUSSION We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative. IMPLICATION FOR PRACTICE Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.
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Affiliation(s)
- Thida Ong
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - C Carrie Liu
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Leslie Elder
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Leslee Hill
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew Abts
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kelly N Evans
- Seattle Children's Hospital, Seattle, Washington, USA.,Craniofacial Medicine, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | | | - Amanda M Striegl
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathryn B Whitlock
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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30
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Liu CC, Parikh SR, Horn DL. Do Antivirals Improve Hearing Outcomes in Neonates With Congenital Cytomegalovirus Infection? Laryngoscope 2020; 130:1609-1612. [PMID: 32010980 DOI: 10.1002/lary.28525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/08/2019] [Accepted: 12/23/2019] [Indexed: 11/06/2022]
Affiliation(s)
- C Carrie Liu
- Sections of Otolaryngology-Head and Neck Surgery and Pediatric Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - David L Horn
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
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31
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Kirkham E, Ma CC, Filipek N, Horn DL, Johnson K, Chen ML, Parikh SR. Polysomnography outcomes of sleep endoscopy-directed intervention in surgically naïve children at risk for persistent obstructive sleep apnea. Sleep Breath 2020; 24:1143-1150. [PMID: 31919717 DOI: 10.1007/s11325-019-02006-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/09/2019] [Accepted: 12/20/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Drug-induced sleep endoscopy (DISE) is useful in children with obstructive sleep apnea (OSA) that persists after adenotonsillectomy (AT), but its utility in surgically naïve children is unclear. We report polysomnography outcomes of surgically naïve children who underwent DISE-directed intervention because they were considered high risk for persistent OSA after adenotonsillectomy. METHODS This study is a case series of 62 surgically naïve children with OSA who were considered high risk for persistence after AT and underwent DISE-directed intervention with pre- and postoperative polysomnography between 2012 and 2016. Analysis was performed with the paired t test. RESULTS Children were on average 5.9 (± 5.5, 0.2-18.6) years old at the time of surgery, 68% male, 18% obese, and 60% white. Thirty-eight percent had a syndromic diagnosis: 19% trisomy 21, 11% hypotonic neuromuscular disorder, and 8% craniofacial condition. The remaining 62% were non-syndromic but underwent DISE because they had at least one risk factor for OSA persistence after AT (age > 7 years, black race, 1+ tonsils, obesity, and/or severe OSA). Forty-two percent underwent AT, while 58% underwent treatment other than AT, including 18% who had multilevel surgery. Children improved significantly in 4 out of 5 polysomnography parameters tested, including obstructive apnea-hypopnea index (oAHI; 22.2 to 7.2, p < 0.01) and oxygen nadir (82 to 87, p < 0.01). Thirty-eight (61%) had a postoperative oAHI < 5; 16 (21%) had a postoperative oAHI < 2. CONCLUSION DISE resulted in intervention other than AT in 58% of surgically naïve children at high risk for persistent OSA after AT. DISE-directed intervention resulted in significant mean improvement in postoperative OSA.
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Affiliation(s)
- Erin Kirkham
- Department of Otolaryngology: Head and Neck Surgery, The University of Michigan, Ann Arbor, MI, USA. .,Mott Children's Hospital, University of Michigan Medical Center, 1540 E. Hospital Dr. CW 5-702, SPC 4241, Ann Arbor, MI, 48109, USA.
