Publications by authors named "Noel Jabbour"

63 Publications

Aerosol and Droplet Risk of Common Otolaryngology Clinic Procedures.

Ann Otol Rhinol Laryngol 2021 Mar 18:34894211000502. Epub 2021 Mar 18.

Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objectives: Define aerosol and droplet risks associated with routine otolaryngology clinic procedures during the COVID-19 era.

Methods: Clinical procedures were simulated in cadaveric heads whose oral and nasal cavities were coated with fluorescent tracer (vitamin B2) and breathing was manually simulated through retrograde intubation. A cascade impactor placed adjacent to the nares collected generated particles with aerodynamic diameters ≤14.1 µm. The 3D printed models and syringes were used to simulate middle and external ear suctioning as well as open suctioning, respectively. Provider's personal protective equipment (PPE) and procedural field contamination were also recorded for all trials using vitamin B2 fluorescent tracer.

Results: The positive controls of nebulized vitamin B2 produced aerosol particles ≤3.30 µm and endonasal drilling of a 3D model generated particles ≤14.1 µm. As compared with positive controls, aerosols and small droplets with aerodynamic diameter ≤14.1 µm were not detected during rigid nasal endoscopy, flexible fiberoptic laryngoscopy, and rigid nasal suction of cadavers with simulated breathing. There was minimal to no field contamination in all 3 scenarios. Middle and external ear suctioning and open container suctioning did not result in any detectable droplet contamination. The clinic suction unit contained all fluorescent material without surrounding environmental contamination.

Conclusion: While patients' coughing and sneezing may create a baseline risk for providers, this study demonstrates that nasal endoscopy, flexible laryngoscopy, and suctioning inherently do not pose an additional risk in terms of aerosol and small droplet generation. An overarching generalization cannot be made about endoscopy or suctioning being an aerosol generating procedure.

Level Of Evidence: 3.
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http://dx.doi.org/10.1177/00034894211000502DOI Listing
March 2021

Droplet and Aerosol Generation With Mastoidectomy During the COVID-19 Pandemic: Assessment of Baseline Risk and Mitigation Measures With a High-performance Cascade Impactor.

Otol Neurotol 2021 04;42(4):614-622

Department of Otolaryngology, University of Pittsburgh Medical Center.

Hypothesis: Aerosols are generated during mastoidectomy and mitigation strategies may effectively reduce aerosol spread.

Background: An objective understanding of aerosol generation and the effectiveness of mitigation strategies can inform interventions to reduce aerosol risk from mastoidectomy and other open surgeries involving drilling.

Methods: Cadaveric and fluorescent three-dimensional printed temporal bone models were drilled under variable conditions and mitigation methods. Aerosol production was measured with a cascade impactor set to detect particle sizes under 14.1 μm. Field contamination was determined with examination under UV light.

Results: Drilling of cadaveric bones and three-dimensional models resulted in strongly positive aerosol production, measuring positive in all eight impactor stages for the cadaver trials. This occurred regardless of using coarse or cutting burs, irrigation, a handheld suction, or an additional parked suction. The only mitigation factor that led to a completely negative aerosol result in all eight stages was placing an additional microscope drape to surround the field. Bone dust was scattered in all directions from the drill, including on the microscope, the surgeon, and visually suspended in the air for all but the drape trial.

Conclusions: Aerosols are generated with drilling the mastoid. Using an additional microscope drape to cover the surgical field was an effective mitigation strategy to prevent fine aerosol dispersion while drilling.
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http://dx.doi.org/10.1097/MAO.0000000000002987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968968PMC
April 2021

Advanced Practice Provider Clinics: Expediting Care For Children Undergoing Tympanostomy Tube Placement.

Laryngoscope 2021 Feb 26. Epub 2021 Feb 26.

Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.

Objective/hypothesis: Advanced practice provider (APP) employment is becoming common in pediatric otolaryngology practices, though few studies have evaluated the consequences that APP-led clinics have on access to care. The objectives of this study were: 1) to investigate whether access to bilateral myringotomy with tympanostomy tube placement (BMT) for recurrent acute otitis media (RAOM) differed between patients seen in otolaryngologist and APP-led clinics 2) to compare clinical characteristics of patients seen by provider type.

Methods: Retrospective cohort study at an academic, tertiary care pediatric otolaryngology practice. All children were <18 years old and underwent evaluation for RAOM followed by BMT. We compared time in days from scheduling pre-operative appointment to appointment date and time from appointment to BMT between patients seen by APPs and otolaryngologists using Mann-Whitney U tests and multivariate linear regression models. We compared clinical characteristics by provider type using Mann-Whitney U tests and Fisher exact tests.

Results: A total of 957 children were included. Children seen by APPs had significantly shorter wait times for appointments (median 19 vs. 39 days, P < .001) and shorter times from preoperative appointment to BMT (median 25 vs. 37 days, P < .001). Patients seen by otolaryngologists had increased prevalence of craniofacial abnormalities, Down Syndrome, hearing loss, history of otologic surgery, and higher ASA physical status classification.

Conclusions: Children seen by APPs received care more quickly than those seen by otolaryngologists. Patients seen by otolaryngologists tended to be more medically complex. Implementation of independent APP clinics may expedite and improve access to BMT for children with RAOM.

Level Of Evidence: 3 Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29477DOI Listing
February 2021

Operable, Low-Cost, High-Resolution, Patient-Specific 3D Printed Temporal Bones for Surgical Simulation and Evaluation.

Ann Otol Rhinol Laryngol 2021 Feb 8:3489421993733. Epub 2021 Feb 8.

Department of Otolaryngology, University of Pittsburgh Medical Center, PA, USA.

