September 2019 HSC Section 1 Congenital and Pediatric Problems

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Congenital and Pediatric Problems

Home Study Course

Hsc Home Study Course

Section 1 September 2019

© 2019 American Academy of Otolaryngology—Head and Neck Surgery Foundation The global leader in optimizing quality ear, nose, and throat patient care.

THE HOME STUDY COURSE IN OTOLARYNGOLOGY — HEAD AND NECK SURGERY

SECTION 1

Congenital and Pediatric Problems

September 2019

1999

SECTION FACULTY: Matthew T. Brigger, MD** Eunice Y. Chen, MD, PhD** Nira Goldstein, MD, MPH** Joseph E. Dohar, MD, MS Steven Goudy, MD Anita Jeyakumar, MD, MS

Erika King, MD Todd Wine, MD

American Academy of Otolaryngology—Head and Neck Surgery Foundation

Section 1 suggested exam deadline: October 7, 2019 Expiration Date: August 6, 2020; 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. 1. Describe the value of safety stops in pediatric universal protocol. 2. Discuss the association of proton pump inhibitors and hospitalization risk in children. 3. Explain the influence of anesthesia on child development. 4. Identify the indications for propranolol administration to treat pediatric hemangiomas. 5. Review guidelines and outcomes for children with type I laryngeal clefts. 8. Review outcomes after pediatric septorhinoplasty. 9. Identify predictors of OSA severity in adolescents. 10. Describe the diagnosis and management of pediatric rhinosinusitis. 11. Explain outcomes for tympanostomy tubes. 12. Discuss the expected hospital course and complications in pediatric thyroidectomy. 13. Summarize an approach to managing oral lesions in children. 6. Discuss voice outcomes after laryngotracheal surgery in children. 7. Explain the surgical management of children with cleft palate. Outcomes Objectives The participant who has successfully completed this section should be able to:

Medium Used The Home Study Course is available in electronic or print format. 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 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 achieve a post-test score of 70% or higher for a passing completion to be recorded and a transcript to be produced. Residents: results will be 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. Two retest opportunities will automatically be available if a minimum of 70% is not achieved with the first attempt. 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

2019 Faculty Section 1 Congenital and Pediatric Problems

**Co-Chairs 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, Associate 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. Faculty Joseph E. Dohar, MD, MS, Professor of Otolaryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine; Professor of Communication Science and Disorders, University of Pittsburgh School of Health and Rehabilitation Sciences; Medical Director of the Voice, Resonance and Swallowing Center, Division of Pediatric Otolaryngology, UPMC Children’s Hospital, Pittsburgh, Pennsylvania. Disclosure: No relationships to disclose. Steven Goudy, MD, Professor, Director of Pediatric Otolaryngology, Emory University School of Medicine, Atlanta, Georgia. Disclosure: No relationships to disclose. Anita Jeyakumar, MD, MS , Associate Professor, Director of Pediatric Otolaryngology, Akron Children’s Hospital, Akron, Ohio Disclosure: No relationships to disclose. Erika King, MD, Assistant Professor of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon; Mary Bridge Children’s Hospital, Tacoma, Washington. Disclosure: No relationships to disclose. Todd Wine, MD , Assistant Professor of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora, CO Disclosure: Stock/stock options: Express Scripts Holding Company; Kimberly Clark Corporation; Pfizer Incorporated; Abbott Laboratories; Abvie Incorporated Intellectual Property Rights: GDT Innovations, LLC

Planner(s): Linda Lee, AAO─HNSF Education Program Manager Stephanie Wilson, Stephanie Wilson Consulting, LLC; Production Manager Richard V. Smith, MD, chair, Education Steering Committee

No relationships to disclose No relationships to disclose

Disclosure: Expert Witness: Various legal firms; Royalty: UpToDate

Jeffrey P. Simons, MD, chair, AAO-HNSF Pediatric Otolaryngology No relationships to disclose Education Committee

This 2019-20 Home Study Course Section 1 Course includes discussion of off-label uses of the following drugs and devices which have not been approved by the United States Food and Drug Administration:

Name of Drug(s) or Device(s)

Nature of Off-label Discussion

Bevacizumab

Treatment of recurrent respiratory papillomatosis Treatment of recurrent respiratory papillomatosis

Cidofovir Mupirocin

External auditory canal for tube otorrhea

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. October 7, 2019: Suggested section 1 Exam submission deadline ; course closes August 6, 2020. 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).

Level 2

Level 3

Level 4

Expert opinion without explicit critical appraisal, or recommendation based on physiology/bench research.

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.

OUTLINE Section 1 Congenital and Pediatric Problems September 2019

I.

General

II.

Laryngology

III.

Facial Plastics and Trauma

IV.

Adenotonsillar Disease and Sleep Disorders

V.

Rhinology

VI.

Otology

VII.

