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OBJECTIVE: Intracranial complications of acute bacterial sinusitis are rare pathologies that occur in children, and are associated with significant neurological morbidity and mortality. There is a subjective concern among neurosurgeons that the incidence of this rare disease has increased since the onset of the novel COVID-19 pandemic. The primary objective of this study was to review the presentation and management of patients admitted at the authors' institution with intracranial extension of sinusitis, to better understand the local disease burden relative to the COVID-19 pandemic. METHODS: This is a single-center retrospective observational cohort study. The patients underwent neurosurgical intervention for intracranial extension of sinusitis between January 1, 2007, and March 1, 2023. The historical cohort was defined as those patients who presented prior to March 2020. Clinical covariates such as surgical and microbiological data were collected and analyzed. RESULTS: A total of 78 patients (55 historical, 23 new) were included; they had a median age of 11.7 years and a male predominance of 69.2%. There was a significant increase in the annual rate of neurosurgical intervention for suppurative intracranial extension of acute bacterial sinusitis after the onset of the COVID-19 pandemic, with an average of 4.2 cases per year prior to March 2020 compared to 7.7 cases per year after that date (p = 0.013). This increase was largely driven by the unprecedented case volume of 13 cases in 2022. Patients in the new cohort were older (p = 0.009) and more likely to have Pott's puffy tumor/frontal bone osteomyelitis (p = 0.003) at the time of presentation than patients in the historical cohort. Patients in the new cohort had lower rates of readmission within 30 days of discharge than those in the historical cohort (p = 0.047). In both cohorts, patients with seizure on presentation were more likely to have neurological sequelae at last follow-up (p = 0.004), which occurred at a median of 2.9 months after discharge. CONCLUSIONS: Clinicians encountering pediatric patients presenting with persistent symptoms of acute bacterial sinusitis must have a high index of suspicion for suppurative intracranial extension. Prompt neuroimaging and subsequent neurosurgical intervention are critical to ensure timely diagnosis and treatment. The results in this study show a significant increase in the number of neurosurgical interventions for suppurative intracranial extension of sinusitis per year after the onset of the COVID-19 pandemic. Further research is needed to understand the underlying pathophysiology of this clinical phenomenon.
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OBJECTIVE: Surgical plume has known potential occupational health hazards. This study compares nanoparticle concentrations in surgical plumes generated between different pediatric tonsillectomy surgical techniques and assesses the efficacy of mitigation measures. METHODS: This is a cross-sectional study performed at a tertiary care academic center. Extracapsular or intracapsular tonsillectomy was performed in 60 patients using four techniques and in 10 additional patients using mitigation measures. Two nanoparticle counters were used to measure particulate concentrations: CPC™ and DiSCmini™. Tonsillectomy techniques included: (1) microdebrider (MD), (2) Bovie with manual suctioning by an assistant (B), (3) Bovie with built-in smoke evacuation system (BS), and (4) Coblator™ (CB). An additional Yankauer suction was used in the mitigation groups (BSY) and (CBY). Comparative analysis was performed using one-way ANOVA on ranks and pairwise comparisons between the groups. RESULTS: The mean concentrations (particles/cm3) and coefficient of variants for the DiSCmini particulate counter were MD: 5140 (1.6), B: 30700 (1.5), BS: 25001 (0.8), CB: 54814 (1.7), CBY: 2395 (1.3) and BSY: 11552 (1.0). Mean concentrations for the CPC particulate counter were MD: 1223 (1.4), B: 3405 (0.7), BS: 5002 (0.9), CB: 13273 (1.0), CBY: 1048 (1.2) and BSY: 3046 (0.6). The lowest mean concentrations were noted in cases using MD and the highest in cases using CB. However, after mitigation, CBY had the lowest overall levels. CONCLUSION: Tonsillectomy technique does impact the levels of nanoparticles emitted within the surgical plume, which may present an occupational hazard for operating room personnel. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2444-2448, 2024.