Objectives: Three-dimensional printed models created on a consumer level printer can be used to practice mastoidectomy and to discern mastoidectomy experience level. Current models in the literature for mastoidectomy are limited by expense or operability. The aims of this study were (1) to investigate the utility of an inexpensive model for mastoidectomy and (2) to assess whether the model can be used as an evaluation tool to discern the experience level of the surgeon performing mastoidectomy.

Methods: Three-dimensional printed temporal bone models from the CT scan of a 7-year old patient were created using a consumer-level stereolithography 3D printer for a raw material cost of $10 each. Mastoidectomy with facial recess approach was performed by 4 PGY-2 residents, 4 PGY-5 residents, and 4 attending surgeons on the models who then filled out an evaluation. The drilled models were collected and then graded in a blinded fashion by 6 attending otolaryngologists.

Results: Both residents and faculty felt the model was useful for training (mean score 4.7 out of 5; range: 4-5) and case preparation (mean score: 4.3; range: 3-5). Grading of the drilled models revealed significant differences between junior resident, senior resident, and attending surgeon scores ( = .012) with moderate to excellent interrater agreement (ICC = 0.882).

Conclusion: The described operable model that is patient-specific was rated favorably for pediatric mastoidectomy case preparation and training by residents and faculty. The model may be used to differentiate between experience levels and has promise for use in formative and summative evaluations.
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http://dx.doi.org/10.1177/0003489421993733DOI Listing
February 2021

Peri-procedural Anticoagulation in Patients with Head and Neck Versus Extremity Venous Malformations.

Laryngoscope 2021 May 10;131(5):1163-1167. Epub 2020 Oct 10.

Division of Pediatric Otolaryngology, Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Objective: (1) Review a multidisciplinary vascular anomalies center's practice regarding periprocedural anticoagulation for venous malformations (VM) and the associated risk of thromboembolic and disseminated intravascular coagulation (DIC) events. (2) Compare the risk of thromboembolic events and DIC post-procedure between head and neck (H&N) and extremity VM patients.

Methods: An Institutional Review Board (IRB)-approved, retrospective chart review was performed on 120 VM patients. A thromboembolic event was defined as a thrombus formation post-sclerotherapy or post-surgery within 2 months in a distant or local venous structure not directly addressed by the procedure.

Results: There were 39 cases involving the H&N and 81 cases based at the extremities. There were eight cases of post-procedure thrombus formation within the extremity VM group (8/71; 11.3%) as opposed to 0 cases in the H&N group (OR: 0, 95% CI .00-.09), p = .049. There was no difference in incidence of post-procedure thromboembolic events between those with elevated D-dimer (H&N: 0%, extremity: 22.7%, 5/22) and normal D-dimer values (H&N: 0%, extremity: 6.3% [1/16], P = .370). There was no difference in incidence of post-procedure thromboembolic events between those who received periprocedural anticoagulation (H&N: 0%, extremity: 21%, 4/19) and those who did not (H&N: 0%, extremity: 8.2%, 4/49), (Extremity: OR: 3.00, .67-13.50, P = .206).

Conclusion: Post-procedure thromboembolism is rare in the treatment of venous malformations, especially in the head and neck subsite. Regardless of anticoagulation use, there were no thromboembolic events for H&N VM patients. Such events are rare, and the odds may approach zero, especially with small sample size.

Level Of Evidence: 4 Laryngoscope, 131:1163-1167, 2021.
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http://dx.doi.org/10.1002/lary.29123DOI Listing
May 2021

Multi-institutional Comparison of Temporal Bone Models: A Collaboration of the AAO-HNSF 3D-Printed Temporal Bone Working Group.

Otolaryngol Head Neck Surg 2020 Oct 6:194599820960474. Epub 2020 Oct 6.

Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.

Objective: The American Academy of Otolaryngology-Head and Neck Surgery Foundation's (AAO-HNSF's) 3D-Printed Temporal Bone Working Group was formed with the goal of sharing information and experience relating to the development of 3D-printed temporal bone models. The group conducted a multi-institutional study to directly compare several recently developed models.

Study Design: Expert opinion survey.

Setting: Temporal bone laboratory.

Methods: The working group convened in 2018. The various methods in which 3D virtual models had been created and printed in physical form were then shared and recorded. This allowed for comparison of the advantages, disadvantages, and costs of each method. In addition, a drilling event was held during the October 2018 AAO-HNSF Annual Meeting. Each model was drilled and evaluated by attending-level working group members using an 15-question Likert scale questionnaire. The models were graded on anatomic accuracy as well as their suitability as a simulation of both cadaveric and operative temporal bone drilling.

Results: The models produced for this study demonstrate significant anatomic detail and a likeness to human cadaver specimens for drilling and dissection. Models printed in standard resin material with a stereolithography printer scored highest in the evaluation, though the margin of difference was negligible in several categories.

Conclusion: Simulated 3D temporal bones created through a number of printing methods have potential benefit in surgical training, preoperative simulation for challenging otologic cases, and the standardized testing of temporal bone surgical skills.
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http://dx.doi.org/10.1177/0194599820960474DOI Listing
October 2020

Novel Use of Vitamin B2 as a Fluorescent Tracer in Aerosol and Droplet Contamination Models in Otolaryngology.

Ann Otol Rhinol Laryngol 2021 Mar 14;130(3):280-285. Epub 2020 Aug 14.

Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objective: During the COVID-19 era, a reliable method for tracing aerosols and droplets generated during otolaryngology procedures is needed to accurately assess contamination risk and to develop mitigation measures. Prior studies have not investigated the reliability of different fluorescent tracers for the purpose of studying aerosols and small droplets. Objectives include (1) comparing vitamin B2, fluorescein, and a commercial fluorescent green dye in terms of particle dispersion pattern, suspension into aerosols and small droplets, and fluorescence in aerosolized form and (2) determining the utility of vitamin B2 as a fluorescent tracer coating the aerodigestive tract mucosa in otolaryngology contamination models.

Methods: Vitamin B2, fluorescein, and a commercial fluorescent dye were aerosolized using a nebulizer and passed through the nasal cavity from the trachea in a retrograde-intubated cadaveric head. In another scenario, vitamin B2 was irrigated to coat the nasal cavity and nasopharyngeal mucosa of a cadaveric head for assessment of aerosol and droplet generation from endonasal drilling. A cascade impactor was used to collect aerosols and small droplets ≤14.1 µm based on average aerodynamic diameter, and the collection chambers were visualized under UV light.

Results: When vitamin B2 was nebulized, aerosols ≤5.4 µm were generated and the collected particles were fluorescent. When fluorescein and the commercial water tracer dye were nebulized, aerosols ≤8.61 µm and ≤2.08 µm respectively were generated, but the collected aerosols did not appear visibly fluorescent. Endonasal drilling in the nasopharynx coated with vitamin B2 irrigation yielded aerosols ≤3.30 µm that were fluorescent under UV light.

Conclusion: Vitamin B2's reliability as a fluorescent tracer when suspended in aerosols and small droplets ≤14.1 µm and known mucosal safety profile make it an ideal compound compared to fluorescein and commercial water-based fluorescent dyes for use as a safe fluorescent tracer in healthcare contamination models especially with human subjects.
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http://dx.doi.org/10.1177/0003489420949588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429918PMC
March 2021

Outcomes of BAHA connect vs BAHA attract in pediatric patients.

Int J Pediatr Otorhinolaryngol 2020 Aug 20;135:110125. Epub 2020 May 20.

Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Faculty Pavilion, 7th Floor, Pittsburgh, PA, 15224, USA. Electronic address:

Introduction: Two of the most commonly employed bone-anchored hearing implant (BAHI) systems are the BAHA Connect and BAHA Attract. The BAHA Connect uses a skin-penetrating titanium abutment. The BAHA Attract uses an implanted magnet, leaving the overlying skin intact. Limited data is available on the difference in complication rates between the two systems. Our hypothesis was that there would be no difference in complications and audiologic data.

Methods: Retrospective chart review was performed of patients who had BAHA Connect vs. Attract at our tertiary care pediatric hospital from 2006 to 2018. Pre- and post-operative information, including demographics, related diagnoses, outcomes and complications were compared between the systems using Mann-Whitney U tests and Firth logistic regression for one year post-implant. Audiology data was analyzed with Wilcoxon rank-sum and Wilcoxon matched pairs signed rank tests.

Results: Twenty-four Attract and 18 Connect BAHA surgeries were identified from 37 patients. Eleven Connect patients had the surgery completed in two stages. Connect patients followed up an average of 6.5 years post-implant and 15 months for Attract. A total of 58.8% of patients with Connect surgeries had complications within a year and 82.4% had a complication by their last follow-up. Aside from magnet strength related issues, there were no major complications with Attract surgery at any time point. Patients with Connect surgeries had significantly more skin overgrowths, cultured infections, times on antibiotics, nursing phone calls, and ENT visits within the first year and for all records, p < .05. The pure-tone average was significantly lower for both Connect [unaided-M(SD) = 61.7(9.8); aided-M(SD) = 26.4(5.5) and Attract (unaided-M(SD) = 66.0(22.5); aided-M(SD) = 25.6(6.1)] after implant, p < .001.

Conclusion: Implantation of both systems lead to improved hearing outcomes with profoundly different complication rates.
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http://dx.doi.org/10.1016/j.ijporl.2020.110125DOI Listing
August 2020

Multicenter Advanced Pediatric Otolaryngology Fellowship Prep Surgical Simulation Course with 3D Printed High-Fidelity Models.

Otolaryngol Head Neck Surg 2020 May 14;162(5):658-665. Epub 2020 Apr 14.

Department of Otolaryngology Head and Neck Surgery, Ann Arbor, Michigan, USA.

Objective: To assess the effect of 3-dimensional (3D)-printed surgical simulators used in an advanced pediatric otolaryngology fellowship preparatory course on trainee education.

Study Design: Quasi-experimental pre/postsurvey.

Setting: Multicenter collaborative course conducted at a contract research organization prior to a national conference.

Subjects And Methods: A 5-station, 7-simulator prep course was piloted for 9 pediatric otolaryngology fellows and 17 otolaryngology senior residents, with simulators for airway graft carving, microtia ear framework carving, and cleft lip/palate repair. Prior to the course, trainees were provided educational materials electronically along with presurveys rating confidence, expertise, and attitude around surgical simulators. In October 2018, surgeons engaged in simulation stations with direction from 2 attending faculty per station, then completed postsurveys for each simulator.

Results: Statistically significant increases ( < .05) in self-reported confidence (average, 53%; range, 18%-80%) and expertise (average, 68%; range, 9%-95%) were seen across all simulators, corresponding to medium to large effect sizes as measured by Cohen's statistic (0.41-1.71). Positive attitudes around 3D printing in surgical education also demonstrated statistically significant increases (average, 10%; range, 8%-13%). Trainees commented positively on gaining such broad exposure, although consistently indicated a preference for more practice time during the course.