| | - Cheng-Cheng Ma
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA
| | - Natalia Filipek
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA
| | - David L Horn
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Hospital, Seattle, WA, USA
| | - Kaalan Johnson
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Hospital, Seattle, WA, USA
| | - Maida L Chen
- Seattle Children's Hospital, Seattle, WA, USA.,Department of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Sanjay R Parikh
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Hospital, Seattle, WA, USA
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Dahl JP, Coppess S, Propst EJ, Snoap A, Parikh SR, Inglis AF, Cotton RT, Johnson K. Development of a Modern Pediatric Airway Reference Tool. Laryngoscope 2019; 130:2428-2431. [PMID: 31886895 DOI: 10.1002/lary.28437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 10/07/2019] [Accepted: 10/29/2019] [Indexed: 11/10/2022]
Affiliation(s)
- John P Dahl
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Steven Coppess
- University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Evan J Propst
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Canada
| | - Adam Snoap
- Department of Otolaryngology-Head & Neck Surgery, University of Florida, College of Medicine, Gainesville, Florida, U.S.A
| | - Sanjay R Parikh
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Andrew F Inglis
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Robin T Cotton
- Division of Pediatric Otolaryngology and Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Kaalan Johnson
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 265] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Liu CC, Soares JJ, Elder L, Hill L, Abts M, Bonilla-Velez J, Dahl JP, Johnson KE, Ong T, Striegl AM, Whitlock K, Parikh SR. Surveillance endoscopy after tracheostomy placement in children: Findings and interventions. Laryngoscope 2019; 130:1327-1332. [PMID: 31670383 DOI: 10.1002/lary.28247] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/26/2019] [Accepted: 08/05/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions. STUDY DESIGN Retrospective case series. METHODS This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ2 tests and logistic regression were used to identify risk factors for the development of abnormal changes. RESULTS There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%). CONCLUSIONS The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1327-1332, 2020.
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Affiliation(s)
- C Carrie Liu
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Jennifer J Soares
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Leslie Elder
- Seattle Children's Hospital, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Leslee Hill
- Seattle Children's Hospital, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Matthew Abts
- Department of Pulmonary and Sleep Medicine, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Juliana Bonilla-Velez
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - John P Dahl
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Kaalan E Johnson
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Thida Ong
- Department of Pulmonary and Sleep Medicine, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Amanda M Striegl
- Department of Pulmonary and Sleep Medicine, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Kathryn Whitlock
- Center for Clinical and Translational Research, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary. Otolaryngol Head Neck Surg 2019; 160:187-205. [PMID: 30921525 DOI: 10.1177/0194599818807917] [Citation(s) in RCA: 166] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age, based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of obstructive sleep-disordered breathing. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. Inclusion of 2 consumer advocates on the guideline update group. Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). Addition of an algorithm outlining KASs. Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Parikh SR, Borrow R, Ramsay ME, Ladhani SN. Lower risk of invasive meningococcal disease during pregnancy: national prospective surveillance in England, 2011-2014. BJOG 2019; 126:1052-1057. [PMID: 30932328 DOI: 10.1111/1471-0528.15701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe cases of invasive meningococcal disease (IMD) in women of childbearing age and to estimate the disease incidence and relative risk of IMD in pregnant compared with non-pregnant women. DESIGN Prospective enhanced national surveillance for IMD. SETTING England. POPULATION Women of reproductive age (15-44 years) with laboratory-confirmed IMD. METHODS Public Health England conducts enhanced national surveillance for IMD in England. Laboratory-confirmed cases are followed up with postal questionnaires to general practitioners. All cases confirmed in women of reproductive age from 1 January 2011 to 31 December 2014 were included. MAIN OUTCOME MEASURES Annual IMD incidence and relative risk of IMD in pregnant compared with non-pregnant women of reproductive age. RESULTS During the 4-year surveillance period, there were 1502 cases of IMD in females across England; of these, 310 (20.6%) cases were in women of reproductive age, including four women who were pregnant at the time of IMD confirmation (1.3%). Serogroup distribution of IMD cases in women of childbearing age was similar to the overall distribution. The four cases in otherwise healthy pregnant women were confirmed across all trimesters and all survived; one case in the first trimester had a septic miscarriage. The incidence of IMD was lower in pregnant than in non-pregnant women (0.16 compared with 0.76 per 100 000 pregnant and non-pregnant years, respectively), giving a lower risk of IMD in pregnant women (incidence rate ratio, IRR, 0.21; 95% confidence interval, 0.06-0.54). CONCLUSIONS Pregnant women are nearly five times less likely to develop IMD compared with non-pregnant women, but the infection can be severe. TWEETABLE ABSTRACT The risk of meningococcal disease is lower in pregnant women compared with non-pregnant women; the infection can occur across all trimesters and can be severe.