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Tonsilectomía , Niño , Humanos , Tonsilectomía/métodos , Estudios Transversales , Adenoidectomía , Electrocirugia , Electrocoagulación/métodos , PolvoAsunto(s)
Trastornos de la Motilidad Ciliar , Síndrome de Kartagener , Humanos , Calidad de Vida , CiliosRESUMEN
BACKGROUND: We describe an unusual presentation of EBV-associated mucocutaneous ulcer presenting as a large tumor of the nasopharynx in an immune suppressed child. This condition is newly characterized and has not been well-studied in the otolaryngology literature. CASE REPORT: Our patient is a 12-year-old female undergoing chemotherapy for T-cell acute lymphoblastic leukemia who presented with progressively severe headaches, nasal obstruction, facial pain/pressure, photophobia, fever and otalgia associated with neutropenia and refractory to empiric antibiotic therapy. Bedside nasal endoscopy and imaging revealed signs of acute sinusitis and a large nasopharyngeal mass suspicious for neoplasm. The mass was eccentric to the right and distending the right fossa of Rosenmuller. She underwent endoscopic sinus surgery and biopsy of her nasopharyngeal mass. Pathologic analysis of the nasopharyngeal mass revealed EBV-positive mucocutaneous ulcer. CONCLUSION: This is an unusual presentation of a rare entity. EBV-positive mucocutaneous ulcer warrants awareness among otolaryngologists and is not well-described in our literature.
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Infecciones por Virus de Epstein-Barr , Neoplasias Nasofaríngeas , Humanos , Niño , Femenino , Herpesvirus Humano 4 , Neoplasias Nasofaríngeas/patología , Úlcera/diagnóstico , Úlcera/etiología , Infecciones por Virus de Epstein-Barr/complicaciones , Infecciones por Virus de Epstein-Barr/diagnóstico , EndoscopíaRESUMEN
BACKGROUND: The indication for frontal sinus drainage is uncertain when managing pediatric acute sinusitis with intracranial complications. OBJECTIVE: The primary objective was to determine if addressing the frontal sinus reduced need for subsequent surgical procedures in children presenting with acute sinusitis complicated by intracranial abscess. METHODS: A case series with chart review was performed at a tertiary children's hospital between 2007 and 2019. Children under 18 years of age requiring surgery for complicated acute sinusitis that included the frontal sinus with noncontiguous intracranial abscess were included. Outcomes were compared among children for whom the frontal sinus was drained endoscopically, opened intracranially, or left undrained. RESULTS: Thirty-five children with a mean age of 11.1 years (95% CI: 9.9-12.3) met inclusion. Most presented with epidural abscess (37%). Hospitalizations lasted 12.9 days (95% CI: 10.2-15.5), 46% required a second surgery, 11% required three or more surgeries, and 31% were readmitted within 60 days. Initial surgery for 29% included endoscopic frontal sinusotomy, 34% had a frontal sinus cranialization and 37% did not have any initial drainage of the frontal sinus. Groups were similar with respect to demographics, severity of infection, need for repeat surgery, length of stay, and readmissions (p > .05). Further, persistence of cranial neuropathies, seizures, or major neurological sequelae after discharge were no different among groups (p > .05). CONCLUSION: Drainage of the frontal sinus, when technically feasible, was not associated with reduced surgical procedures or increased complications and there is unclear benefit on measured clinical outcomes.