Conclusion: We demonstrate the benefit of high-fidelity, 3D-printed simulators in exposing trainees to advanced procedures, allowing them hands-on practice in a zero-risk environment. In the future, we hope to refine this course design, develop standardized tools to assess their educational value, and explore opportunities for integration into use in milestone assessment and accreditation.
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http://dx.doi.org/10.1177/0194599820913003DOI Listing
May 2020

Quality and Readability Assessment of Websites on Human Papillomavirus and Oropharyngeal Cancer.

Laryngoscope 2021 01 13;131(1):87-94. Epub 2020 Apr 13.

Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A.

Objectives/hypothesis: The incidence of human papillomavirus-positive (HPV+) oropharyngeal cancer is rising, but public knowledge about this diagnosis remains low. This study aimed to investigate the quality and readability of online information about HPV+ oropharyngeal cancer.

Study Design: Cross-sectional website analysis.

Methods: This study conducted a total of 12 web searches across Google, Yahoo, and Bing to identify websites related to HPV+ oropharyngeal cancer. The QUality Evaluation Scoring Tool (QUEST) was used to measure quality based on seven website criteria. The Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) were used to measure readability, with scores estimating the education level a reader would require to understand a piece of text. Readability improves as FRES increases and FKGL decreases.

Results: Twenty-seven unique web pages were evaluated. The mean USA reading grade level as measured by FKGL was 10.42 (standard deviation = 1.54). There was an inverse relationship between quality and readability, with a significant positive correlation between QUEST score and FKGL (r = 0.343, P = .040) and a significant negative correlation between QUEST score and FRES (r = -0.537, P = .002).

Conclusions: With a mean USA reading grade level more than four grades above the American Medical Association's recommendation and results indicating that readability suffers as quality improves, these findings suggest that the currently available online information about HPV+ oropharyngeal cancer is insufficient. Improved patient education practices and resources about this diagnosis are needed.

Level Of Evidence: NA Laryngoscope, 131:87-94, 2021.
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http://dx.doi.org/10.1002/lary.28670DOI Listing
January 2021

Utilization of Diagnostic Testing for Renal Anomalies and Congenital Heart Disease in Patients with Microtia.

Otolaryngol Head Neck Surg 2020 Apr 21;162(4):554-558. Epub 2020 Jan 21.

Department of Otolaryngology, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Objective: Congenital ear anomalies are associated with congenital cardiac and renal defects. Renal ultrasounds, electrocardiogram, and echocardiogram can be utilized for diagnosis of these concurrent defects. No standard of care exists for the workup of patients with microtia. The goals of this study were to describe the utilization of diagnostic testing for cardiac and renal anomalies and to identify their prevalence in patients with microtia.

Study Design: Case series with chart review.

Setting: Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center.

Subjects And Methods: This study is an Institutional Review Board-approved retrospective review of consecutive patients born between 2002 and 2016 who were diagnosed with microtia and seen in the otolaryngology clinic at a tertiary care children's hospital. Demographics, sidedness and grade of microtia, comorbid diagnoses, and details of renal and cardiovascular evaluations were recorded. Factors associated with retroperitoneal ultrasound and cardiac testing were assessed with logistic regression.

Results: Microtia was present in 102 patients, and 98 patients were included as they received follow-up. Microtia was associated with craniofacial syndrome in 34.7% of patients. Renal ultrasound was performed in 64.3% of patients, and 12.9% of patients with ultrasounds had renal aplasia. Cardiac workup (electrocardiogram or echocardiogram) was completed in 60.2% of patients, and of this subset, 54.2% had a congenital heart defect.

Conclusion: Diagnostic testing revealed renal anomalies and cardiac defects in patients with isolated microtia at a higher rate than in the general population. This suggests the need for further evaluation of the role of routine screening in patients with microtia.
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http://dx.doi.org/10.1177/0194599820901351DOI Listing
April 2020

Eustachian Tube Dysfunction in Children With Unilateral Cleft Lip and Palate: Differences Between Ipsilateral and Contralateral Ears.

Cleft Palate Craniofac J 2020 06 23;57(6):723-728. Epub 2019 Dec 23.

Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Objective: To evaluate Eustachian tube dysfunction in the ipsilateral and contralateral ears, in children with unilateral cleft lip and palate (UCLP).

Design: Retrospective chart review.

Setting: Tertiary care children's hospital.

Patients: Seventy-four consecutive patients with UCLP born between 2005 and 2011 and treated at UPMC Children's Hospital of Pittsburgh Cleft-Craniofacial Center were included.

Main Outcome Measures: Conductive hearing loss, tympanogram type, number of middle ear effusions, tympanostomy tubes, and complications. Hypothesis was formulated prior to data collection.

Results: Conductive hearing loss was nearly twice as common in the ipsilateral ear (43.2%) compared with contralateral (23.0%; = .001, McNemar test). There were no significant differences in the frequency of each type of tympanogram between the contralateral and ipsilateral ears. The proportions of ipsilateral (90.5%) and contralateral (91.9%) ears with effusion were not significantly different. The total number of tubes received was not significantly different between the 2 ears (median of 2 bilaterally). When combined, complications (retractions, perforations, and cholesteatomas) were significantly more common in the ipsilateral ear (29.7%) compared with the contralateral ear (18.9%; = .039, McNemar test).

Conclusion: In children with UCLP, there were significantly more instances of conductive hearing loss and complications on the cleft side compared to the noncleft side. This suggests that Eustachian tube dysfunction may indeed be more severe on the cleft side. Considering this information, clinicians may need to be especially observant of the ipsilateral ear.
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http://dx.doi.org/10.1177/1055665619895635DOI Listing
June 2020

When Slight Degrees of Hearing Impairment in Children May Actually Matter.