Head and Neck

T ABLE OF C ONTENTS Selected Recent Materials - Reproduced in this Study Guide

SECTION 1: CONGENITAL AND PEDIATRIC PROBLEMS SEPTEMBER 2019

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

I.

General Caruso TJ, Munshey F, Aldorfer B, Sharek PJ. Safety stop: a valuable addition to the pediatric universal protocol. Jt Comm J Qual Patient Saf . 2018; 44(9):552-556. EBM level 4...................1-5 Summary : This manuscript describes a multidisciplinary perioperative quality improvement project in a tertiary care children’s hospital to improve the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery for pediatric cases. The protocol implemented a novel adjunct, the safety stop, that took place just prior to preparation and draping, in addition to the required time out that took place prior to incision. Sixty audits of the process took place over 4 weeks, demonstrating 96.7% (58/60) compliance with the new policy. The safety stop is expected to lessen the risk of wrong-site or wrong-patient surgery, because the small bodies of pediatric patients are not obscured by drapes as may occur during the traditional time-out. Duncan DR, Mitchell PD, Larson K, et al. Association of proton pump inhibitors with hospitalization risk in children with oropharyngeal dysphagia. JAMA Otolaryngol Head Neck Surg . 2018 Oct 11. doi: 10.1001/jamaoto. 2018.1919 [Epub ahead of print]. EBM level 3...................6-14 Summary : In this retrospective cohort study of 293 children under 2 years of age with aspiration/penetration on videofluoroscopic swallow studies, patients treated with proton pump inhibitors had significantly higher hospitalization rates (incident rate ratio 1.77 [95% CI 1.16 – 2.68]) and hospital nights (incident rate ratio 2.51 [95% CI 1.36-4.62]) compared to those not treated, even after adjustment for comorbidities. These results support growing concerns about the risks of proton pump inhibitor use in children. O’Leary JD, Janus M, Duku E, et al. Influence of surgical procedures and general anesthesia on child development before primary school entry among matched sibling pairs. JAMA Pediatr . 2019; 173(1):29-36. EBM level 3...........................................................................................................15-22 Summary : This population-based study of 10,897 sibling pairs aged 5 to 6 years of scores on the Early Development Instrument before primary school entry in Ontario, Canada, found no differences in the adjusted odds of developmental vulnerability (scores in the lowest 10 th percentile) for the overall score and the five major domains (physical health and well-being, social knowledge and competence, emotional health and maturity, language and cognitive development, and communication skills and general knowledge) between biological siblings exposed or unexposed to surgical procedures that required general anesthesia. Scores were adjusted for age at testing, sex, mother’s age at birth, and eldest sibling status. By controlling for genetic and environmental factors, exposure to general anesthesia was not associated with adverse developmental outcomes.

II.

Laryngology Cole E, Dreyzin A, Shaffer AD, et al. Outcomes and swallowing evaluations after injection laryngoplasty for type I laryngeal cleft: does age matter? Int J Pediatr Otorhinolaryngol . 2018; 115:10-18. EBM level 4...............................................................................................................23-31 Summary : This retrospective review on injection laryngoplasty in pediatric patients noted that age was not a factor in outcomes of patients’ post-injection. Further study would be needed on the role of modified barium swallows versus functional endoscopic swallow evaluations. Pullens B, Hakkesteegt M, Hoeve H, et al. Voice outcome and voice-related quality of life after surgery for pediatric laryngotracheal stenosis. Laryngoscope . 2017; 127(7):1707-1711. EBM level 2............................................................................................................................................32-36 Summary : The paper is a prospective cohort study of patients who have had open airway surgery in the past. The study reports significant voice issues postoperatively, especially in those patients who had glottic involvement of the stenosis. Summary : The article studies children who have had swallow studies and highlights silent aspiration as being more present, potentially even in the absence of a cough. The article emphasizes the role of modified barium studies in the management of these patients. Yeung JC, Balakrishnan K, Cheng ATL, et al. International Pediatric Otolaryngology Group: consensus guidelines on the diagnosis and management of type I laryngeal clefts. Int J Pediatr Otorhinolaryngol . 2017; 101:51-56. EBM level 3......................................................................43-48 Summary : Consensus guideline on the diagnostic workup, medical management, and preoperative, intraoperative, and postoperative considerations for type I laryngeal cleft, based on existing published evidence and literature. Facial Plastics and Trauma Buchanan EP, Xue AS, Hollier LH Jr. Craniofacial syndromes. Plast Reconstr Surg . 2014; 134(1):128e-153e. EBM level 4...................................................................................................49-74 Summary : This comprehensive review of craniofacial syndromes will help develop an understanding of the most common craniofacial anomalies, determine the appropriate surgical plan, and review the most common surgical complications. This is a review article that has ample clinical pictures, 3D reconstructed CT images, and diagrams. Listed here are the most common syndromes that all otolaryngologists should be familiar with. This is a review article and there is certainly the chance of bias. Velayutham P, Irace AL, Kawai K, et al. Silent aspiration: who is at risk? Laryngoscope . 2018; 128(8):1952-1957. EBM level 4...................................................................................................37-42

III.