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Affiliation(s)
- S R Parikh
- Immunisation and Countermeasures Division, Public Health England, London, UK
| | - R Borrow
- Immunisation and Countermeasures Division, Public Health England, London, UK.,Meningococcal Reference Unit, Public Health England, Manchester, UK
| | - M E Ramsay
- Immunisation and Countermeasures Division, Public Health England, London, UK
| | - S N Ladhani
- Immunisation and Countermeasures Division, Public Health England, London, UK.,St. George's University of London, London, UK
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Parikh SR, Archer S, Ishman SL, Mitchell RB. Why Is There No Statement Regarding Partial Intracapsular Tonsillectomy (Tonsillotomy) in the New Guidelines? Otolaryngol Head Neck Surg 2019; 160:213-214. [DOI: 10.1177/0194599818810507] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Partial intracapsular tonsillectomy (PIT) was revisited in 2003 as an alternate surgical option to total tonsillectomy for the treatment of tonsillar hypertrophy. However, evaluation of the existing literature on PIT reveals that it is largely focused on comparing perioperative outcomes after PIT and total tonsillectomy, with few data regarding long-term outcomes. The goal of this commentary is to explain why PIT was not incorporated into the 2019 American Academy of Otolaryngology–Head and Neck Surgery Foundation clinical practice guideline for tonsillectomy, while acknowledging its use and potential advantages and disadvantages and outlining future research opportunities.
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Affiliation(s)
- Sanjay R. Parikh
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Sanford Archer
- Department of Otolaryngology–Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Stacey L. Ishman
- Divisions of Otolaryngology–Head and Neck Surgery and Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ron B. Mitchell
- Division of Pediatric Otolaryngology, Department of Otolaryngology–Head and Neck Surgery, UT Southwestern, Children’s Health Dallas, Dallas, Texas, USA
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Padia R, Coppess S, Horn DL, Parikh SR, Hoang J, Faherty A, DeMarre K, Johnson K. Pediatric dysphagia: Is interarytenoid mucosal height significant? Laryngoscope 2019; 129:2588-2593. [PMID: 30671968 DOI: 10.1002/lary.27535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The clinical significance of the interarytenoid mucosal height (IAMH) in pediatric dysphagia, ranging from normal anatomy to a laryngeal cleft, is unknown. This study seeks to evaluate a cohort of patients who underwent evaluation of their IAMH during microdirect laryngoscopy (MDL) for associations between IAMH and dysphagia as diagnosed on preoperative videofluoroscopic swallow study (VFSS). METHODS A retrospective case series of 1,351 patients who underwent MDL between 2011 and 2016 were reviewed for intraoperative evaluation of IAMH using our interarytenoid assessment protocol. After exclusions, 182 patients were divided into three groups: 1) thickened diet: VFSS with recommendation for thickened liquids (n = 82 of 182; 45.1%), 2) normal diet: VFSS with allowance of thin liquids (n = 19 of 182; 10.4%), and 3) control: no VFSS performed (n = 81 of 182; 44.5%). RESULTS There was no difference in IAMH between groups (P = 0.35). Power analysis was able to achieve > 80% power to detect an effect size of ≥ 0.5 (1-5 mucosal height scale). The majority of patients in each group had an IAMH above the false vocal folds (thickened diet: 57.3%, normal diet: 57.9%, control: 64.2%). There were similar percentages of patients in each group with an IAMH at or below the true vocal folds (thickened diet: 4.9%, normal diet: 5.3%, control: 6.1%). CONCLUSION There was no significant association between IAMH and preoperative thickened liquid recommendation in this cohort. This data fails to support the hypothesis that the IAMH is an independent etiological factor for pediatric pharyngeal dysphagia. Further studies comparing IAMH with outcomes after feeding therapy and surgery may better clarify this relationship between anatomy and physiology. LEVEL OF EVIDENCE 4. Laryngoscope, 129:2588-2593, 2019.