JAMA Otolaryngol Head Neck Surg 2020 02;146(2):120-121

Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

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http://dx.doi.org/10.1001/jamaoto.2019.3613DOI Listing
February 2020

The Association Between Age at Palatoplasty and Speech and Language Outcomes in Children With Cleft Palate: An Observational Chart Review Study.

Cleft Palate Craniofac J 2020 02 24;57(2):148-160. Epub 2019 Oct 24.

Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, PA, USA.

Objective: To determine whether timing of palatoplasty (early, standard, or late) is associated with speech and language outcomes in children with cleft palate.

Design: Retrospective case series.

Setting: Tertiary care children's hospital.

Participants: Records from 733 children born between 2005 and 2015 and treated at the Cleft Craniofacial Clinic of a tertiary children's hospital were retrospectively reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, syndromes, staged palatoplasty, and introduction to clinic after 12 months of age. Data from 232 children with cleft palate ± cleft lip were analyzed.

Interventions: Palatoplasty.

Main Outcome Measures: Speech/language delays and disorders at 20 months and 5 years of age based on formal hospital or community-based testing or screening evaluation in the Cleft Craniofacial Clinic; additional speech surgery.

Results: Median age at palatoplasty was 12.6 months (range: 8.8-21.9 months). Age at palatoplasty was classified as early (<11 months, n = 28), standard (11-13 months, n = 158), or late (>13 months, n = 46). Late palatoplasty was associated with increased odds of speech/language delays and speech therapy at 20 months, and language delays at 5 years, compared with standard or early palatoplasty ( < .05 for all comparisons). However, speech sound production disorders, velopharyngeal incompetence, tube replacement, and hearing loss were not significantly associated with age at palatoplasty.

Conclusions: Late palatoplasty may be associated with short- and long-term delays in speech/language development. Future studies with standardized surgical technique/timing and outcome measures are required to more definitively describe the impact of age at palatoplasty on speech/language development.
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http://dx.doi.org/10.1177/1055665619882566DOI Listing
February 2020

Pediatric partial gelfoam myringoplasty with ventilation tube placement.

Int J Pediatr Otorhinolaryngol 2019 Nov 9;126:109632. Epub 2019 Aug 9.

Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Faculty Pavilion, 7th Floor, Pittsburgh, PA, 15224, USA. Electronic address:

Objective: For children with a history of persistent Eustachian tube dysfunction (ETD) or otitis media with effusion presenting with recurring tympanic membrane (TM) perforation, surgeons must often balance the treatment goals of correcting the perforation and maintaining ventilation to the middle ear to prevent future perforation formation. A partial gelfoam myringoplasty with ventilation tube placement is a previously unreported procedural option for addressing these goals. The objective of this study is to describe the partial myringoplasty technique and report preliminary outcome data for the procedure.

Methods: Retrospective cohort study of 29 children <18 years old undergoing partial myringoplasty at a tertiary care children's hospital or satellite location. Size and course of initial perforation, time to tube extrusion, audiogram findings, and need for future otological procedures were studied.

Results: During a partial myringoplasty, a tympanostomy tube is placed in a TM perforation larger than the tube itself. The edges of the perforation are freshened, a tube is placed, and a piece of gelfoam is inserted to support the tube and to cover any remaining perforation. Out of 32 ears in 29 patients, 23 procedures were completed to correct existing perforations. The remainder were indicated in placement (n = 7) or replacement (n = 2) where the myringotomy or existing perforation was deemed too large to retain the tympanostomy tube without further support due to atelectatic or monomeric tympanic membranes. Thirteen tubes extruded within 1 year, of which 12 were Armstrong tubes and 1 was a T-tube. Out of 25 TM perforations corrected, 4 shrank in size and 2 did not close. For patients who underwent pre-surgical audiograms with findings indicating conductive hearing loss and had post-operative audiograms at follow-up, 8/10 showed improvement and 2/10 showed no change in hearing.

Conclusion: A partial myringoplasty is a simple procedure to close existing TM perforations while maintaining ventilation to the middle ear that can potentially improve hearing, provide ongoing ventilation, and eventually result in TM closure without the need for more complex repair. It may serve as a reasonable first line treatment for repair of perforations, reserving tympanoplasty for patients who fail this procedure.
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http://dx.doi.org/10.1016/j.ijporl.2019.109632DOI Listing
November 2019

Multicenter Interrater Reliability in the Endoscopic Assessment of Velopharyngeal Function Using a Video Instruction Tool.

Otolaryngol Head Neck Surg 2019 04 15;160(4):720-728. Epub 2019 Jan 15.

1 Department of Otolaryngology: Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.

Objective: Assess interrater agreement of endoscopic assessment of velopharyngeal (VP) function before and after viewing the video instruction tool (VIT). We hypothesized improvement in interrater agreement using the Golding-Kushner scale (GKS) after viewing the VIT.

Study Design: Prospective study.

Setting: Multi-institutional.

Methods: Sixteen fellowship-trained pediatric otolaryngologists who treat velopharyngeal insufficiency (VPI) rated 50 video segments using the GKS before and after watching the VIT. Raters assessed gap size percentage and lateral pharyngeal wall (LPW), soft palate (SP), and posterior pharyngeal wall (PPW) movement. Intraclass correlation coefficient was estimated for these continuous measures. Raters also indicated the presence of a palatal notch, Passavant's ridge, and aberrant pulsations (categorical variables). Fleiss κ coefficient was used for categorical variables. Wilcoxon signed-rank test was performed on the difference between the pre/post individual video ratings.

Results: Reliability improved for all continuous variables after watching the instructional video. The improvement was significant for PPW (0.22-0.30, P < .001), SP (left: 0.63-0.68, P < .001 and right: 0.64-0.68, P = .001), and LPW (left: 0.49-0.54, P = .01 and right: 0.49-0.54, P = .09) but not significant for gap size (0.65-0.69, P = .36). Among categorical variables, agreement on Passavant's ridge significantly improved (0.30-0.36, P = .03).

