2015 HSC Section 1 Book of Articles

THE HOME STUDY COURSE IN OTOLARYNGOLOGY — HEAD AND NECK SURGERY

SECTION 1

Congenital and Pediatric Problems

September 2015

1999

SECTION FACULTY:

William O. Collins, MD ** J. Fredrik Grimmer, MD** Marc C. Thorne, MD MPH** Matthew T. Brigger, MD Eunice Y. Chen, MD, PhD Nira Goldstein, MD, MPH Jeffrey C. Rastatter, MD Carlton J. Zdanski, MD

American Academy of Otolaryngology—Head and Neck Surgery Foundation

Section 1 exam deadline: October 9, 2015 Expiration Date: August 5, 2016; CME credit not available after that date

SECTION 1 CONGENITAL AND PEDIATRIC PROBLEMS

Introduction (Purpose) The Home Study Course is designed to provide relevant and timely clinical information for physicians in training and current practitioners in otolaryngology - head and neck surgery. The course, spanning four sections, allows participants the opportunity to explore current and cutting edge perspectives within each of the core specialty areas of otolaryngology. The Selected Recent Material represents primary fundamentals, evidence-based research, and state of the art technologies in congenital and pediatric problems. The scientific literature included in this activity forms the basis of the assessment examination. The number and length of articles selected are limited by editorial production schedules and copyright permission issues, and should not be considered an exhaustive compilation of knowledge on congenital and pediatric problems. The Additional Reference Material is provided as an educational supplement to guide individual learning. This material is not included in the course examination and reprints are not provided. Needs Assessment AAO-HNSF’s education activities are designed to improve healthcare provider competence through lifelong learning. The Foundation focuses its education activities on the needs of providers within the specialized scope of practice of otolaryngologists. Emphasis is placed on practice gaps and education needs identified within eight subspecialties. The Home Study Course selects content that addresses these gaps and needs within all subspecialties. Target Audience The primary audience for this activity is physicians and physicians-in-training who specialize in otolaryngology-head and neck surgery.

Outcomes Objectives The participant who has successfully completed this section should be able to:

Airway, Bronchoesophagology, and Laryngology 1) Recognize the societal costs of airway foreign bodies, including potential serious complications that might affect these patients. 2) Apply a possible method to more effectively wean sedation following laryngotracheal reconstruction, and the potential advantages and disadvantages of different protocols. 3) Decribe the changes in vocal fold structure and pathologic findings such as nodules in children as they mature, and how these changes affect treatment decisions. 4) Define mechanisms of swallowing dysfunction following laryngeal cleft repair.

Craniofacial Abnormalities and Trauma 1) Recognize common patterns of craniosynostosis, and be able to understand the etiology and treatment options. 2) Describe the manifestations of obstructive sleep apnea in the cleft population, including risk factors for airway obstruction and potential complications of treatment. 3) Identify the indications for mandibular distraction in micrognathic patients, and potential costs as well as success rates for surgical repair. 4) Recognize common patterns of facial fractures in children, as well as unique characteristics in this patient population which guide management. Adenotonsillar Disease and Sleep Disorders 1) Weigh the advantages and disadvantages of treatment with perioperative dexamethasone. 2) Apply medical treatment options for children with mild obstructive sleep apnea. 3) Interpret common practice guidelines for obtaining a polysomnogram in children prior to consideration of undergoing an adenotonsillectomy. 4) Consider the implications of using common anti-inflammatory medications for pain control following an adenotonsillectomy, including possible complications requiring trips to the emergency department. 5) Recognize the possibilities regarding weight gain following an adenotonsillectomy. Rhinology 1) Communicate in a coordinated manner regarding common manifestations of pediatric chronic rhinosinusitis. 2) Recognize the implications of anti-Pneumococcal vaccines on the prevalence and complications of pediatric sinusitis. 3) Describe the advantages and disadvantages of different surgical approaches for treatment of juvenile nasopharyngeal angiofibroma. 4) Understand long term implications in patients undergoing sinus surgery for complications of acute sinusitis. Otology 1) Recognize the long term costs to individuals and society of pediatric cochlear implantation. 2) Define the indications for cochlear implantation in children, particularly as it relates to the hearing loss identified on auditory brainstem response testing. 3) Use the clinical practice guidelines regarding tympanostomy tube placement in children. 4) Recognize the indications of a canal wall up vs. canal wall down mastoidectomy in children. 5) Describe surgical treatment options of cochlear nerve deficiency. Head and Neck 1) Compare different diagnostic imaging modalities in the management of pediatric patients with lateral neck abscesses. 2) Compare potential genetic etiologies of thyroid carcinoma in pediatric patients. 3) Describe common etiologies of pediatric neck masses, including diagnostic and therapeutic modalities. 4) Apply guidelines for use of Propranolol in the treatment of infants with hemangiomas 5) Recognize the classification of vascular anomalies in children.