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Affiliation(s)
- Reema Padia
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle, Washington, U.S.A.,the Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Steven Coppess
- Seattle Children's Hospital, the University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - David L Horn
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle, Washington, U.S.A.,the Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle, Washington, U.S.A.,the Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Jennifer Hoang
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle, Washington, U.S.A.,the Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Amy Faherty
- the Speech and Language Services, Department of Rehabilitation Services, Seattle, Washington, U.S.A
| | - Kimberley DeMarre
- the Speech and Language Services, Department of Rehabilitation Services, Seattle, Washington, U.S.A
| | - Kaalan Johnson
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle, Washington, U.S.A.,the Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, University of Washington, Seattle, Washington, U.S.A
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Miller C, Kirkham E, Ma C, Filipek N, Horn DL, Johnson K, Chen ML, Parikh SR. Polysomnography outcomes in children with small tonsils undergoing drug‐induced sleep endoscopy–directed surgery. Laryngoscope 2018; 129:2771-2774. [DOI: 10.1002/lary.27759] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Craig Miller
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Erin Kirkham
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Cheng‐Cheng Ma
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Natalia Filipek
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - David L. Horn
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Kaalan Johnson
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Maida L. Chen
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Sanjay R. Parikh
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
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Akkina SR, Ma CC, Kirkham EM, Horn DL, Chen ML, Parikh SR. Does drug induced sleep endoscopy-directed surgery improve polysomnography measures in children with Down Syndrome and obstructive sleep apnea? Acta Otolaryngol 2018; 138:1009-1013. [PMID: 30776267 DOI: 10.1080/00016489.2018.1504169] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Children with Down Syndrome (DS) and obstructive sleep apnea (OSA) are difficult to treat, as first line therapies may not lead to significant improvement. Drug-induced sleep endoscopy (DISE) directed surgery may be particularly beneficial for these patients. OBJECTIVE To assess change in polysomnography (PSG) measures of patients with DS who underwent DISE-directed surgery. METHODS Retrospective chart review was performed on patients with DS who underwent DISE-directed surgery and had pre- and post-surgery PSG. Patients were analyzed in groups defined by previous adenotonsillectomy. Two-sided t-tests with equal variances were used to assess statistical significance. RESULTS Of 24 patients reviewed, 14 were surgically naïve and 10 had undergone prior adenotonsillectomy. The primary outcome was change in PSG parameters including apnea hypopnea index, obstructive apnea hypopnea index, oxygen nadir, oxygen desaturation index, and mean carbon dioxide level. While improvement was seen in all PSG parameters, only improvement in oxygen nadir in children who had undergone prior adenotonsillectomy was statistically significant (88.5% to 90.9%, p = .04). CONCLUSIONS AND SIGNIFICANCE DISE-directed surgery may be beneficial for children with DS and OSA, with improvement in the means of main PSG measures observed. A larger, prospective study is warranted to further explore DISE utility.