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Absceso Encefálico , Seno Frontal , Sinusitis Frontal , Sinusitis , Adolescente , Niño , Drenaje , Seno Frontal/cirugía , Sinusitis Frontal/cirugía , Humanos , Estudios Retrospectivos , Sinusitis/cirugíaRESUMEN
BACKGROUND: Suppurative intracranial complications of sinusitis are rare events in children and can lead to harmful neurologic sequelae and significant morbidity. We sought to review the presentation and management of patients admitted at our hospital with these conditions. METHODS: This was a retrospective study of pediatric patients admitted to a quaternary children's hospital from 2007 to 2019 for operative management of sinusitis with intracranial extension. Clinical characteristics, including surgical and microbiological data, were collected and analyzed. RESULTS: Fifty-four patients were included; the median age was 11.0 years, and there was a male predominance. Eighty-nine percent of patients had prior healthcare visits for the current episode of sinusitis; 46% of patients had an abnormal neurologic exam on admission. Epidural abscess and subdural empyema were the most common complications, and subdural empyema was associated with repeat surgical intervention. The dominant pathogens were Streptococcus anginosus group organisms (74%). The majority of patients completed treatment parenterally, with a median duration of therapy of 35 days. Neurological sequelae, including epilepsy or ongoing focal deficits, occurred in 22% of patients. History of seizure or an abnormal neurological exam at admission were associated with neurological sequelae. CONCLUSIONS: Clinicians should consider intracranial complications of sinusitis in patients with symptoms of sinusitis for >1 week. Patients should undergo urgent neuroimaging, as neurosurgical intervention is essential for these patients. Subdural empyema was associated with repeat neurosurgical intervention. Neurological sequelae occurred in 22% of patients, and new onset seizure or an abnormal neurological exam at admission were associated with neurological sequelae.
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Empiema Subdural , Absceso Epidural , Sinusitis , Niño , Empiema Subdural/etiología , Empiema Subdural/cirugía , Absceso Epidural/etiología , Absceso Epidural/cirugía , Humanos , Masculino , Procedimientos Neuroquirúrgicos , Estudios Retrospectivos , Sinusitis/complicacionesRESUMEN
BACKGROUND: The extent of surgery required in the management of pediatric non-medial subperiosteal orbital abscess (SPOA) due to medically refractory complicated acute sinusitis is unknown. OBJECTIVES: The primary objective is to compare operative outcomes of children treated with combined endoscopic sinus surgery (ESS) and external orbital drainage (EOD) versus those treated with EOD alone. METHODS: Retrospective case series from a tertiary children's hospital analyzing outcomes in children requiring surgical management for acute sinusitis complicated by non-medial SPOA between November 2007 and September 2019. RESULTS: Sixteen children with a mean age of 9.4 years (95% CI: 7.3-11.4) met inclusion. Eleven (68.8%) underwent combined EOD and ESS, while five (31.2%) underwent EOD alone. Groups were similar in age, symptom duration, white blood cell count, C-reactive protein level, intraocular pressure, Lund-Mackay score, and abscess volume. There was no significant difference in median length of stay between patients treated with a combined approach versus those treated by EOD alone. Cultures identified non-beta-hemolytic Streptococcus species in 56.3% of patients, with Streptococcus intermedius representing the most common organism in 37.5%. In one case, ESS identified a pathogen not acquired via concomitant EOD, which did influence management. No child required a subsequent surgical procedure and there were no operative complications. CONCLUSIONS: The addition of ESS in the management of pediatric non-medial SPOA was not associated with a statistically different duration of hospitalization. Cultures from concomitant ESS rarely aided in diagnosis or antibiotic therapy. Further study should delineate the indications for ESS in these cases.