Dao AM, Goudy SL. Cleft palate repair, gingivoperiosteoplasty, and alveolar bone grafting. Facial Plast Surg Clin North Am . 2016; 24(4):467-476. EBM level 4..................................................75-84

Summary : This is a review that covers the etiology, techniques, and timing for assessing and planning surgical management of cleft alveolus and palate repair. The authors introduce the genetics and embryology of palate formation. They then describe the feeding and airway issues that may be present at birth. Last, they describe the appropriate timing and management of surgical approaches and what to do when there are complications. Gupta A, Svider PF, Rayess H, et al. Pediatric rhinoplasty: a discussion of perioperative considerations and systematic review. Int J Pediatr Otorhinolaryngol . 2017; 92:11-16. EBM level 1............................................................................................................................................85-90 Summary : This is a systematic review comparing 7 studies with a total of 253 patients to evaluate perioperative and postoperative outcomes. They compared the age and indication for surgery and how the surgery was performed. They noted the type of cartilage used for nasal reconstruction. Comparison of postoperative outcomes demonstrated that younger age at surgery may affect the revision rate for rhinoplasty. Manteghi A, Din H, Bundogji N, Leuin SC. Pediatric septoplasty and functional septorhinoplasty: a quality of life outcome study. Int J Pediatr Otorhinolaryngol . 2018; 111:16-20. EBM level 2............................................................................................................................................91-95 Summary : This is a prospective evaluation of pediatric patients undergoing septoplasty vs functional septorhinoplasty (FSR) to address nasal obstruction. The patients self-reported nasal function score was compared using the NOSE QOL survey. In this paper, the authors describe the improvements associated with septoplasty alone compared to FSR and the associated complications. Adenotonsillar Disease and Sleep Disorders Baker M, Scott B, Johnson RF, Mitchell RB. Predictors of obstructive sleep apnea severity in adolescents. JAMA Otolaryngol Head Neck Surg . 2017; 143(5):494-499. EBM level 4........96-101 Summary : Using a retrospective uncontrolled case series design, this study correlates demographics and clinical characteristics with the apnea-hypopnea index severity in adolescents. Male gender, body mass index z-score, and tonsillar hypertrophy were significantly associated with severe sleep apnea as measured by the apnea-hypopnea index. A low threshold for obtaining overnight polysomnography should be applied to obese, adolescent males with tonsillar hypertrophy and symptoms of obstructive sleep-disordered breathing.

IV.

Byars SG, Stearns SC, Boomsma JJ. Association of long-term risk of respiratory, allergic, and infectious diseases with removal of adenoids and tonsils in childhood. JAMA Otolaryngol Head Neck Surg . 2018; 144(7):594-603. EBM level 3.....................................................................102-111

Rosenfeld RM. Old barbers, young doctors, and tonsillectomy. JAMA Otolaryngol Head Neck Surg . 2018; 144(7):603-604. EBM level 5..............................................................................111-112

Summary : Although not directly discussing obstructive sleep apnea (OSA), this highly referenced and controversial study is a must-read for clinicians treating OSA in children. Tonsillectomy and adenoidectomy (T&A) is most commonly performed for airway obstruction, and firmly stands as first-line surgical treatment for OSA in children. The study represents a “big data” population- based cohort study from Denmark and concluded that T&A was associated with long-term risks of respiratory, infectious, and allergic diseases. The article is followed by an invited commentary by Richard M. Rosenfeld, MD, MPH, a pediatric otolaryngologist, who masterfully critiques the study and puts it into a practical context for surgeons when counseling families of the long-term risks of T&A in children 9 years of age and younger. Lin CY, Chen CN, Kang KT, et al. Ultrasonographic evaluation of upper airway structures in children with obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg . 2018; 144(10):897-905. EBM level 2.................................................................................................113-121 Summary : This prospective, observational study compared ultrasonographic assessment of upper airway structures in children with OSA vs. primary snoring and, surprisingly, found that there was no statistically significant difference in tonsillar dimensions or volume. However, the mean thicknesses for both the total lateral pharyngeal wall and total neck at the retropalatal level were greater in children with OSA than in those with primary snoring. Rhinology Beswick DM, Messner AH, Hwang PH. Pediatric chronic rhinosinusitis management in rhinologists and pediatric otolaryngologists. Ann Otol Rhinol Laryngol. 2017; 126(9):634-639. EBM level 2...............................................................................................................................122-127 Summary : This article is a prospective comparison between management of pediatric chronic rhinosinusitis by pediatric otolaryngologists (members of ASPO) and rhinologists (members of ARS). This study found that overall, there are many similarities between management styles, but a few key differences exist, such as the use of perioperative systemic steroids and the use of CT imaging prior to adenoidectomy. House LK, Lewis AF, Ashmead MG. A cost-effectiveness analysis of the up-front use of balloon catheter dilation in the treatment of pediatric chronic rhinosinusitis. Am J Otolaryngol. 2018; 39(4):418-422. EBM level 4.....................................................................................................128-132 Summary : This article presents a cost-effectiveness study comparing adenoidectomy versus adenoidectomy combined with balloon catheter dilation for the treatment of chronic rhinosinusitis failing medical therapy. The cost effectiveness was measured by calculating the incremental cost- effective ratio and performing a sensitivity analysis. Due to the high incremental cost associated with a very small expected clinical benefit, adding balloon catheter dilation to adenoidectomy is not recommended based on this study.