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Affiliation(s)
| | - Cheng C. Ma
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Erin M. Kirkham
- Otolaryngology, University of Washington, Seattle, WA, USA
- Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - David L. Horn
- Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington, Otolaryngology, Seattle, WA, United States
| | - Maida L. Chen
- Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Sanjay R. Parikh
- Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington, Otolaryngology, Seattle, WA, United States
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Miller C, Parikh SR. Does supraglottoplasty improve outcomes in children with laryngomalacia? Laryngoscope 2018; 129:285-287. [PMID: 30329149 DOI: 10.1002/lary.27127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Craig Miller
- Department of Otolaryngology-Head and Neck Surgery , University of Washington, Seattle, Washington
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery , University of Washington, Seattle, Washington.,Division of Pediatric Otolaryngology , Seattle Children's Hospital, Seattle, Washington, U.S.A
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Coppess S, Padia R, Horn D, Parikh SR, Inglis A, Bly R, Dahl J, Dudley D, Johnson K. Standardizing Laryngeal Cleft Evaluations: Reliability of the Interarytenoid Assessment Protocol. Otolaryngol Head Neck Surg 2018; 160:533-539. [DOI: 10.1177/0194599818806283] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective While the Benjamin-Inglis classification system is widely used to categorize laryngeal clefts, it does not clearly differentiate a type 1 cleft from normal anatomy, and there is no widely accepted or validated protocol for systematically evaluating interarytenoid mucosal height. We sought to propose the interarytenoid assessment protocol as a method to standardize the description of the interarytenoid anatomy and to test its reliability. Study Design Retrospective review of endoscopic videos. Setting Pediatric academic center. Subjects and Methods The interarytenoid assessment protocol comprises 4 steps for evaluation of the interarytenoid region relative to known anatomic landmarks in the supraglottis, glottis, and subglottis. Thirty consecutively selected videos of the protocol were reviewed by 4 otolaryngologists. The raters were blinded to identifying information, and the video order was randomized for each review. We assessed protocol completion times and calculated Cohen’s linear-weighted κ coefficient between blinded expert raters and with the operating surgeon to evaluate interrater/intrarater reliability. Results Median age was 4.9 years (59 months; range, 1 month to 20 years). Median completion time was 144 seconds. Interrater and intrarater reliability showed substantial agreement (interrater κ = 0.71 [95% confidence interval (CI), 0.55-0.87]; intrarater mean κ = 0.70 [95% CI, 0.59-0.92/rater 1, 0.47-0.85/rater 2]; P < .001). Comparing raters to the operating surgeon demonstrated substantial agreement (mean κ = 0.62; 95% CI, 0.31-0.79/rater 1, 0.48-0.89/rater 2; P < .001). Conclusion The interarytenoid assessment protocol appears reliable in describing interarytenoid anatomy. Rapid completion times and substantial interrater/intrarater reliability were demonstrated. Incorporation of this protocol may provide important steps toward improved standardization in the anatomic description of the interarytenoid region in pediatric dysphagia.
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Affiliation(s)
- Steven Coppess
- University of Washington School of Medicine, University of Washington, Seattle, Washington, USA
| | - Reema Padia
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
| | - David Horn
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Sanjay R. Parikh
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Andrew Inglis
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Randall Bly
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
| | - John Dahl
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Daniel Dudley
- University of Washington School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kaalan Johnson
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
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Montague GL, Bly RA, Nadaraja GS, Conrad DE, Parikh SR, Chan DK. Endoscopic percutaneous suture lateralization for neonatal bilateral vocal fold immobility. Int J Pediatr Otorhinolaryngol 2018; 108:120-124. [PMID: 29605340 DOI: 10.1016/j.ijporl.2018.02.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/09/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Bilateral vocal-fold immobility (BFVI) is a rare but significant cause of severe respiratory distress in neonates. The primary aim of treatment is to provide an adequate airway while minimizing adverse effects such as aspiration and dysphonia. Our objective here is to describe the outcomes of a series of neonates undergoing percutaneous endoscopic suture lateralization for BVFI using a novel technique. METHODS In this retrospective case series, we present 6 neonates (mean age: 18 days) with BVFI from three tertiary academic medical centers. The etiologies included 4 idiopathic, 1 unspecified neurodegenerative disorder, and 1 acquired from cardiac surgery. All had stridor and respiratory distress with hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal-fold lateralization was performed under spontaneous-breathing suspension laryngoscopy using a novel technique of percutaneous needle-directed placement of 4-0 prolene suture without use of specialized equipment. RESULTS All patients had clinical improvement in stridor and respiratory support requirements and avoided tracheostomy. One patient had persistent aspiration after lateralization that resolved after suture removal. One patient required bilateral lateralization procedures. One patient expired of epilepsy due to neurodegenerative disease unrelated to airway pathology. At last follow-up (mean 12.6 months), 5/5 remaining patients were on room air without tracheostomy and feeding orally without aspiration; 4/5 had partial or complete return of vocal-fold function. CONCLUSION Endoscopic percutaneous suture lateralization may be a safe and effective non-destructive primary treatment modality for neonatal BVFI. All neonates undergoing this procedure avoided tracheotomy.