Medium Used The Home Study Course is available as printed text. The activity includes a review of outcomes objectives, selected scientific literature, and a self-assessment examination. Method of Physician Participation in the Learning Process The physician learner will read the selected scientific literature, reflect on what they have read, and complete the self-assessment exam. After completing this section, participants should have a greater understanding of congenital and pediatric problems as they affect the head and neck area, as well as useful information for clinical application. Accreditation Statement The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit Designation The AAO-HNSF designates this enduring material for a maximum of 40.0 AMA PRA Category 1 Credit(s) ™. Physicians should claim credit commensurate with the extent of their participation in the activity. ALL PARTICIPANTS must record the amount of credit claimed based on the number of hours actually spent in this activity. Indicate this amount in the appropriate section of the exam in order to either receive Credit or to have exam results provided to the Training Program Director. PHYSICIANS ONLY : In order to receive Credit for this activity a post-test score of 70% or higher is required . Credit will not automatically be awarded. Only when you achieve a score of 70% or higher on the post-test will you be awarded Credit. A one-time retest opportunity will be available with a retest fee. Disclosure The American Academy of Otolaryngology Head and Neck Surgery/Foundation (AAO-HNS/F) supports fair and unbiased participation of our volunteers in Academy/Foundation activities. All individuals who may be in a position to control an activity’s content must disclose all relevant financial relationships or disclose that no relevant financial relationships exist. All relevant financial relationships with commercial interests 1 that directly impact and/or might conflict with Academy/Foundation activities must be disclosed. Any real or potential conflicts of interest 2 must be identified, managed, and disclosed to the learners. In addition, disclosure must be made of presentations on drugs or devices, or uses of drugs or devices that have not been approved by the Food and Drug Administration. This policy is intended to openly identify any potential conflict so that participants in an activity are able to form their own judgments about the presentation. [1] A “Commercial interest” is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. 2 “Conflict of interest” is defined as any real or potential situation that has competing professional or personal interests that would make it difficult to be unbiased. Conflicts of interest occur when an individual has an opportunity to affect education content about products or services of a commercial interest with which they have a financial relationship. A conflict of interest depends on the situation and not on the character of the individual. Estimated time to complete this activity: 40.0 hours

Faculty **Co-Chairs William O. Collins, MD, Associate Professor, University of Florida College of Medicine, Department of Otolaryngology-Head & Neck Surgery, Gainesville, Florida. Disclosure: No relationships to disclose. J. Fredrik Grimmer, MD, Associate Professor, Department of Surgery, Division of Otolaryngology, University of Utah, Salt Lake City, Utah. Disclosure: No relationships to disclose. Marc C. Thorne, MD , MPH, Associate Professor, Department of Otolaryngology─Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Michigan, Ann Arbor, Michigan. Disclosure: No relationships to disclose. Faculty Matthew T. Brigger, MD, Associate Professor, Department of Surgery, Division of Otolaryngology, University of California San Diego, Rady Children’s Hospital San Diego, San Diego, California. Disclosure: No relationships to disclose. Eunice Y. Chen, MD, PhD, Assistant Professor, Department of Surgery and Pediatrics, Section of Otolaryngology-Head and Neck Surgery, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Disclosure: No relationships to disclose. Nira Goldstein, MD, MPH, Professor of Clinical Otolaryngology, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, New York. Disclosure: No relationships to disclose. Jeffrey C. Rastatter, MD, Pediatric Otolaryngology - Head and Neck Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago; Assistant Professor, Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Disclosure: No relationships to disclose. Carlton J. Zdanski, MD, Associate Professor of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Disclosures: Salary: Research Triangle Institute Royalty: Covidien Intellectual Property: National Institutes of Health

Planner(s): Linda Lee, AAO─HNSF Education Program Manager Stephanie Wilson, Stephanie Wilson Consulting, LLC;

No relationships to disclose No relationships to disclose

Production Manager Sonya Malekzadeh MD, chair, AAO-HNSF Education Steering No relationships to disclose Committee Kenny Chan, MD, chair, AAO-HNSF Pediatric Otolaryngology No relationships to disclose Education Committee

This 2015 Home Study Course Section 1does not include discussions of any drugs and devices that have not been approved by the United States Food and Drug Administration.

Disclaimer The information contained in this activity represents the views of those who created it and does not necessarily represent the official view or recommendations of the American Academy of Otolaryngology – Head and Neck Surgery Foundation.

June 10, 2016: Deadline for all 2015-16 exams to be received without late score fee .

EVIDENCE BASED MEDICINE The AAO-HNSF Education Advisory Committee approved the assignment of the appropriate level of evidence to support each clinical and/or scientific journal reference used to authenticate a continuing medical education activity. Noted at the end of each reference, the level of evidence is displayed in this format: [EBM Level 3] .

Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) Level 1

Randomized 1 controlled trials 2 or a systematic review 3 (meta-analysis 4 ) of randomized controlled trials 5 . Prospective (cohort 6 or outcomes) study 7 with an internal control group or a systematic review of prospective, controlled trials. Retrospective (case-control 8 ) study 9 with an internal control group or a systematic review of retrospective, controlled trials. Case series 10 without an internal control group (retrospective reviews; uncontrolled cohort or outcome studies). Expert opinion without explicit critical appraisal, or recommendation based on physiology/bench research.

Level 2

Level 3

Level 4

Level 5

Two additional ratings to be used for articles that do not fall into the above scale. Articles that are informational only can be rated N/A , and articles that are a review of an article can be rated as Review. All definitions adapted from Glossary of Terms, Evidence Based Emergency Medicine at New York Academy of Medicine at www.ebem.org .