V.

Newton L, Kotowski A, Grinker M, Chun R. Diagnosis and management of pediatric sinusitis: a survey of primary care, otolaryngology and urgent care providers. Int J Pediatr Otorhinolaryngol . 2018; 108:163-167. EBM level 2.............................................................................................133-137 Summary : This article provides a prospective comparison between physician groups in the adherence to previously published rhinosinusitis guidelines. It identifies some of the areas where the guidelines are followed and where current practice deviates from the guidelines overall or within the subgroups. This highlights potential areas for improvement, such as use of adjunctive therapies, proper length of antibiotic usage, and proper antibiotic choice. Otology Knutsson J, Priwin C, Hessén-Söderman AC, et al. A randomized study of four different types of tympanostomy ventilation tubes – full-term follow-up. Int J Pediatr Otorhinolaryngol . 2018; 107:140-144. EBM level 1.......................................................................................................138-142 Summary : The authors compared the impact of different types of ventilation tubes (material and shape) on time to extrusion, otorrhea, occlusion, need for tube removal, and perforation risk. Four hundred children between 1 to 10 years of age were randomized to receive a different tube in each ear, and were followed every 3 months until 6 months following extrusion of both tubes. They concluded that long tubes are less prone to early extrusion, while silicone tubes render a longer time until the first infection. Liming BJ, Carter J, Cheng A, et al. International Pediatric Otolaryngology Group (IPOG) consensus recommendations: hearing loss in the pediatric patient. Int J Pediatr Otorhinolaryngol . 2016; 90:251-258. EBM level 5...............................................................................................143-150 Summary : Senior author Richard Smith, MD. This article provides consensus recommendations of an international group of pediatric otolaryngologists regarding the identification and workup of the child with hearing loss. They make recommendations and present algorithms for newborn screening and initial workup, auditory neuropathy spectrum disorder, sensorineural hearing loss, and conductive or mixed hearing loss. Yankey H, Isaacson G. Efficacy of topical 2% mupirocin ointment for treatment of tympanostomy tube otorrhea caused by community-acquired methicillin resistant Staphylococcus aureus . Int J Pediatr Otorhinolaryngol . 2018; 109:36-39. EBM level 3.....................................................151-154 Summary : The authors performed a case-control study in which children with MRSA tympanostomy tube otorrhea were treated with systemic antibiotics with or without fluoroquinolone drops (prior to 2014) vs the addition of a single application of topical mupirocin (after 2014). They treated a total of 29 children (37 ears), and compared the recurrence of MRSA and non-MRSA otorrhea between the groups, as well as the incidence of sensorineural hearing loss.

VI.

VII.

Head and Neck Canfarotta M, Moote D, Finck C, et al. McGill Thyroid Nodule Score in differentiating benign and malignant pediatric thyroid nodules: a pilot study. Otolaryngol Head Neck Surg . 2017; 157(4):589-595. EBM level 4...................................................................................................155-161 Summary : This article is a retrospective chart review that pilots using the McGill Thyroid Nodule Score (MTNS) to assess the risk of malignancy in pediatric thyroid nodules. The authors reviewed the charts of 46 pediatric patients who presented with a thyroid nodule treated with surgical resection. A cumulative MTNS was calculated and compared with pathology. The pediatric MTNS was able to differentiate between benign and malignant disease in nodules that had indeterminate cytology.

Hanba C, Svider PF, Siegel B, et al. Pediatric thyroidectomy: hospital course and perioperative complications. Otolaryngol Head Neck Surg . 2017; 156(2):360-367. EBM level 4.............162-169

Summary : This article is a retrospective database review that evaluates the Kids’ Inpatient Database for thyroidectomy patients and reports on hospital length of stay and postoperative complications. Younger patients (< 6 years of age) had a significantly longer hospital length of stay than those 6 years or older. The most common postoperative complication was hypocalcemia at nearly 20%. Respiratory complications occurred more frequently in the younger patients. Vocal cord paralysis was noted in 1.7%.