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Enfermedades Orbitales , Sinusitis , Absceso/cirugía , Antibacterianos/uso terapéutico , Niño , Drenaje , Humanos , Enfermedades Orbitales/cirugía , Estudios Retrospectivos , Sinusitis/tratamiento farmacológico , Sinusitis/cirugíaRESUMEN
PURPOSE: Surgeons resuming elective procedures during the COVID-19 pandemic should consider strategies to mitigate risk of exposure. For otolaryngologists performing surgery on children, unique vulnerability to SARS-CoV-2 results from a regular interface with the upper respiratory tract mucosa. A growing interest in perioperative application of povidoneiodine (PVP-I) to the nasopharynx and oropharynx has emerged. The purpose of this review is to provide an evidence-based assessment of PVP-I in pediatric oral, nasal and pharyngeal surgery. METHODS: A contemporary literature review with algorithmic approach to the potential use of PVP-I in pediatric mucosal surgery. RESULTS: Several formulations of PVP-I have shown rapid in vitro virucidal activity against SARS-CoV-2. Antisepsis using 1.0% PVP-I mouthwash and 0.45% PVP-I throat spray can occur after 30 seconds of contact time. To date, in vivo effectiveness of PVP-I against SARS-CoV-2 has yet to be established and possible risks of its direct use on upper aerodigestive mucosa of children must be weighed. CONCLUSION: Further research is required prior to strongly recommending PVP-I use in preparation for nasal, oral or pharyngeal surgery in children.
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Antiinfecciosos Locales/administración & dosificación , Infecciones por Coronavirus/prevención & control , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Procedimientos Quirúrgicos Otorrinolaringológicos , Pandemias/prevención & control , Neumonía Viral/prevención & control , Povidona Yodada/administración & dosificación , Betacoronavirus , COVID-19 , Niño , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/transmisión , Humanos , Nasofaringe , Orofaringe , Neumonía Viral/epidemiología , Neumonía Viral/transmisión , SARS-CoV-2RESUMEN
Vascular malformations presenting in the nasal cavity and paranasal sinuses are rare. Differentiating benign vascular malformations of the sinonasal cavity from other pathologic entities can be challenging and the role of preoperative angiography and embolization is not well defined. We present two unique cases of large pediatric sinonasal vascular malformations and describe their presentation, diagnosis and subsequent management. Both patients underwent embolization of the ipsilateral arterial supply followed by successful and complete endonasal surgical excision. This report provides description of management of the very rare occurrence of sinonasal vascular malformation in two adolescents.
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Cavidad Nasal/patología , Senos Paranasales/patología , Malformaciones Vasculares , Adolescente , Humanos , Malformaciones Vasculares/diagnóstico por imagen , Malformaciones Vasculares/cirugíaRESUMEN
BACKGROUND: Exhaled nitric oxide (eNO) is a known biomarker for the diagnosis and monitoring of bronchial hyperreactivity in adults and children. AIMS: To investigate the potential role of eNO measurement for predicting perioperative respiratory adverse events in children, we sought to determine its feasibility and acceptability before adenotonsillectomy. METHODS: We attempted eNO testing in children, 4-12 years of age, immediately prior to admission for outpatient adenotonsillectomy. We used correlations between eNO levels and postoperative adverse respiratory events to make sample size predictions for future studies that address the predictability of the device. RESULTS: One hundred and three (53%) of 192 children were able to provide an eNO sample. The success rate increased with age from 23% (9%-38%) at age 4 to over 85% (54%-98%) after age 9. Using the eNO normal value (<20 ppb) as a cutoff, an expected sample size to detect a significant difference between children with and without adverse events is 868, assuming that respiratory adverse events occur in 29% of children. CONCLUSIONS: eNO testing on the day of surgery has limited feasibility in children younger than 7 years of age. The most common reason for failure was inadequate physical performance while interacting with the testing device. The role of this respiratory biomarker in the context of perioperative outcomes for pediatric adenotonsillectomy remains unknown and should be further studied with improved technologies.