1 A technique which gives every patient an equal chance of being assigned to any particular arm of a controlled clinical trial. 2 Any study which compares two groups by virtue of different therapies or exposures fulfills this definition. 3 A formal review of a focused clinical question based on a comprehensive search strategy and structure critical appraisal. 4 A review of a focused clinical question following rigorous methodological criteria and employing statistical techniques to combine data from independently performed studies on that question. 5 A controlled clinical trial in which the study groups are created through randomizations. 6 This design follows a group of patients, called a “cohort”, over time to determine general outcomes as well as outcomes of different subgroups. 7 Any study done forward in time. This is particularly important in studies on therapy, prognosis or harm, where retrospective studies make hidden biases very likely. 8 This might be considered a randomized controlled trial played backwards. People who get sick or have a bad outcome are identified and “matched” with people who did better. Then, the effects of the therapy or harmful exposure which might have been administered at the start of the trial are evaluated. 9 Any study in which the outcomes have already occurred before the study has begun. 10 This includes single case reports and published case series.

CONGENITAL AND PEDIATRIC PROBLEMS Section 1 September 2015 Outline

I.

Airway, Bronchoesophagology, and Laryngology

II.

Craniofacial Abnormalities and Trauma

III.

Adenotonsillar Disease and Sleep Disorders

IV.

Rhinology

V.

Otology

VI.

Head and Neck

TABLE OF CONTENTS

Section 1 September 2015 CONGENITAL AND PEDIATRIC PROBLEMS SELECTED RECENT MATERIALS—REPRODUCED IN THIS STUDY GUIDE

ADDITIONAL REFERENCE MATERIAL ...................................................................................... i - iii

I.

Airway, Bronchoesophagology, and Laryngology Kim IA, Shapiro N, Bhattacharyya N. The national cost burden of bronchial foreign body aspiration in children. Laryngoscope . 2014 Nov 1. doi:10.1002/lary.25002. (Epub ahead of print). EBM level 2c.........................................................................................1-4 Summary: This article provides a national perspective on foreign-body aspirations during the period of 2009-2011 using a publicly available database that samples a wide range of hospitals in the United States. The study presents descriptive statistics regarding the significant public health impact of this potentially fatal problem. Kozin ED, Cummings BM, Rogers DJ, et al. Systemwide change of sedation wean protocol following pediatric laryngotracheal reconstruction. JAMA Otolaryngol Head Neck Surg . 2015; 141(1):27-33. EBM level 2..............................................................5-11 Summary: This article describes the experience of implementing a defined quality- improvement strategy with a goal of decreasing variation and ultimately duration of sedation weaning after open airway reconstructive procedures. The study delivers interesting data regarding how the duration of sedation has improved after the introduction of the protocol as well as a framework for other quality improvement projects. Nardone HC, Recko T, Huang L, Nuss RC. A retrospective review of the progression of pediatric vocal fold nodules. JAMA Otolaryngol Head Neck Surg . 2014; 140(3):233- 236. EBM level 4.........................................................................................................12-15 Summary: This article reviews the progression of vocal fold nodules followed in a pediatric voice clinic with a goal of determining the change in size based on initial grade, various management strategies, and age. The authors conclude that directed speech therapy or surgery is associated with a greater rate of decreasing size in high- grade nodules than observation or behavioral modification alone.

Osborn AJ, de Alarcon A, Tabangin ME, et al. Swallowing function after laryngeal cleft repair: more than just fixing the cleft. Laryngoscope . 2014; 124(8):1965-1969. EBM level 4...........................................................................................................................16-20 Summary: This retrospective review of swallowing outcomes after laryngeal cleft repair provides a detailed postoperative characterization using a validated swallowing scale applied to video fluoroscopic and video endoscopic swallowing examinations. The authors conclude that most children achieve resolution of dysphagia or require minimal dietary modification while a subset of children with developmental disorders is at increased risk for persistent dysphagia. This data is important given the increasing recognition of laryngeal cleft as a cause of dysphagia.

Rogers DJ, Setlur J, Raol N, et al. Evaluation of true vocal fold growth as a function of age. Otolaryngol Head Neck Surg . 2014; 151(4):681-686. EBM level 4.................21-26

Summary: This article provides an in vivo evaluation of vocal fold length as a function of age and gender. The authors found that vocal fold length increases linearly as a function of age with no difference between genders. Ultimately, the study concludes that the critical developmental vocal changes that occur during adolescence are not attributable to vocal fold length differences.

II.

Craniofacial Abnormalities and Trauma Boyette JR. Facial fractures in children. Otolaryngol Clin North Am . 2014; 47(5):747- 761. EBM level 5.........................................................................................................27-41 Summary: This articles provides an overview of the unique aspects of diagnosis and management of facial fractures in children. Because of their growing facial skeletons, facial fractures in children can present differently than in adults, and potential surgical treatments must be appropriately modified based on the patient’s age. Different facial subsites are reviewed in detail, and the article provides a current protocol for managing pediatric facial fractures. In addition, long-term awareness of facial growth changes must be considered in this patient population. Lam DJ, Tabangin ME, Shikary TA, et al. Outcomes of mandibular distraction osteogenesis in the treatment of severe micrognathia. JAMA Otolaryngol Head Neck Surg . 2014; 140(4):338-345. EBM level 3.................................................................42-49 Summary: Children with severe micrognathia are often afflicted with upper airway obstruction, and management is both difficult and controversial. This article reviews the outcomes of mandibular distraction osteogenesis, both with and without preexisting tracheotomy, in a study of 123 patients with severe micrognathia who underwent mandibular distraction and examines the long-term success rates with each approach. In addition, specific patient populations are examined for their success rates.