Ivancic R, Iqbal H, deSilva B, et al. Current and future management of recurrent respiratory papillomatosis. Laryngoscope Investig Otolaryngol . 2018; 3(1):22-34. EBM level 4..........170-182

Summary : This article reviews the current and future management of recurrent respiratory papillomatosis (RRP) in children and adults. Standard treatment is surgical excision with cold microlaryngeal instruments, microdebrider, and/or lasers. Adjuvant therapies for severe disease not controlled with surgery include cidofovir and bevacizumab. The HPV vaccine has been shown to have preventative as well as therapeutic effects. Novel immunomodulatory agents may provide a better approach to manage and treat RRP in the future. Yuhan BT, Svider PF, Mutchnick S, Sheyn A. Benign and malignant oral lesions in children and adolescents: an organized approach to diagnosis and management. Pediatr Clin North Am . 2018; 65(5):1033-1050. EBM level 4.................................................................................................183-200 Summary : This article reviews common pediatric benign and malignant oral lesions. Its goal is to familiarize the reader with clinical features that may warrant further work up and to provide diagnostic and therapeutic strategies for oral cavity lesions. Understanding the oral cavity anatomy, obtaining a thorough patient history, and performing a detailed physical examination are crucial for formulating differential diagnoses and optimizing work up and intervention. Zamani M, Grønhøj C, Schmidt Jensen J, et al. Survival and characteristics of pediatric salivary gland cancer: a systematic review and meta-analysis. Pediatr Blood Cancer . 2019; 66(3):e27543. EBM level 4...............................................................................................................................201-208 Summary : This article is a systematic review of studies including children from infants to 19 years of age with salivary gland cancer. Nineteen studies with 749 children were included in the review. Overall, 95% of the patients were treated with primary surgery and 24% underwent adjuvant radiotherapy. Mucoepidermoid carcinoma was most common in all salivary glands, followed by acinic cell carcinoma and adenoid cystic carcinoma. Five-year overall survival was 94%.

2019-20 SECTION 1 ADDITIONAL REFERENCES

Bergevin A, Zick CD, McVicar SB, Park AH. Cost-benefit analysis of targeted hearing directed early testing for congenital cytomegalovirus infection. Int J Pediatr Otorhinolaryngol . 2015; 79(12):2090- 2093.

Butskiy O, Mistry B, Chadha NK. Surgical interventions for pediatric unilateral vocal cord paralysis: a systematic review. JAMA Otolaryngol Head Neck Surg . 2015; 141(7):654-660.

Carlson ML, Sladen DP, Gurgel RK, et al. Survey of the American Neurotology Society on cochlear implantation: part 1, candidacy assessment and expanding indications. Otol Neurotol . 2018; 39(1):e12- e19.

Carter J, Rahbar R, Brigger M, et al. International Pediatric ORL Group (IPOG) laryngomalacia consensus recommendations. Int J Pediatr Otorhinolaryngol . 2016; 86:256-261.

Chen L, Zhang J, Pan G, et al. Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis. Open Med (Wars) . 2018; 13:366-373.

Cockerill CC, Gross BC, Contag S, et al. Pediatric malignant salivary gland tumors: 60 year follow up. Int J Pediatr Otorhinolaryngol . 2016; 88:1-6.

Coon D, Kosztowski M, Mahoney NR, et al. Principles for management of orbital fractures in the pediatric population: a cohort study of 150 patients. Plast Reconstr Surg . 2016; 137(4):1234-1240.

Dahl JP, Miller C, Purcell PL, et al. Airway obstruction during drug-induced sleep endoscopy correlates with apnea-hypopnea index and oxygen nadir in children. Otolaryngol Head Neck Surg . 2016; 155(4):676-680.

Dehlink E, Tan HL. Update on paediatric obstructive sleep apnoea. J Thorac Dis . 2016; 8(2):224-235.

Dermody S, Walls A, Harley EH Jr. Pediatric thyroid cancer: an update from the SEER database 2007- 2012. Int J Pediatr Otorhinolaryngol . 2016; 89:121-126.

Dremmen MH, Tekes A, Mueller S, et al. Lumps and bumps of the neck in children-neuroimaging of congenital and acquired lesions. J Neuroimaging . 2016; 26(6):562-580.

Duval M, Grimmer JF, Meier J, et al. The effect of age on pediatric tympanoplasty outcomes: a comparison of preschool and older children. Int J Pediatr Otorhinolaryngol . 2015; 79(3):336-341.

Farhood Z, Ong AA, Discolo CM. PANDAS: a systematic review of treatment options. Int J Pediatr Otorhinolaryngol . 2016; 89:149-153.

Flores RL, Greathouse ST, Costa M, et al. Defining failure and its predictors in mandibular distraction for Robin sequence. J Craniomaxillofac Surg . 2015; 43(8):1614-1619.

Fordham MT, Rock AN, Bandarkar A, et al. Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess. Laryngoscope . 2015; 125(12):2799-2804.

i

Friedmann DR, Ahmed OH, McMenomey SO, et al. Single-sided deafness cochlear implantation: candidacy, evaluation, and outcomes in children and adults. Otol Neurotol . 2016; 37(2):e154-e160.

Garetz SL, Mitchell RB, Parker PD, et al. Quality of life and obstructive sleep apnea symptoms after pediatric adenotonsillectomy. Pediatrics . 2015; 135(2):e477-e486.