Conclusion: Exposure to a video instruction tool improves interrater agreement of endoscopic assessment of VP function. Significant improvement was observed in our primary end points, specifically posterior pharyngeal wall movement, soft palate movement, and lateral pharyngeal wall movement. There was less impact of the VIT on the interrater agreement of the categorical variables, palatal notch, Passavant's ridge, and aberrant pulsations.
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http://dx.doi.org/10.1177/0194599818822989DOI Listing
April 2019

Hazardous noise exposure from noisy toys may increase after purchase and removal from packaging: A call for advocacy.

Int J Pediatr Otorhinolaryngol 2019 Jan 22;116:84-87. Epub 2018 Oct 22.

Department of Otolaryngology, University of Minnesota School of Medicine, 516 Delaware St. SE, Suite 8-240, Minneapolis, MN, 55455, USA. Electronic address:

Objective: Previous studies identified hazardous noise levels from packaged toys. Sound levels may increase when packaging is removed and therefore, complicate the ability to accurately assess noise levels before purchase. The goal of this study was to evaluate how packaging affects the decibel (dB) level of toys by: 1) Assessing dB level of toys with and without packaging. 2) Evaluating the percentage of packaged and unpackaged toys that exceed a safety limit of 85 dB.

Methods: Thirty-five toys were selected from the 2009-2011 Sight and Hearing Association (SHA) based on availability for purchase. Toys' speakers were categorized as Exposed, Partially Exposed, or Covered, based on its packaging. The dB level of each toy was tested at 0 cm and 25 cm from the speaker using a handheld digital sound meter in a standard audiometric booth. T tests and ANOVA were performed to assess mean change in sound level before and after packaging removal.

Results: Significant dB increases were noted after packaging was removed (mean change 11.9 dB at 0 cm; and 2.5 dB at 25 cm, p < 0.001). Sixty-four percentage of Covered toys (n = 14) had dB greater than 85 dB when packaged and this increased to 100% when unpackaged.

Conclusion: Many manufactured toys have hazardous sound levels. Caregivers and healthcare providers should be aware that toys tested in the store may actually be louder when brought home and removed from their packaging. Limits on and disclosure of dB level of toys should be considered nationally.
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http://dx.doi.org/10.1016/j.ijporl.2018.10.028DOI Listing
January 2019

Airway anomalies in patients with craniosynostosis.

Laryngoscope 2019 Nov 19;129(11):2594-2602. Epub 2018 Nov 19.

Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A.

Objectives: 1) Characterize the spectrum of airway anomalies in patients with craniosynostosis, and 2) identify clinical characteristics of these patients that may be associated with the development of airway anomalies.

Methods: This study is a retrospective case series assessing the type and frequency of airway anomalies in all patients with craniosynostosis seen at a tertiary-care children's hospital between 2000 and 2016. Cohort analyses were then performed to identify differences in airway anomalies dependent on syndromic associations, multisutural fusion, and location of suture fusion. Clinical characteristics examined included demographics and additional neurologic and craniofacial abnormalities.

Results: Four hundred and ninety-six patients with craniosynostosis (83.5% white, 64.5% male; 33.9% sagittal, 28.8% metopic, 11.5% coronal, 1.2% lambdoid, and 24.6% multisutural) were included. Notable airway anomalies included the following: 13.3% adenotonsillar hypertrophy, 8.9% laryngomalacia, 7.3% tracheomalacia, 7.1% subglottic stenosis, 4.0% bronchomalacia, 3.8% laryngeal cleft, and 1.2% vocal fold paresis. Multisutural craniosynostosis patients (n = 122) were more likely to have obstructive sleep apnea (P = 0.005), adenotonsillar hypertrophy (P = 0.014), tracheomalacia (P = 0.011), subglottic stenosis (P < 0.001), and epiglottic/base of tongue collapse (P = 0.003) and require tracheostomy (P = 0.001) and mechanical ventilation (P = 0.017) compared with single suture craniosynostosis. Syndromic craniosynostosis patients (n = 33) were more likely to have obstructive sleep apnea (P < 0.001), laryngomalacia (P = 0.047), and subglottic stenosis (P = 0.009) compared with nonsyndromic patients.

Conclusion: Airway anomalies are prevalent in patients with craniosynostosis; patients with multisutural or syndromic types have an increased risk of developing certain abnormalities. There should be a lower threshold for referral for airway evaluation in these populations.

Level Of Evidence: 4. Laryngoscope, 129:2594-2602, 2019.
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http://dx.doi.org/10.1002/lary.27589DOI Listing
November 2019

The Impact of Timing of Tympanostomy Tube Placement on Sequelae in Children With Cleft Palate.

Cleft Palate Craniofac J 2019 07 11;56(6):720-728. Epub 2018 Nov 11.

1 Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Objective: To describe the impact of timing of tympanostomy tube insertion on the number of tubes received and complications in children with routine tube placement.

Design: Retrospective case series.

Setting: Tertiary care children's hospital.

Participants: Records from a consecutive sample of 401 children with cleft palate were reviewed. Sixty-five patients with isolated cleft palate and 82 patients with cleft lip and palate had follow-up until 5 years of age and were included.

Interventions: Tympanostomy tubes.

Main Outcome Measure(s): Number of tubes received and tube-related complications. The hypothesis was formulated prior to data collection.