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Pruebas Respiratorias , Óxido Nítrico , Adulto , Biomarcadores , Niño , Preescolar , Espiración , Estudios de Factibilidad , HumanosRESUMEN
OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic requires clinicians to explore alternatives to routine patient management. Otolaryngologists caring for children commonly depend on physical examination, laboratory data, and ambulatory surgical procedures. Limiting patient care, mindful allocation of resources, and concern for safety have challenged all aspects of our health care system. This evidence-based clinical consensus is designed to guide practitioners of pediatric otolaryngology for common scenarios during this time. DATA SOURCES: Peer-reviewed literature, published reports, institutional guidelines, and expert consensus. REVIEW METHODS: A clinical consensus on 6 common scenarios in pediatric otolaryngology developed with evidence-based strategies. CONCLUSIONS: Providers should suspend all in-person nonessential office visits and elective surgical procedures. An emphasis on medical management and caregiver education will provide reasonable approaches to many of the common outpatient concerns. Surgery for chronic otitis media, obstructive sleep apnea, and acute rhinosinusitis should occur only in response to severe complications or failure of medical regimens. The approach to the pediatric neck mass focuses on timely management for oncologic etiologies and cautious surgical intervention for abscess drainage or tissue sampling. Finally, epistaxis and otorrhea must be triaged and addressed without the usual ambulatory procedures. IMPLICATIONS FOR PRACTICE: Adaptation of practice patterns during this unprecedented moment for our health care system requires thoughtful planning. The strategies described allow for safe handling of common pediatric otolaryngology diagnoses. Ultimately, otolaryngologists must be stewards of our global health community while advocating for the care of individual pediatric patients.
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Algoritmos , Betacoronavirus , Consenso , Infecciones por Coronavirus/complicaciones , Hospitales Pediátricos , Otolaringología/normas , Enfermedades Otorrinolaringológicas/terapia , Neumonía Viral/complicaciones , COVID-19 , Niño , Infecciones por Coronavirus/epidemiología , Manejo de la Enfermedad , Salud Global , Humanos , Enfermedades Otorrinolaringológicas/complicaciones , Pandemias , Philadelphia , Neumonía Viral/epidemiología , SARS-CoV-2RESUMEN
OBJECTIVE: To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia. METHODS: A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations. RESULTS: Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging. CONCLUSION: Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.
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Atresia de las Coanas/diagnóstico , Atresia de las Coanas/cirugía , Niño , Preescolar , Consenso , Endoscopía , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Otolaringología , Atención Dirigida al Paciente , Guías de Práctica Clínica como Asunto , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: The microbiology of pediatric complicated acute rhinosinusitis (ARS) has evolved, and our current understanding of pathogenic organisms is limited. The objectives of this study are to describe the incidence of pathogens causing complicated ARS requiring surgical intervention at our institution over a 10-year period as well as their associated treatment outcomes. STUDY DESIGN: Retrospective cohort study. SETTING: A single tertiary care children's hospital. SUBJECTS AND METHODS: Data were reviewed from all patients who underwent surgery for complicated ARS and had positive culture data from 2006 to 2016. Associations among pathogens, complications, and outcomes were analyzed with Pearson χ2 and Wilcoxon rank-sum tests. RESULTS: Eighty-nine patients met criteria. Complications included orbital infections (78%), intracranial infections (48%), Pott's puffy tumor (13%), and cavernous sinus thrombosis (9.0%). Bacterial isolates were majority polymicrobial (55%) and included Streptococcus species (58%), Staphylococcus species (49%; including methicillin-resistant S aureus [MRSA], 11%), and anaerobic bacteria (35%). S pneumoniae (9.0%), Haemophilus species (4.5%), and Moraxella catarrhalis (1.1%) were relatively uncommon. Bacterial isolates were similar among patients with all types of complications. CONCLUSION: Among a large cohort of pediatric patients with complicated ARS, most bacterial isolates were polymicrobial, with Streptococcus and Staphylococcus species contributing to the majority of cases. S aureus species, including MRSA and anaerobic pathogens, were common. The pattern of bacterial isolates was similar among patients with all types of complications of ARS. We suggest treatment for complicated ARS with broad-spectrum antibiotics with coverage for Streptococcus species, Staphylococcus species including MRSA, and anaerobic bacteria.