Garin A, Thierry B, Leboulanger N, et al. Pediatric sinogenic epidural and subdural empyema: the role of endoscopic sinus surgery. Int J Pediatr Otorhinolaryngol . 2015; 79(10):1752-1760.

Greinwald J, DeAlarcon A, Cohen A, et al. Significance of unilateral enlarged vestibular aqueduct. Laryngoscope. 2013; 123(6):1537-1546.

Hoppe IC, Kordahi AM, Paik AM, et al. Examination of life-threatening injuries in 431 pediatric facial fractures at a level 1 trauma center. J Craniofac Surg . 2014; 25(5):1825-1828.

Huyett P, Monaco SE, Choi SS, Simons JP. Utility of fine-needle aspiration biopsy in the evaluation of pediatric head and neck masses. Otolaryngol Head Neck Surg . 2016; 154(5):928-935.

Kamil RJ, Roxbury C, Boss E. Pediatric rhinoplasty: a national surgical quality improvement program analysis. Laryngoscope . 2019; 129(2):494-499.

Katzel EB, Shakir S, Naran S, et al. Speech outcomes after clinically indicated posterior pharyngeal flap takedown. Ann Plast Surg . 2016; 77(4):420-424.

Lawlor CM, Riley CA, Carter JM, Rodriguez KH. Association between age and weight as risk factors for complication after tonsillectomy in healthy children. JAMA Otolaryngol Head Neck Surg . 2018; 144(5):399-405.

Léauté-Labrèze C, Hoeger P, Mazereeuw-Hautier J, et al. A randomized, controlled trial of oral propranolol in infantile hemangioma. N Engl J Med . 2015; 372(8):735-746.

Lin HC, Friedman M, Chang HW, et al. Minimally invasive, single-stage, multilevel surgery for obstructive sleep apnea in Asian patients. JAMA Otolaryngol Head Neck Surg . 2017; 143(2):147-154.

Lowe AJ, Leung DYM, Tang MLK, et al. The skin as a target for the prevention of the atopic march. Ann Allergy Asthma Immonol. 2018; 120(2):145-151.

Pawar SS, Koch CA, Murakami C. Treatment of prominent ears and otoplasty: a contemporary review. JAMA Facial Plast Surg . 2015; 17(6):449-454.

Prosser JD, Shott SR, Rodriguez O, et al. Polysomnographic outcomes following lingual tonsillectomy for persistent obstructive sleep apnea in Down syndrome. Laryngoscope . 2017; 127(2):520-524.

Rees P, Al-Hussaini A, Maguire S. Child abuse and fabricated or induced illness in the ENT setting: a systematic review. Clin Otolaryngol . 2017; 42(4):783-804.

Richter A, Chen DW, Ongkasuwan J. Surveillance direct laryngoscopy and bronchoscopy in children with tracheostomies. Laryngoscope . 2015; 125(10):2393-2397.

Rosenfeld RM. Tonsillectomy for obstructive sleep-disordered breathing or recurrent throat infection in children. JAMA Otolaryngol Head Neck Surg . 2018; 144(1):5-6.

ii

Saal HM. Genetic evaluation for craniofacial conditions. Facial Plast Surg Clin North Am . 2016; 24(4):405-425.

Sadick M, Wohlgemuth WA, Huelse R, et al. Interdisciplinary management of head and neck vascular anomalies: clinical presentation, diagnostic findings and minimal-invasive therapies. Eur J Radiol Open . 2017; 4:63-68. Sagi L, Eviatar E, Gottlieb P, Gavriel H. Quantitative evaluation of facial growth in children after unilateral ESS for subperiosteal orbital abscess drainage. Int J Pediatr Otorhinolaryngol . 2015; 79(5):690-693.

Skotko BG, Macklin EA, Muselli M, et al. A predictive model for obstructive sleep apnea and Down syndrome. Am J Med Genet A . 2017; 173(4):889-896.

Sloan-Heggen CM, Bierer AO, Shearer AE, et al. Comprehensive genetic testing in the clinical evaluation of 1119 patients with hearing loss. Hum Genet . 2016; 135(4):441-450.

Szefler SJ, Chipps B. Challenges in the treatment of asthma in children and adolescents. Ann Allergy Asthma Immunol . 2018; 120(4):382-388.

Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics . 2013; 132(1):e262-e280.

Wang MC, Wang YP, Chu CH, et al. The protective effect of adenoidectomy on pediatric tympanostomy tube re-insertions: a population-based birth cohort study. PLOS One . 2014; 9(7):e101175.

Wentland CJ, Ronner EA, Basonbul RA, et al. Utilization of diagnostic testing for pediatric sensorineural hearing loss. Int J Pediatr Otorhinolaryngol . 2018; 111:26-31.