Muntz HR. Management of sleep apnea in the cleft population. Curr Opin Otolaryngol Head Neck Surg . 2012; 20(6):518-521. EBM level 4................................................50-53

Summary: This article reviews the importance of the diagnosis and management of obstructive sleep apnea in children with facial clefting. Diagnostic work-up and potential interventions are discussed in detail. Commonly encountered clinical scenarios, including Pierre Robin sequence, post-VPI repair OSA, and midface hypoplasia are discussed as well as potential surgical treatment options for each. Okada H, Gosain AK. Current approaches to management of nonsyndromic craniosynostosis. Curr Opin Otolaryngol Head Neck Surg . 2012; 20(4):310-317. EBM level 4...........................................................................................................................54-61 Summary: This is a review article detailing the pathogenesis of non-syndromic craniosynostosis and the imaging necessary to accurately make the diagnosis. A review of the history of surgical repair options is included as well as descriptions for current surgical techniques. Advantages and limitations of different interventions are discussed in detail. Runyan CM, Uribe-Rivera A, Karlea A, et al. Cost analysis of mandibular distraction versus tracheostomy in neonates with Pierre Robin sequence. Otolaryngol Head Neck Surg . 2014; 151(5):811-818. EBM level 3.................................................................62-69 Summary: Several surgical options are available to treatment upper airway obstruction in neonates with Pierre Robin sequence. This article examines the cost of two of those surgical approaches, tracheotomy and mandibular distraction, in a study of 47 patients. The mandibular distraction groups appeared to have lower overall costs, despite having no difference in overall hospital stay length between the groups. Adenotonsillar Disease and Sleep Disorders Bedwell JR, Pierce M, Levy M, Shah RK. Ibuprofen with acetaminophen for postoperative pain control following tonsillectomy does not increase emergency department utilization. Otolaryngol Head Neck Surg . 2014; 151(6):963-966. EBM level 3...........................................................................................................................70-73 Summary: This is a retrospective case series of children who underwent tonsillectomy with or without adenoidectomy comparing pain control in patients who received acetaminophen with codeine vs. acetaminophen and ibuprofen. The proportion of patients requiring emergency department visits for inadequate pain management was not significantly different between groups on both bivariate and multivariate analysis controlling for age and antibiotic use.

III.

Gallagher TQ, Hill C, Ojha S, et al. Perioperative dexamethasone administration and risk of bleeding following tonsillectomy in children: a randomized controlled trial. JAMA . 2012; 308(12):1221-1226. EBM level 1......................................................................74-79 Summary: This is a multicenter, prospective, randomized placebo-controlled trial of perioperative dexamethasone as a risk factor for postoperative bleeding following tonsillectomy. Using a noninferiority study design, perioperative dexamethasone was not associated with excessive clinically significant bleeding requiring hospital admission or reoperation, but increased mild, self-reported bleeding events could not be excluded.

Katz ES, Moore RH, Rosen CL, et al. Growth after adenotonsillectomy for obstructive sleep apnea: an RCT. Pediatrics . 2014; 134(2):282-289. EBM level 1....................80-87

Summary: This article describes secondary outcomes from a multicenter, randomized controlled trial of adenotonsillectomy in children for treatment of obstructive sleep apnea evaluating anthropometric changes. The adenotonsillectomy children demonstrated significantly greater weight increases in all weight categories at the 7-month follow up compared to the children in the watchful waiting group. This occurred in both overweight and non-overweight children, but overweight children were more likely to be obese at follow up.

Kheirandish-Gozal L, Bhattacharjee R, Bandla HP, Gozal D. Antiinflammatory therapy outcomes for mild OSA in children. Chest . 2014; 146(1):88-95. EBM level 4........88-95

Summary: This is a retrospective review of 836 children with mild obstructive sleep apnea treated with a combination of 12 weeks of an intranasal steroid and oral montelukast to determine polysomnography outcomes. A beneficial response was found in >80% of children. The authors recommend implementation of a multicenter randomized trial to further establish the role of anti-inflammatory therapy for children with mild OSA. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg . 2011; 145(1S):S1-S15. EBM level 1.......................96-110 S ummary: This is a clinical practice guideline produced for otolaryngologists by the American Academy of Otolaryngology–Head and Neck Surgery Foundation to provide evidence-based recommendations for using polysomnography to assess sleep-disordered breathing prior to tonsillectomy in children aged 2 to 18 years. Specific action statements were formulated regarding the indications for polysomnography, advocating for polysomnography, communication with the anesthesiologist, inpatient admission for children with obstructive sleep apnea, and the use of unattended polysomnography.

IV.