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Rinitis/complicaciones , Rinitis/microbiología , Sinusitis/complicaciones , Sinusitis/microbiología , Enfermedad Aguda , Adolescente , Factores de Edad , Antibacterianos/uso terapéutico , Niño , Preescolar , Femenino , Haemophilus/aislamiento & purificación , Humanos , Masculino , Moraxella/aislamiento & purificación , Estudios Retrospectivos , Rinitis/terapia , Sinusitis/terapia , Staphylococcus/aislamiento & purificación , Streptococcus/aislamiento & purificaciónRESUMEN
INTRODUCTION: Invasive fungal sinusitis (IFS) is a rare but deadly clinical entity that occurs in immunocompromised patients. Diagnosis in children typically requires operative biopsies under general anesthesia, which has associated risks. Findings on bedside nasal endoscopy (BNE) can be used with history, exam, and imaging to determine the need for surgery, however, the accuracy of this tool has not been established among pediatric patients. METHODS: Patients who underwent BNE for evaluation of IFS from 2008 to 2016 at the Children's Hospital of Philadelphia were identified using Current Procedural Terminology (CPT) codes. Retrospective chart analysis was performed and included underlying diagnoses, presenting signs and symptoms, imaging findings, endoscopic findings and outcomes. RESULTS: Nineteen patients were identified who underwent evaluation for IFS using BNE during the period studied. Eight patients had exam findings that were concerning for IFS, including debris or crusting, darkened or pale mucosa, or copious, thick and/or purulent secretions. Immediate operative biopsies and debridement revealed IFS in six of eight patients. Eleven patients had exam findings deemed not concerning for IFS including mucosal edema, mucous without purulence, or normal findings. Six of eleven patients underwent operative biopsy despite negative endoscopy, and five were observed clinically. None of the 11 patients with negative bedside endoscopy developed IFS. CONCLUSIONS: All patients with IFS had concerning exam findings on endoscopy and were treated with immediate biopsies and debridement. No patient with normal or non-concerning findings on BNE progressed to have invasive fungal sinusitis. While suspicion for IFS in immunocompromised children must remain high, BNE is feasible and useful in its assessment.
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Endoscopía/métodos , Infecciones Fúngicas Invasoras/diagnóstico , Sinusitis/diagnóstico , Adolescente , Niño , Preescolar , Desbridamiento/métodos , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Nariz/patología , Senos Paranasales/microbiología , Philadelphia , Estudios Retrospectivos , Sinusitis/microbiología , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
OBJECTIVES/HYPOTHESIS: To determine the pediatric age groups viable for nasoseptal flap (NSF) reconstruction of endoscopic endonasal approaches (EEA) to intracranial pathology of suprasella neoplasms. STUDY DESIGN: Retrospective cohort study. METHODS: Retrospective review of 16 pediatric patients who underwent EEA with NSF reconstruction for a suprasellar defect from 2012 to 2014. Radioanatomic analysis was utilized to assess feasibility of NSF reconstruction of suprasellar neoplasms approached via EEA. Computed tomography (CT) measurements for defect size and potential flap coverage were measured by preoperative maxillofacial CT. Radiographic measurements and surgical outcomes were compared to determine if flap size would be sufficient to cover said defects in two pediatric age groups: those>10 years of age (mean age 14 years) and those<10 years (mean age 6 years). RESULTS: Of all patients encountered in this cohort, one postoperative cerebrospinal fluid leak was identified in the >10 years of age population, and this was not due to insufficient flap coverage. Average potential flap length and width are sufficient to cover average suprasellar defect length and width in both age groups (P<.05 in all age groups). CONCLUSIONS: Patient selection is critical for successful pediatric EEA. Preoperative radiographic assessment of NSF feasibility is a critical to ensure adequate flap coverage for suprasellar defects. NSF appears to provide a sufficient and reliable coverage option in reconstruction of suprasellar defects in pediatric patients. LEVEL OF EVIDENCE: 4.