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Affiliation(s)
- Glenda Lois Montague
- UCSF-Benioff Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, United States
| | - Randall A Bly
- Seattle Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington, United States
| | - Garani S Nadaraja
- UCSF-Benioff Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, United States
| | - David E Conrad
- UCSF-Benioff Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, United States
| | - Sanjay R Parikh
- Seattle Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington, United States
| | - Dylan K Chan
- UCSF-Benioff Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, United States.
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Patel NA, Bly RA, Adams S, Carlin K, Parikh SR, Dahl JP, Manning S. A clinical pathway for the postoperative management of hypocalcemia after pediatric thyroidectomy reduces blood draws. Int J Pediatr Otorhinolaryngol 2018; 105:132-137. [PMID: 29447801 DOI: 10.1016/j.ijporl.2017.12.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/23/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Postoperative calcium management is challenging following pediatric thyroidectomy given potential limitations in self-reporting symptoms and compliance with phlebotomy. A protocol was created at our tertiary children's institution utilizing intraoperative parathyroid hormone (PTH) levels to guide electrolyte management during hospitalization. The objective of this study was to determine the effect of a new thyroidectomy postoperative management protocol on two primary outcomes: (1) the number of postoperative calcium blood draws and (2) the length of hospital stay. STUDY DESIGN Institutional review board approved retrospective study (2010-2016). METHODS Consecutive pediatric total thyroidectomy and completion thyroidectomy ± neck dissection cases from 1/1/2010 through 8/5/2016 at a single tertiary children's institution were retrospectively reviewed before and after initiation of a new management protocol. All cases after 2/1/2014 comprised the experimental group (post-protocol implementation). The pre-protocol control group consisted of cases prior to 2/1/2014. Multivariable linear and Poisson regression models were used to compare the control and experimental groups for outcome measure of number of calcium lab draws and hospital length of stay. RESULTS 53 patients were included (n = 23, control group; n = 30 experimental group). The median age was 15 years. 41 patients (77.4%) were female. Postoperative calcium draws decreased from a mean of 5.2 to 3.6 per day post-protocol implementation (Rate Ratio = 0.70, p < .001), adjusting for covariates. The mean number of total inpatient calcium draws before protocol initiation was 13.3 (±13.20) compared to 7.2 (±4.25) in the post-protocol implementation group. Length of stay was 2.1 days in the control group and 1.8 days post-protocol implementation (p = .29). Patients who underwent concurrent neck dissection had a longer mean length of stay of 2.32 days compared to 1.66 days in those patients who did not undergo a neck dissection (p = .02). Hypocalcemia was also associated with a longer mean length of stay of 2.41 days compared to 1.60 days in patients who did not develop hypocalcemia (p < .01). CONCLUSIONS The number of calcium blood draws was significantly reduced after introduction of a standardized protocol based on intraoperative PTH levels. The hospital length of stay did not change. Adoption of a standardized postoperative protocol based on intraoperative PTH levels may reduce the number of blood draws in children undergoing thyroidectomy.