Results: Males comprised 55.8% of included patients, and tubes were placed in 98.6% of patients at a median age of 6.5 months. Effusion was documented at first tube placement for 96.5% of patients. Most (67.4%) patients required replacement of tubes, and 10.6% required long-term tubes. Complications included otorrhea (71.0%), myringosclerosis (35.2%), granulation (22.8%), perforation (17.9%), retained tubes (5.5%), and cholesteatoma (1.4%). Cleft lip and palate ( < .001) and otorrhea ( = .023) were associated with tube placement before palatoplasty. Patients with tube placement before palatoplasty ( = .033), genetic disorders ( = .007), failed newborn hearing screen ( = .012), otorrhea ( < .001), and granulation ( < .001) received more tubes.

Conclusions: Nearly universal effusion in patients with cleft palate supports the need for routine tube placement. The potential for otorrhea and requiring more tubes should be weighed against the risks associated with prolonged effusion when considering tube placement before palatoplasty.
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http://dx.doi.org/10.1177/1055665618809228DOI Listing
July 2019

Safety of Drilling 3-Dimensional-Printed Temporal Bones.

JAMA Otolaryngol Head Neck Surg 2018 09;144(9):797-801

Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Importance: Three-dimensional (3-D) printing of temporal bones is becoming more prevalent. However, there has been no measure of the safety of drilling these models to date. It is unknown whether the heat and sheer from the drill may create harmful volatile organic compounds (VOCs).

Objective: To determine the level of exposure to airborne contaminants when conducting high-speed drilling on 3-D-printed models and to explore whether there is a need for exposure control measures.

Design, Setting, And Participants: In this occupational safety assessment carried out in a temporal bone laboratory, 3 individual 3-D-printed temporal bones were made using 3 different materials commonly cited in the literature: polylactic acid (PLA), photoreactive acrylic resin (PAR), and acrylonitrile butadiene styrene (ABS). Each model was drilled for 40 minutes while the surgeon wore a sampling badge. Sampling was conducted for airborne concentrations of VOCs and total particulate (TP). Monitoring for VOCs was conducted using Assay Technology 521-25 organic vapor badge worn at the surgeon's neckline. Monitoring for TP was conducted using a polyvinyl chloride filter housed inside a cassette and coupled with an SKC AirChek 52 personal air-sampling pump. Samples were collected and analyzed in accordance with NIOSH Method 500.

Main Outcomes And Measures: Presence of VOCs and TP count exposures at Occupational Safety and Health Administration (OSHA) actionable levels.

Results: Results of the VOC sample were less than detection limits except for isopropyl alcohol at 0.24 ppm for PAR. The TP samples were less than the detection limit of 1.4 mg/m3. The results are below all applicable OSHA Action Levels and Permissible Exposure Limits for all contaminants sampled for.

Conclusions And Relevance: Drilling 3-D-printed models made from PLA, ABS, and PAR was safe by OSHA standards. Continued monitoring and safety testing are needed as 3-D-printed technologies are introduced to our specialty.
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http://dx.doi.org/10.1001/jamaoto.2018.1516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233629PMC
September 2018

Subglottic hemangioma: Understanding the association with facial segmental hemangioma in a beard distribution.

Int J Pediatr Otorhinolaryngol 2018 Oct 12;113:34-37. Epub 2018 Jul 12.

Department of Otolaryngology--Head & Neck Surgery Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA, USA, 15224. Electronic address:

Objective: A subglottic hemangioma (SGH) is a benign tumor of infancy that can cause severe obstruction of the airway. Infantile hemangiomas, in general, are the most common head and neck tumor in children, affecting 4-5% of the pediatric population. This retrospective cohort study characterizes subglottic infantile hemangiomas at a single vascular anomaly center over a 5-year period (2013-2017) during the era of propranolol treatment.

Methods: Queried the Vascular Anomaly Database at Children's Hospital of Pittsburgh for all infantile hemangioma(s) and then identified case of subglottic hemangiomas. Characterized key features of presentation, natural history and management for subglottic hemangiomas. A secondary differentiation focused on differences between subglottic hemangiomas associated with Beard Distribution (BD) vs not (NBD).

Results: Analysis of 761 cases of infantile hemangiomas demonstrated only 13 patients with subglottic hemangiomas (1.7%). Of those 13 patients, only 4 patients (30%) had BD while 2 patients (15%) had other cutaneous hemangiomas and 7 patients (55%) had no cutaneous hemangiomas. Secondarily, a total of 31 case of beard distribution cutaneous hemangiomas with 11 patients having oropharyngeal involvement (35%) but only 4 patients with subglottic hemangiomas (13%). Interestingly, 2 of the 4 BD patients had treatment failure on propranolol and required second line treatment with steroids or surgical excision while only 1 of 9 NBD patients failed propranolol treatment. As well the same 2 BD patients which failed propranolol also had PHACES syndrome.

Conclusion: Subglottic hemangiomas are a rare presentation of infantile hemangiomas but with significant morbidity. While the classic teaching that a segmental beard distribution hemangioma raises concern for a subglottic hemangioma, this cohort indicates subglottic hemangiomas occur in a NBD presentation (1.3%), and demonstrated only an approximate 10% incidence rate with a beard distribution. But more importantly, this study raises the question that beard distribution in setting of PHACES syndrome may herald a more recalcitrant and complicated natural history for a subglottic hemangioma. This is of significant concern as risk for CVA in setting of PHACES is highest with use of steroid treatment. None of our patients had high risk extra or intra cranial vascular arterial anomalies and no CVA were noted.
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http://dx.doi.org/10.1016/j.ijporl.2018.07.019DOI Listing
October 2018

Accuracy of chest X-Ray measurements of pediatric esophageal coins.