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Tabique Nasal/cirugía , Colgajos Quirúrgicos , Adolescente , Pérdida de Líquido Cefalorraquídeo/etiología , Niño , Estudios de Cohortes , Craneofaringioma/cirugía , Endoscopía , Humanos , Nariz , Neoplasias Hipofisarias/cirugía , Complicaciones Posoperatorias , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Neoplasias de la Base del Cráneo/cirugía , Tomografía Computarizada por Rayos XRESUMEN
IMPORTANCE: More than 500,000 children undergo tonsillectomy each year in the United States. Although prior studies suggest that most patients received perioperative antibiotics, practice varies across centers. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published a practice guideline recommending against perioperative antibiotic use for pediatric tonsillectomy. The impact of this recommendation has not been thoroughly examined. OBJECTIVE: To determine the impact of the AAO-HNS guideline on the use of perioperative antibiotics and patient outcomes for pediatric tonsillectomy. DESIGN, SETTING, AND PARTICIPANTS: This was a quasi-experimental study including 9265 children who underwent routine tonsillectomy from January 2009 through August 2012 within a large pediatric health care network containing hospital-based and ambulatory surgical facilities. Data were collected from a shared electronic health record and validated through manual medical record review. We used an interrupted time series analysis with segmented logistic regression and a nonequivalent dependent variable (tympanoplasty) to assess acute changes and differences in trends over time relative to guideline publication. INTERVENTIONS: Publication of the AAO-HNS clinical practice guideline. MAIN OUTCOMES AND MEASURES: The primary outcome was antibiotic administration on the day of surgery. Secondary outcomes included otolaryngology clinic encounters, emergency department encounters, hospital admissions, and surgical procedures for bleeding in the 30 days following tonsillectomy. RESULTS: Of 9265 tonsillectomies during the study period, 5359 met inclusion criteria. Immediately after guideline publication, perioperative antibiotic use dropped by 86.5% (P < .001) and was sustained throughout the postintervention period. Rates of otolaryngology clinic encounters, emergency department encounters, and hospital admissions did not change significantly over time. There was a small but statistically significant increase in surgical procedures for bleeding following the intervention from 1.35% (95% CI, 0.57%-2.14%) to 3.48% (95% CI, 1.85%-5.10%). CONCLUSIONS AND RELEVANCE: AAO-HNS guideline publication decreased perioperative antibiotic use for pediatric tonsillectomy across a large pediatric health care network. Although there were no changes in otolaryngology clinic visits, emergency department visits, or admissions, we found a small but significant increase in surgery for bleeding following guideline publication. Additional studies are necessary to verify this unexpected association.
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Antibacterianos/uso terapéutico , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Tonsilectomía , Niño , Femenino , Humanos , Masculino , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: Retrospective studies have limitations in predicting perioperative risk following adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS). Few prospective studies exist. We hypothesized that demographic and polysomnographic (PSG) variables would predict respiratory and general perioperative complications. STUDY DESIGN: Prospective, observational cohort study. SETTING: Pediatric tertiary center. SUBJECTS AND METHODS: Consecutive children undergoing adenotonsillectomy for OSAS within 12 months of PSG were evaluated for complications occurring within 2 weeks of surgery. RESULTS: There were 329 subjects, with 27% <3 years old, 24% obese, 16% preterm, and 29% with comorbidities. In this higher risk population, 28% had respiratory complications (major and/or minor), and 33% had nonrespiratory complications. Significant associations were found between PSG parameters and respiratory complications as follows: apnea hypopnea index (rank-biserial correlation coefficient [r] = 0.174, P = .017), SpO2 nadir (r = -0.332, P < .0005), sleep time with SpO2 <90% (r = 0.298, P < .0005), peak end-tidal CO2 (r = 0.354, P < .0005), and sleep time with end-tidal CO2 >50 mm Hg (r = 0.199, P = .006). Associations were also found between respiratory complications and age <3 years (r = -0.174, P = .003) or black race (r = 0.123, P = .039). No significant associations existed between PSG parameters and nonrespiratory complications. A model using age <3 years, SpO2 nadir, and peak CO2 predicted respiratory complications better than the American Academy of Pediatrics or American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines but was imperfect (area under the curve = 0.72). CONCLUSION: Thus, PSG predicted perioperative respiratory, but not nonrespiratory, complications in children with OSAS. Age <3 years or black race are high-risk factors. Present guidelines have limitations in determining the need for postoperative admission.