Rhinology Boghani Z, Husain Q, Kanumuri VV, et al. Juvenile nasopharyngeal angiofibroma: a systematic review and comparison of endoscopic, endoscopic-assisted, and open resection in 1047 cases. Laryngoscope . 2013; 123(4):859-869. EBM level 3a......................................................................................................................111-121 Summary: This article presents a systematic review of English-language articles reporting on results of surgical management of juvenile nasopharyngeal angiofibroma published between 1990 and 2012. The authors separately analyze those studies reporting individual patient data (mainly case reports and small case series) and aggregate patient data (larger case series and prospective studies). Brietzke, SE, Shin JJ, Choi S, et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg . 2014; 151(4):542-553. EBM level 5.......................................................................................................................122-133 Summary: This article is a summary of an expert panel consensus which was convened to help optimize the diagnosis and management of pediatric chronic rhinosinusitis (PCRS). The conclusions were assembled after using a Delphi method survey of nine experts and can be categorized as topics relevant to the definition and diagnosis of PCRS, medical management, adenoiditis/adenoidectomy, and endoscopic sinus surgery and turbinate surgery. Lindstrand A, Bennet R, Galanis I, et al. Sinusitis and pneumonia hospitalization after introduction of pneumococcal conjugate vaccine. Pediatrics . 2014; 134(6):e1528-e1536. EBM level 3..............................................................................................................134-142 Summary: This is a population study examining the risk of hospitalization for pneumonia, sinusitis, and empyema following vaccination with pneumococcal conjugate vaccines PCV7 and PCV13. This study shows reduced risk of hospitalization for pneumonia in children under age 5 years and sinusitis in children under 2 years. Olarte L, Hulten KG, Lamberth L, et al. Impact of the 13-valent pneumococcal conjugate vaccine on chronic sinusitis associated Streptococcus pneumoniae in children. Pediatr Infect Dis J . 2014; 33(10):1033-1036. EBM level 3..............................................143-146 Summary: This is a retrospective study of 91 pediatric patients who underwent endoscopic sinus surgery and S. pneumoniae was identified via intraoperative culture. Comparison was made of the serotype of S. pneumoniae identified before and after 13-valent pneumococcal conjugate vaccine (PCV13) vaccinations were implemented. Following the introduction of PCV13, the rate of isolation of S. pneumoniae decreased, particularly of serotype 19A.

Patel RG, Daramola OO, Linn D, et al. Do you need to operate following recovery from complications of pediatric acute sinusitis? Int J Pediatr Otorhinolaryngol . 2014; 78(6):923-925. EBM level 4....................................................................................147-149 Summary: This is a retrospective study of 86 pediatric patients who were hospitalized and treated for complications of acute sinusitis. Overall, these patients, whether they were initially treated medically or surgically, were unlikely to require secondary endoscopic sinus surgery in the future. Otology Colletti L, Colletti G, Mandalà M, Colletti V. The therapeutic dilemma of cochlear nerve deficiency: cochlear or brainstem implantation? Otolaryngol Head Neck Surg . 2014; 151(2):308-314. EBM level 3..................................................................................150-156 Summary: This is an excellent article presenting the largest case series on auditory brainstem implants for children with cochlear nerve deficiency. Speech and language results and reasonable expectations from both cochlear implantation and auditory brainstem implantation are discussed. Hang AX, Roush PA, Teagle HF, et al. Is “no response” on diagnostic auditory brainstem response testing an indication for cochlear implantation in children? Ear Hear . 2015; 36(1):8-13. EBM level 4................................................................................157-162 Summary: This article provides a review of clinical outcomes of children who had “no response” diagnostic auditory brainstem responses, which was highly predictive of receiving a cochlear implant in the vast majority of children (a few children did not receive cochlear implants for various reasons but not due to residual hearing). Sound recommendations regarding caregiver counseling and treatment planning are outlined. Osborn AJ, Papsin BC, James AL. Clinical indications for canal wall-down mastoidectomy in a pediatric population. Otolaryngol Head Neck Surg . 2012; 147(2):316-322. EBM level 4..................................................................................163-169 Summary: This article presents a large case series of canal wall-up and canal wall- down mastoidectomy in children with cholesteatoma. The authors present compelling reasoning for choosing either procedure depending upon the clinical scenario and a variety of other factors. Reasonable expectations for outcomes, both with respect to recidivism and hearing, are presented.

V.

Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical practice guideline: tympanostomy tubes in children. Otolaryngol Head Neck Surg . 2013; 149(1S):S1-S35. EBM level 1..............................................................................................................170-204 Summary: Rosenfeld et al provide an excellent, state-of-the-art review and clinical practice guideline regarding tympanostomy tubes in children that makes very clear recommendations for this extremely common surgical procedure.