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Affiliation(s)
- Neha A Patel
- Cohen Children's Medical Center, Division of Pediatric Otolaryngology, New Hyde Park, NY, USA; Hofstra Northwell School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Hempstead, NY, USA; Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
| | - Randall A Bly
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
| | - Seth Adams
- University of Washington, Department of Pediatrics and Hospital Medicine, Seattle, WA, USA.
| | - Kristen Carlin
- Seattle Children's Research Institute, Center for Clinical and Transitional Research, Seattle, WA, USA.
| | - Sanjay R Parikh
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
| | - John P Dahl
- Indiana University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Indianapolis, IN, USA; Riley Hospital for Children at IU Health, Indianapolis, IN, USA.
| | - Scott Manning
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. 过敏和鼻科学国际共识声明 : 鼻窦炎. Int Forum Allergy Rhinol 2017. [DOI: 10.1002/alr.21695_c] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Objectives We assessed the safety and efficacy of balloon dilation as treatment for recurrent stenosis after pediatric laryngotracheoplasty. Methods We studied a retrospective case series at an academic tertiary care children's hospital. We included all patients under the age of 18 years with subglottic or tracheal stenosis treated at our institution with balloon dilation between June 2007 and April 2009. The records were analyzed for patient demographics, presenting symptoms, surgical technique, and airway description. The outcome measures were airway diameter, postoperative symptoms, tracheotomy status, and complications. Results Ten patients (9 with subglottic stenosis and 1 with tracheal stenosis) underwent 20 balloon dilation procedures without complication. The average age at the time of the procedure was 17 months (range, 3 months to 9 years). The patient presenting symptoms were stridor in 7 cases and tracheotomy in 3 cases. Vascular balloons (diameter range, 6 to 12 mm; length, 20 mm) were inflated to 10 to 12 cm H2O pressure for an average of 40 seconds (range, 10 to 120 seconds). Each procedure consisted of 1 to 3 dilation cycles. The immediate postdilation airway area increased by an average factor of 4.9 (range, 1.9 to 9). Six patients had repeat procedures with an average interval between dilations of 67 days (range, 6 to 337 days). Stridor was eliminated or greatly improved in all patients on the first postoperative day; 7 patients sustained this benefit, with an average follow-up time of 10 months (range, 4 to 23 months). Six of the 10 patients had undergone previous laryngeal reconstruction (age range, 3 months to 4 years). Of these 6, 3 have no tracheotomy, with a mean follow-up of 12.5 months. The 3 children who benefited the least from dilation were noted to have more diffuse and chronic inflammation of the larynx in comparison to the responders. Conclusions This case series suggests that balloon dilation is a relatively safe and effective procedure. It may be particularly well suited to recent stenosis after laryngotracheal reconstruction.
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Affiliation(s)
- John P. Bent
- Department of Otorhinolaryngology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Maulik B. Shah
- Department of Otorhinolaryngology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Ryan Nord
- Department of Otorhinolaryngology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Sanjay R. Parikh
- Department of Otorhinolaryngology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Abstract
Tonsillectomy is a commonly performed procedure with an accepted risk of posttonsillectomy hemorrhage (PTH) approaching 5%, but catastrophic effects of hemorrhage are exceedingly rare. A variety of surgical techniques and hemostatic agents have been used to reduce the rate of hemorrhage, although none eliminate the risk. Numerous patient, surgical, and postoperative care factors have been studied for an association with PTH. The most consistent risk factors for PTH seem to be patient age and coagulopathies. Surgeon skill and surgical technique are most consistently associated with primary PTH.
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Affiliation(s)
- Ryan M Mitchell
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 256515, Seattle, WA 98195, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 256515, Seattle, WA 98195, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.329, Seattle, WA 98105, USA.