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Adenoidectomía/efectos adversos , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/cirugía , Tonsilectomía/efectos adversos , Adenoidectomía/métodos , Adolescente , Distribución por Edad , Niño , Preescolar , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Hospitales Pediátricos , Humanos , Incidencia , Masculino , Polisomnografía/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Medición de Riesgo , Índice de Severidad de la Enfermedad , Distribución por Sexo , Tonsilectomía/métodos , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: The timing and role of surgery in the management of pediatric chronic rhinosinusitis (pCRS) remains unclear. This review attempts to summarize the existing literature regarding this topic. RECENT FINDINGS: pCRS is a complex clinical syndrome that results from multiple potential causes. Multimodal medical therapy is the accepted primary treatment. Adenoidectomy continues to be the appropriate first-line surgical therapy, and the addition of antral lavage or balloon dilation to this procedure may improve outcomes. Functional endoscopic sinus surgery (FESS) in children is safe and effective in relieving symptoms in the majority of patients. Failure to respond to maximal medical therapy continues to be a commonly cited, although poorly defined, requisite for proceeding to surgery. Recent literature has been focused on the outcomes after FESS rather than specifically defining when this intervention should be considered. Nevertheless, the literature seems to continue to support FESS in children with persistent symptoms despite adenoidectomy and appropriate medical treatment for pCRS. As the symptoms of chronic rhinosinusitis (CRS) may result from multiple underlying causes, clinicians must understand that the role and timing of surgery may vary with particular patients' disease. SUMMARY: Surgical management of CRS in children continues to be a frequent topic of study in the otolaryngology literature. As recent research tends to be focused on outcomes after surgery, further prospective studies comparing surgical versus nonsurgical treatment of CRS will likely be required to better define indications for proceeding to surgery at all.
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Rinitis/cirugía , Sinusitis/cirugía , Niño , Enfermedad Crónica , Humanos , Resultado del TratamientoAsunto(s)
Tonsila Palatina/cirugía , Tonsilectomía/métodos , Obstrucción de las Vías Aéreas/patología , Obstrucción de las Vías Aéreas/cirugía , Anestesia , Antiinflamatorios/uso terapéutico , Niño , Dexametasona/uso terapéutico , Humanos , Laringoscopía , Masculino , Fibras Ópticas , Tonsila Palatina/patología , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/etiología , Lengua/patología , Lengua/cirugíaRESUMEN
PURPOSE: The aim of the study was to determine the prognostic impact of preepiglottic space (PES) involvement on local failure after concurrent chemoradiation therapy for squamous cell carcinoma. MATERIALS AND METHODS: Retrospective chart review of patients who underwent concurrent chemoradiation therapy for T3 or T4 laryngeal, T4 hypopharyngeal, and T3 or T4 oropharyngeal squamous cell carcinoma were eligible for inclusion. Patients were then stratified by the presence or absence of PES tumor involvement. A multivariate analysis was performed on the presence of recurrence using the following pretreatment variables: PES involvement, tumor extent, pathologic cell differentiation, lymph node involvement, age, and sex. RESULTS: A total of 102 patients were included in the study. Twenty-seven (28%) patients had documented PES involvement. Mean follow-up for all patients was 46 months. Involvement of the PES was not significantly associated with local tumor persistence or recurrence (P = .69). No other variables significantly impacted tumor recurrence. CONCLUSION: Preepiglottic space involvement does not negatively impact local tumor control after concurrent chemoradiation therapy.