Semenov YR, Yeh ST, Seshamani M, et al. Age-dependent cost-utility of pediatric cochlear implantation. Ear Hear . 2013; 34(4):402-412. EBM level 2..................205-215

Summary: An excellent, multi-center NIH funded study yielded this analysis of the effect of age at the time of cochlear implantation on educational placement, quality of life, and cost to society amongst many other findings. Early implantation (patient age <18 months) is shown to be clearly beneficial to individuals and society. Some barriers to early implantation are exposed along with the difficulties in overcoming these barriers. Head and Neck Collins B, Stoner JA, Digoy GP. Benefits of ultrasound vs. computed tomography in the diagnosis of pediatric lateral neck abscesses. Int J Pediatr Otorhinolaryngol . 2014; 78(3):423-426. EBM level 4....................................................................................216-219 Summary: This article investigates the utility of ultrasound vs computed tomography (CT) in the diagnosis of pediatric lateral neck abscesses. This retrospective study compares ultrasound and CT accuracy to diagnose lateral neck abscesses which were confirmed by incision and drainage procedures. Ultrasound imaging was found to have similar sensitivity and positive predictive value and higher specificity as compared to CT imaging for the diagnosis of lateral neck abscesses. Drolet BA, Frommelt PC, Chamlin SL, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics . 2013; 131(1):128- 140. EBM level 2.....................................................................................................220-232 Summary: This article summarizes the report of the multidisciplinary consensus conference on the initiation and use of propranolol for infantile hemangiomas (IH). The pharmacologic properties and adverse events of propranolol in the pediatric population were reviewed. Recommendations were made regarding when to treat IH; contraindications to treatment with propranolol; pretreatment ECG; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol; and monitoring during treatment.

VI.

Givens DJ, Buchmann LO, Agarwal AM, et al. BRAF V600E does not predict aggressive features of pediatric papillary thyroid carcinoma. Laryngoscope . 2014; 124(9):E389-E393. EBM level 4.............................................................................233-237 Summary: This article investigates the BRAF V600E mutation in pediatric papillary thyroid carcinoma (PTC). In adult papillary thyroid carcinoma, the BRAF V600E mutation predicts more aggressive disease. This study reveals that the BRAF V600E mutation is more prevalent than previously reported in pediatric PTC patients, but the mutation was not associated with aggressive clinical features in the pediatric population. Summary: This article summarizes the evaluation and management of neck masses in children. Neck masses are divided into three categories: developmental/ congenital, inflammatory/reactive, and neoplastic. Depending on the history of the neck mass, laboratory or imaging studies may be indicated. Management depends on what category the neck mass falls in and ranges from watchful waiting to antibiotic therapy, incision and drainage, or surgical excision. Tekes A, Koshy J, Kalayci TO, et al. S.E. Mitchell Vascular Anomalies Flow Chart (SEMVAFC): a visual pathway combining clinical and imaging findings for classification of soft-tissue vascular anomalies. Clin Radiol . 2014; 69(5):443-457. EBM level 5.......................................................................................................................244-258 Summary: This article provides an algorithm for the diagnosis, management, and treatment for vascular anomalies. The algorithm utilizes the classification system established by the International Society for the Study of Vascular Anomalies (ISSVA) separating the vascular tumors and vascular malformations along with the use of radiological studies to guide practitioners. Meier JD, Grimmer JF. Evaluation and management of neck masses in children. Am Fam Physician . 2014; 89(5):353-358. EBM level 5..............................................238-243

ADDITIONAL REFERENCES

Abel F, Bajaj Y, Wyatt M, Wallis C. The successful use of the nasopharyngeal airway in Pierre Robin sequence: an 11-year experience. Arch Dis Child . 2012; 97(4):331-334.

Adams MT, Saltzman B, Perkins JA. Head and neck lymphatic malformation treatment: a systematic review. Otolaryngol Head Neck Surg . 2012; 138(2):177-182.

Bauman NM, McCarter RJ, Guzzetta PC, et al. Propranolol vs. prednisolone for symptomatic proliferating infantile hemangiomas: a randomized clinical trial. JAMA Otolaryngol Head Neck Surg . 2014; 140(4):323-330.

Bookman LB, Melton KR, Pan BS, et al. Neonates with tongue-based airway obstruction: a systematic review. Otolaryngol Head Neck Surg . 2012; 146(1):8-18.

Boons T, Brokx JP, Dhooge I, et al. Predictors of spoken language development following pediatric cochlear implantation. Ear Hear . 2012; 33(5):627-639.

Browning GG, Rovers MM, Williamson I, et al. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children (Review). Cochrane Database Syst Rev . 2012; 146(4):659- 663.

Capra G, Liming B, Boseley ME, Brigger MT. Trends in orbital complications of pediatric rhinosinusitis in the United States. JAMA Otolaryngol Head Neck Surg . 2015; 141(1):12-17.

Chan DK, Liming BJ, Horn DL, Parikh SR. A new scoring system for upper airway pediatric sleep endoscopy. JAMA Otolaryngol Head Neck Surg . 2014; 140(7):595-602.

Chen LS, Sun W, Wu PN, et al. Endoscope-assisted versus conventional second branchial cleft cyst resection. Surg Endosc . 2012; 26(5):1397-1402.

Chinnadurai S, Goudy S. Understanding velocardiofacial syndrome: how recent discoveries can help you improve your patient outcomes. Curr Opin Otolaryngol Head Neck Surg . 2012; 20(6): 502-506.

Clayburgh D, Milczuk H, Gorsek S, et al. Efficacy of tonsillectomy for pediatric patients with dysphagia and tonsillar hypertrophy. Arch Otolaryngol Head Neck Surg . 2011; 137(12):1197-1202.

Collins J, Cheung K, Farrokhyar F, Strumas N. Pharyngeal flap versus sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency: a meta-analysis. J Plast Reconstr Aesthet Surg . 2012; 65(7):864-868.