Zdanski CJ, Austin GK, Walsh JM, et al. Transoral robotic surgery for upper airway pathology in the pediatric population. Laryngoscope . 2017; 127(1):247-251.

iii

Reprinted by permission of Jt Comm J Qual Patient Saf. 2018; 44(9):552-556.

The Joint Commission Journal on Quality and Patient Safety 2018; 44:552–556

Safety

Stop: A Valuable Addition

to

the Pediatric

Universal Protocol Thomas J. Caruso, MD, MEd; Farrukh Munshey, MD, FRCPC; Brea Aldorfer, MS, RN, CPHQ; Paul J.

Sharek, MD,

MPH

Problem Definition: The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery TM must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk. Approach: The multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several pe- rioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption. Outcomes: In seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrat- ing compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice. Key Insights: Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong- patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.

procedure.” 3 (p. 11)

PROBLEM DEFINITION During the last decade,

confirming

the

correct

patient,

site

and

Joint Commission

requirements

and WHO

recommenda-

there

has

been marked

improve-

tions

state

that

the

time-out

is

to

be

performed

just

prior

1 The

ment

in

perioperative

surgical

safety.

development

incision,

after

preparation

and

draping

(P&D)

of

the

to

successful

implementations

of

surgical

safety

check- adverse being Safety “Safe

and lists

3–4 At

to minimize

surgical morbidity

and mortality.

patient

have

played

a

significant

role

in minimizing

institution, prior

to a

routine

Joint Commission accred-

our

in

the

perioperative

period,

the most

notable

events

itation

survey,

a mock

survey

recorded

that we

performed

Health

Organization

(WHO)

Surgical

the World Checklist.

time-out prior

to P&D

of

the patient, not

afterward

as

the

1–3 Introduced

in

2008

as

part

of

the

5

a patient

safety

and

regulatory

risk.

recommended, posing

the

checklist was 2009 . The

revised

in

Surgery Saves Lives” campaign,

Despite

evidence

to

the

effectiveness

of

the

Universal

the WHO Guidelines

for

Safe

Surgery

guidelines

adults,

there

continues

to be

implementation

Protocol with

10

“essential team will

objectives

for

safe

surgery,” beginning

feature

compliance

variability

to

the

Universal

Protocol

in

and

“The

operate

on

the

correct

patient

at

the

with

6 Stakeholder

hospitals. training,

disengagement,

absence

pediatric

site.” 3 (p. 10) One

of WHO’s

“highly

recommended”

correct

formal

and unreliable process

compliance mea-

of

as

“a

practice

that that

should

be

in

place

in

practices—defined

sures

contribute

to

the

lack

of

widespread,

standardized

operation” 3 (p. 7) —to meet the Universal Protocol. As

first

objective

is

the

every

6 Although

tailoring

the

Universal

Protocol

to to

adoption.

of

developed Universal Procedure,

and mandated

use

pediatric

population

has

been

reported

as

an

effort

the

The

Joint

Commission,

the

Protocol

for

by

7,8 no

compliance,

formal

recommended

pediatric

increase standard

Wrong

Site,

Wrong

and

Wrong

Preventing

from accredited bodies exists.

Incorrect and partial

TM is

Surgery

a

three-step

process

consisting

of

Person

of

the Universal Protocol

contributes

to

increased

risks

use

time-out. 4

verification,

site marking,

and

a

preprocedure The WHO complementary

in the perioperative pediatric population. 7

events

of adverse

guidelines

note

that

each

of

the

three

steps

“is of

Prompted

by of

both

the mock

Joint Commission

survey

and

adds

redundancy

to

the

practice

the

goal

reducing

patient

risk,

we

embarked

on

a

and

improvement

effort

to

develop

a

novel WHO

multidisciplinary

1553-7250/$-see front matter © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jcjq.2018.03.015

Universal

Protocol

that

aligned

with

pediatric

1

Volume 44, No. 9, September 2018

final

recommendations, surgical population.

tailored

to

the

specific

needs

of

our

patient

identity

check,

final

procedure

confirmation,

of

site marking

in

field,

and

confirmation

of

visualization

administration

( Figure

1 ).

antibiotic

interdepartmental

electronic meetings,

correspondence,

Following

APPROACH This project

perioperative education,

leadership

and

periopera-

several

tive

team

the

enhanced pediatric Universal Pro-

was

conducted

at

Lucile

Packard

Children’s

tocol ment

was was

initiated. increased employees

Stakeholder

engagement

and

agree- both

Stanford,

a

freestanding,

311-bed

academic hospital

chil-

Hospital

through

active

championing

by

dren’s

hospital

in Northern California. The

has

7

who

are

members anesthesia,

of

the

periopera- perioperative

frontline

rooms

(ORs)

and

12

non-OR

settings,

such

as

operating

tive

QI

team

and

surgical,

and

rooms and providers

interventional

suites. The

ambulatory procedure

leaders.