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Rutter MJ, Hart CK, Alarcon AD, Daniel SJ, Parikh SR, Balakrishnan K, Lam D, Johnson K, Sidell DR. Endoscopic anterior-posterior cricoid split for pediatric bilateral vocal fold paralysis. Laryngoscope 2017; 128:257-263. [DOI: 10.1002/lary.26547] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/14/2016] [Accepted: 01/27/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Michael J. Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
- Department of Otolaryngology-Head and Neck Surgery; University of Cincinnati College of Medicine; Cincinnati Ohio U.S.A
- Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Catherine K. Hart
- Division of Pediatric Otolaryngology-Head and Neck Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
- Department of Otolaryngology-Head and Neck Surgery; University of Cincinnati College of Medicine; Cincinnati Ohio U.S.A
- Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology-Head and Neck Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
- Department of Otolaryngology-Head and Neck Surgery; University of Cincinnati College of Medicine; Cincinnati Ohio U.S.A
- Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Sam J. Daniel
- Department of Otolaryngology-Head and Neck Surgery; Montreal Children's Hospital, McGill University Health Centre; Montreal Quebec Canada
| | - Sanjay R. Parikh
- Department of Otolaryngology-Head and Neck Surgery; University of Washington School of Medicine and Seattle Children's Hospital; Seattle Washington U.S.A
| | - Karthik Balakrishnan
- Department of Otorhinolaryngology; Mayo Clinic College of Medicine; Rochester Minnesota U.S.A
| | - Derek Lam
- Division of Pediatric Otolaryngology; Oregon Health & Science University Doernbecher Children's Hospital, Oregon Health and Science University; Portland Oregon U.S.A
| | - Kaalan Johnson
- Department of Otolaryngology-Head and Neck Surgery; University of Washington School of Medicine and Seattle Children's Hospital; Seattle Washington U.S.A
| | - Douglas R. Sidell
- Department of Otolaryngology-Head and Neck Surgery; Division of Pediatric Otolaryngology, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine; Stanford California U.S.A
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Abstract
CONCLUSIONS Pediatric septoplasty may be associated with short-term symptomatic benefit. This benefit may be greater in female patients and equally achievable in young patients and using less invasive surgical approaches. OBJECTIVE To determine the short-term effect of pediatric septoplasty, which is not routinely performed, on sinus and nasal-specific quality-of-life. METHODS This study is a retrospective case series of 28 pediatric patients that underwent septoplasty. Pre- and post-septoplasty SN-5 overall (mean of all five items, range = 1-7) and visual analog scale (VAS; range = 0-10) scores were obtained and compared using a Wilcoxon signed-rank test. Comparisons of pre- to post-septoplasty changes by sex (female vs male), age (<13 vs ≥13 years), and surgical approach (open vs closed) were performed using a Mann-Whitney U-test. Median and interquartile range are reported. RESULTS Overall and VAS scores significantly improved from pre- to post-septoplasty (3.5 [2.8, 4.3] to 2.0 [1.4, 2.8], p < .001; 5.0 [4.0, 6.3] to 8.0 [8.0, 10.0], p < .001). Females reported significantly greater overall and VAS score improvements compared to males (-1.8 [-2.6, -1.6] compared to -1.0 [-1.6, -0.2], p = .01; 5.0 [4.0, 5.0] compared to 3.0 [1.5, 4.0], p = .007). Comparisons of changes by age and surgical approach were not significantly different.
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Richards MK, Czechowicz J, Goldin AB, Gow KW, Doski J, Goldfarb M, Nuchtern J, Langer M, Beierle EA, Vasudevan S, Gupta D, Parikh SR. Survival and Surgical Outcomes for Pediatric Head and Neck Melanoma. JAMA Otolaryngol Head Neck Surg 2017; 143:34-40. [DOI: 10.1001/jamaoto.2016.2630] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Morgan K. Richards
- Department of Surgery, University of Washington, Seattle2Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington
| | - Josephine Czechowicz
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
| | - Adam B. Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington
| | - Kenneth W. Gow
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington
| | - John Doski
- Division of Pediatric Surgery, Methodist Children’s Hospital of South Texas, San Antonio
| | - Melanie Goldfarb
- Department of Surgery, John Wayne Cancer Institute, Santa Monica, California
| | - Jed Nuchtern
- Division of Pediatric Surgery, Baylor College of Medicine, Houston, Texas
| | | | | | - Sanjeev Vasudevan
- Division of Pediatric Surgery, Baylor College of Medicine, Houston, Texas
| | - Deepti Gupta
- Department of Dermatology, Seattle Children’s Hospital, Seattle, Washington
| | - Sanjay R. Parikh
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
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