Dai Y, Hou F, Buckmiller L, et al. Decreased eNOS protein expression in involuting and propranolol- treated hemangiomas. Arch Otolaryngol Head Neck Surg . 2012; 138(2):177-182.

de Alarcon A, Rutter MJ. Cervical slide tracheoplasty. Arch Otolaryngol Head Neck Surg . 2012; 138(9):812-816.

Dedhia K, Yellon RF, Branstetter BF, Egloff AM. Anatomic variants on computed tomography in congenital aural atresia. Otolaryngol Head Neck Surg . 2012; 147(2): 323-328.

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Reprinted by permission of Laryngoscope. 2014 Nov 1. doi:10.1002/lary.25002. (Epub ahead of print).

The Laryngoscope V C 2014 The American Laryngological, Rhinological and Otological Society, Inc.

The National Cost Burden of Bronchial Foreign Body Aspiration in Children

Irene A. Kim, MD; Nina Shapiro, MD; Neil Bhattacharyya, MD

Objectives/Hypothesis: Foreign body aspiration (FBA) continues to be a concerning pediatric problem, accounting for thousands of emergency room visits and more than 100 deaths each year in the United States. The costs incurred with hospi- talizations and procedures following these events are the focus of this study. Study Design: Retrospective review. Methods: The Nationwide Inpatient Sample from 2009 to 2011 was analyzed, and all cases with pediatric bronchial for- eign body aspirations (International Classification of Diseases-9 codes: 934.0, 934.1, 934.8, and 934.9) were reviewed. Cases were analyzed to determine type of foreign body aspiration, procedural interventions performed, duration of inpatient stay, mortality rate, complications, and posthospitalization disposition. The median length of hospital stay and total costs associ- ated with aspiration events were determined. Results: An estimated 1,908 6 273 pediatric bronchial FBA patients were admitted annually over the 3-year period (mean age, 3.6 6 0.3 years; 61.3% 6 1.9% male). The ratio of foreign object aspiration to food aspiration was 5:3. Overall, 56%.0 6 3.6% of the patients underwent a bronchoscopic procedure for foreign body removal; of those, 41.5% 6 2.5% had a foreign body removed at the time of the endoscopy. The hospital mortality rate associated with bronchial aspiration was 1.8% 6 0.4%; and 2.2% 6 0.5% of patients were diagnosed with anoxic brain injury. The median length of stay was 3 days (25th–75th interquartile range, 1–7 days).The median charges and actual costs per case were $20,820 ($10,800–$53,453) and $6,720 ($3,628–$16,723), respectively. Conclusion: The annual overall inpatient cost associated with pediatric bronchial foreign-body aspiration is approxi- mately $12.8 million. Combined, the rate of death or anoxic brain injury associated with pediatric foreign body is approxi- mately 4%. Key Words: Foreign body, aspiration, choking, bronchial, national, cost. Level of Evidence: 2C. Laryngoscope , 00:000–000, 2014

INTRODUCTION Foreign body aspiration poses a significant public health issue because it accounts for thousands of emer- gency room visits and more than 100 deaths each year in the United States alone. In fact, according to the Cen- ters for Disease Control and Prevention, pediatric FBA accounted for more than 17,500 emergency room visits in 2001. 1–3 The pediatric population is globally more affected than older patient cohorts by FBA of both food and non- food objects, given the inherent characteristics of this group. Young children are more likely to explore their environment by placing objects into their mouths and unfortunately have underdeveloped swallowing and From the Otolaryngology–Head & Neck Surgery, David Geffen School of Medicine at UCLA ( I . A . K ., N . S .), Los Angeles, California; and the Department of Otology & Laryngology, Harvard Medical School ( N . B .), Boston, Massachusetts, U.S.A Editor’s Note: This Manuscript was accepted for publication October 6, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Irene A. Kim, Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, CHS 62–237, Los Angeles, CA 90095-1624. E-mail: iakim@mednet.ucla.edu

coughing mechanisms. Thus, the majority of patients with FBA are younger than 5 years old. 1 When these patients present to the emergency room with a wit- nessed choking event—or concerning symptoms such as shortness of breath, cough, or wheezing—the patients’ history, clinical examination, and radiographic studies usually prompt the healthcare provider to consult an otolaryngologist who is equipped to perform a bronchos- copy in the operating room. The patients are then typi- cally admitted following these procedures, or for observation if a procedure is not performed. Bronchial FBAs lead to numerous hospital admis- sions and procedures each year, but related hospital charges and costs to the healthcare system have not been objectively delineated previously. The aim of this study was to review and examine FBA cases gathered from the 2009 to 2011 Nationwide Inpatient Sample (NIS) to determine the type of foreign body involved, procedural interventions performed, duration of inpa- tient stay, mortality rate, complications, posthospitaliza- tion disposition, and the overall healthcare costs of FBA in the United States.