To

increase

visibility

of

this

novel

compo-

nurse nent,

and

surgical

include

academic

faculty,

anesthesia

residents,

nurse

practitioners,

and

physician

assis-

large

posters were

displayed

in

each OR

and

in

each com- four

fellows,

chart

along

with

the

consent.

In-person

patient’s pliance weeks.

tants.

As

a

quaternary

care

trauma ICUs,

center

with

neonatal,

audits

were

performed

by

OR

nurses

over

and

cardiovascular

the surgical population from complex neonates

pediatric,

includes a diverse group of patients,

ambulatory

procedures

on

healthy Review quality

children.

The

Stan-

to

ford

University

Institutional

Board

approved

a

OUTCOMES Convenience

of

consent

for

this

improvement

(QI)

waiver project. The

audits of 60

safety

stop

and

time-out

compo-

perioperative

QI

team,

consisting

of physicians, accreditation

nents

of

the

enhanced Universal

Protocol were

completed

four weeks. Of

those

completed, 96.7%

(58/60) demon-

in

and

an

nurses, pharmacists, quality managers,

regulatory

compliance

specialist,

used

an

A3

project

strated

compliance perioperative

with

the

new

policy.

Verbal

feedback

and plan

9 Current

to

guide development of

a new process.

state

members

involved

was

unanimously

from

positive.

revealed

that had

the

time-out was

performed

after

the

analysis

the

subsequent

Joint Commission

accreditation

During

completed

all

induction

procedures

anesthesiologists

prior

to

P&D. This was

intentionally

done

to

ensure

the

enhanced

pediatric Universal

Protocol with

in-

and that the

survey, clusion

of

the

safety

stop

was

highlighted

by

The

Joint

the

correct

patient

and

surgical

site were

prepared

by of

as

a

leading practice.

Commission

circulating RNs. Unlike

an

adult,

the

operative field

pediatric

patient

is

relatively

smaller,

increasing

the

pos- body

a

10 Also,

sibility

of wrong-site

preparation.

due

to

the

KEY INSIGHTS QI methodology was

relative

to

the OR

table,

a

child’s

limbs

are

often

not

size

beyond

the

table

on

arm

boards,

which

further

used

to

optimize

the Universal

Pro-

extended reduces

11 Although

visual

cues

and

worsens

access

to

the

name

band with- could

tocol

for

pediatric

patients

at

our

institution.

P&D. Multiple

surgeons

were

concerned

that site

that

simply moving

the

time-out

from solu- P&D bod- table.

after

initially we believed

out

a

safety

check

prior

to

P&D,

the

wrong

to

P&D

to

just

prior

to

incision surgeons’

would

be

a

prior tion,

inadvertently

prepared,

which

could

lead

to

a

wrong-

further

analysis

revealed

concerns

of

be

site

or

wrong-patient

surgery

despite

a

time-out

prior

to

wrong being

site

or

wrong

patient

due

to

their

small

the ies

After

problem

analysis,

we

decided Protocol,

to

imple-

obscured

by

draping

on

a

typical

OR

incision.

ment safety

a

novel

adjunct

to

the Universal

called

the

the

Joint Commission

report

that wrong-site, wrong-

Given

stop .

procedure, wrong-patient ond most commonly

surgeries

continue

to

be

the

sec-

safety

stop would

occur

just

prior

to

patient P&D,

reported

sentinel event, developing an

The

the

time-out would be performed

just prior

to incision, circulating

to mitigate

the

risk of

these events was an

and

enhanced protocol

12 By

with WHO

recommendations.

The

for

the

development

of

the

safety

stop.

using

aligning OR nurse

impetus

initiated

the

safety

stop after

the anesthesiologists

team

approach

to

the

development

of

the

safety

stop, we

a

completed

all

induction

procedures.

This

time

point

the new process. The

had

achieved near perfect compliance with

in

the

chart

as

“anesthesia

ready.” Participants

audits

that were noncompliant were

associated with

an

was denoted

two OR with

the

safety

stop

included

all

personnel

in

the OR,

who

RN who

had

been

recently

hired

and was

unfamiliar

in

were

a

surgical

attending

or

fellow,

anesthesiol-

our

novel

process, which

reinforced

the

need

to

em-

typically

ogist,

circulating

RN,

and

surgical

scrub

technician.

Key

phasize

this

component

of

the Universal

Protocol

during

of

the

safety

stop

included

introduction

of

all

components personnel by

orientation.

name, readily

the

arm

band

patient

identifier

check

to

the Universal Protocol

that

are

applica- 7,8 Lee

Modifications

was

available

prior

to

P&D),

procedure expected

ble

for

the

pediatric

population

have

been

reported. performed

(which

against written administration,

consent,

site marking,

an

extended induction

surgical

time-out

prior con-

verification antibiotic

described

anticipated

postoperative

desti-

anesthesia

(in

addition incision)

to

the

time-out

to

nation,

and

fire

risk

( Figure

1 ).

The

time-out

included

a

ducted

immediately

before

and

showed

that

the

2