MATERIALS AND METHODS The data source for this study consisted of the NIS for the calendar years 2009 to 2011. This study was reviewed by our

DOI: 10.1002/lary.25002

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injury and 34 patients died, representing a hospital mor- tality rate of 1.8% 6 0.4%. Data for length of stay, total charges, and actual costs were extracted and divided into quartiles because they were not normally distributed. The median length of stay was 3 days (25th–75th interquartile range, 1–7 days). The median charges and actual costs per case were $20,820 ($10,800–$53,453) and $6,720 ($3,628– 16,723), respectively. Table I presents the means for length of stay, charges, and actual costs for each quar- tile, as well as the overall means for these values. DISCUSSION Bronchial FBA continues to pose a significant healthcare concern in the pediatric population. Although the vast majority of these events are nonfatal, thousands of patients present to the emergency room for evalua- tion, procedures, and admissions. Our study, which included aggregated 2009 to 2011 data from the NIS, included information from nearly 1,149 (unweighted N) admissions. Incorporating sample weights and the struc- tured survey design variables from the NIS allows for extrapolation to an overall national estimate of 1,908 6 273 pediatric airway foreign bodies, with approx- imately $41.0 million in inpatient healthcare expendi- tures annually. There exists some heterogeneity in the literature regarding the most common type of foreign body aspi- rated among pediatric patients; a recent study reviewing 72 articles showed that 94% of studies reported food for- eign bodies as the most frequently aspirated items. 1 In our study, the ratio of nonfood object aspiration to food object aspiration in the study was 5:3. Regardless of whether an aspirated object is edible or not, its size and shape are important considerations. Various cylindrical and spherical objects (nuts, hard candies, grapes, mar- bles) are capable of occluding the pediatric airway. 1 What remains constant and perpetually concerning is the morbidity of these events, as well as the nonnegli- gible incidence of anoxic brain injury and death (2.2% and 1.8%, respectively, in this study). This is the first study to quantify the incidence of anoxic brain injury with bronchial foreign body aspiration. Clearly, these rates for anoxic brain injury and mortality are concern- ing in and of themselves. Currently, to our knowledge, no studies reviewing data regarding only airway FBA admissions have been performed. There does exist a study of patient admis- sions for both airway and esophageal foreign bodies from the Kids’ Inpatient Database 2003 performed by Shah et al.; there was a 3.4% mortality rate among patients and the average length of stay was 11.7 days. 5 The mean total charges were $34,652. 5 Our study, which focused on bronchial foreign body aspirations alone, showed a $20,820 charge for each hospital admission and an annual overall inpatient cost associated with pediatric bronchial FBA to be approximately $12.8 mil- lion. One notable difference between our study and that of Shah et al. concerns the sampled hospitals. Shah et al. examined foreign body admissions in a database of

TABLE I. Quartile Stratification and Overall Mean Length of Stay, Actual Costs, and Total Charges per Hospital Admission.

Quartile Mean Length of Stay Actual Costs ($)

Total Charges ($)

0.80 6 0.02 days 2,306 6 52

6,518 6 173

First

Second 2.00 6 0.01 days 5,046 6 57 15,371 6 171 Third 4.12 6 0.07 days 10,648 6 211 33,118 6 699 Fourth 21.0 6 1.13 days 68,475 6 3831 209,537 6 14,207 Overall mean 7.08 6 0.96 days 21,479 6 2,432 65,590 6 7,819

hospital institutional review board and deemed exempt from review. For each of these calendar years, all admissions with a pediatric (age ! 16 years) foreign-body aspiration diagnosis code (International Classification of Diseases [ICD]-9 diagnosis codes: 934.0, 934.1, 934.8, and 934.9) were extracted. The data were then imported into SPSS (version 21.0, Chicago, Illinois) for analysis. Standard descriptive demographic information was com- puted for the admission population. The incidence of food ver- sus object aspiration, the airway procedure intervention rate (ICD-9 procedure codes—bronchoscopy: 33.22, 33.23, and 33.24; bronchoscopy with foreign body removal: 98.15; laryn- goscopy or tracheoscopy: 31.42; foreign body removal from lar- ynx, pharynx, or site not otherwise specified: 98.13, 98.14 and 98.20) were determined. Data for length of stay, total charges, and actual costs were extracted and divided into quartiles because they were not normally distributed. The mean values for length of stay, total charges, and actual costs were com- puted for each quartile. Finally, disposition status for the population including inpatient death and the incidence of anoxic brain injury (ICD-9 code 348.1) was also tabulated. Data were analyzed using the complex sample algorithm, which takes into account survey design variables contained within the NIS that allow for estima- tion of these variables at the national level. In accordance with published analyses from the Agency for Healthcare Research and Quality, data were considered reliable as a national esti- mate if the relative standard error of the estimate was less than 30%. 4 RESULTS An estimated 1,908 6 273 pediatric bronchial foreign-body aspiration patients were admitted annually over a 3-year period. Of this group, 61.3% 6 1.9% were male, with an average age at presentation of 3.6 6 0.25 years. The ratio of nonfood foreign object aspiration to food aspiration was 5:3. Approximately half of the patients (56.0 6 3.6%) underwent an airway endoscopic procedure (1068 6 117 cases, annually) for diagnostic and/or therapeutic purposes. Among those children undergoing airway endoscopy, 41.5% 6 2.5% had a for- eign body removed at the time of the endoscopy. Follow- ing their hospital stay, 86.6% 6 2.0% of patients were discharged to home without nursing care; 5.3% 1 1.6% were discharged to home with home healthcare; 3.5% 1 0.7% were transferred to another hospital; and 2.6% 1 0.5% were transferred to a skilled care facility. Forty-one patients (2.2% 6 0.5%) suffered anoxic brain

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