Int J Pediatr Otorhinolaryngol 2018 Oct 10;113:1-3. Epub 2018 Jul 10.

Department of Otolaryngology, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.

Objective: To determine the accuracy of chest x-ray measurements in children using ingested radiopaque foreign bodies of known size.

Methods: A database of foreign body ingestions at a tertiary care children's hospital was queried from 2013 to 2016 for children who had ingested a US coin, had a pre-operative chest x-ray and documentation of coin type at the time of endoscopic removal. Four blinded research subjects measured the coin diameter on chest x-ray using iSite PACS software and based on the measurement, predicted the coin type. Measurements were compared to the known coin diameters published by the US Mint.

Results: A total of 51 patients with sixteen esophageal quarters (diameter 24.26 mm), fourteen nickels (21.21 mm), fourteen pennies (19.05 mm) and seven dimes (17.91 mm) were included in the study. The four subjects had a mean accuracy of 60.3% (range 49.0%-72.5%) in predicting the correct coin type. Across all raters, there was poor agreement for pennies (kappa = 0.161) and dimes (kappa = 0.131), fair agreement for nickels (kappa = 0.259), good agreement for quarters (kappa = 0.687), and fair agreement overall (kappa = 0.371). The study measurements overestimated the coin size in 203 of the 204 measurements by a mean of 1.84 mm (range -0.31-3.85 mm). The mean size discrepancy was larger (2.40 vs. 1.30 mm, p < 0.001) and accuracy of coin type identification was worse (44.6% vs. 74.1%, p = 0.001) in children <4 years old.

Conclusions: Measurement of esophageal coins on chest x-ray is relatively inaccurate and overestimates the size in the majority of cases. Clinicians should use caution when performing fine measurements on chest x-rays, especially in children younger than 4 years old.
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http://dx.doi.org/10.1016/j.ijporl.2018.07.011DOI Listing
October 2018

Laryngomalacia in Patients With Craniosynostosis.

Ann Otol Rhinol Laryngol 2018 Aug 20;127(8):543-550. Epub 2018 Jun 20.

1 Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Objective: To characterize differences in the clinical presentation and treatment outcomes of laryngomalacia in patients with and without craniosynostosis.

Methods: A retrospective cohort study was performed comparing all patients with concomitant laryngomalacia and craniosynostosis seen at a tertiary care children's hospital between 2000 and 2016 with a control group of patients with isolated laryngomalacia. Thirty-two patients with craniosynostosis (59% male) and 68 control patients (56% male) were included. There were no significant differences in age of diagnosis or incidence of prematurity. Symptom presentation, disease severity, swallowing function, comorbidities, treatment modalities, and outcomes were examined using logistic regression.

Results: Patients with craniosynostosis had increased odds of presenting with stertor (odds ratio [OR] = 3.41, P = .022), increased work of breathing (OR = 18.8, P = .007), obstructive sleep apnea (OR = 8.48, P = .003), dysphagia (OR = 3.40, P = .008), and aspiration (OR = 40.2, P < .001) and decreased odds of presenting with stridor (OR = 0.0804, P < .001) compared with controls. Patients with craniosynostosis had increased odds of severe laryngomalacia (OR = 5.00, P = .031) and other airway anomalies such as tracheomalacia (OR = 5.73, P = .004), bronchomalacia (OR = 15.5, P = .013), and subglottic stenosis (OR = 2.75, P = .028). Treatment of patients with craniosynostosis was more likely to include tracheostomy (OR = 24.8, P < .001) and gastrostomy tube (OR = 88.4, P < .001). There were no significant differences in rates of supraglottoplasty.

Conclusion: Clinical presentations, comorbidities, and treatments of laryngomalacia are significantly different in the context of craniosynostosis.
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http://dx.doi.org/10.1177/0003489418779413DOI Listing
August 2018

Quality, Readability, and Trends for Websites on Ankyloglossia.

Ann Otol Rhinol Laryngol 2018 Jul 18;127(7):439-444. Epub 2018 May 18.

2 Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA.

Objective: This study evaluates the quality and readability of websites on ankyloglossia, tongue tie, and frenulectomy.

Methods: Google was queried with six search terms: tongue tie, tongue tie and breastfeeding, tongue tie and frenulectomy, ankyloglossia, ankyloglossia and breastfeeding, and ankyloglossia and frenulectomy. Website quality was assessed using the DISCERN instrument. Readability was evaluated using the Flesch-Kincaid Reading Grade Level, Flesch Reading Ease Score, and Fry readability formula. Correlations were calculated. Search terms were analyzed for frequency using Google Trends and the NCBI database.

Results: Of the maximum of 80, average DISCERN score for the websites was 65.7 (SD = 9.1, median = 65). Mean score for the Flesch-Kincaid Reading Grade Level was 11.6 (SD = 3.0, median = 10.7). Two websites (10%) were in the optimal range of 6 to 8. Google Trends shows tongue tie searches increasing in frequency, although the NCBI database showed a decreased in tongue tie articles.

Conclusions: Most of the websites on ankyloglossia were of good quality; however, a majority were above the recommended reading level for public health information. Parents increasingly seek information on ankyloglossia online, while fewer investigators are publishing articles on this topic.
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http://dx.doi.org/10.1177/0003489418776343DOI Listing
July 2018

What parents are reading about laryngomalacia: Quality and readability of internet resources on laryngomalacia.

Int J Pediatr Otorhinolaryngol 2018 May 28;108:175-179. Epub 2018 Feb 28.

Children's Hospital of Pittsburgh of UPMC, Division of Otolaryngology, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States. Electronic address:

Objective: The goal of this study is to measure the quality and readability of websites related to laryngomalacia, and to compare the quality and readability scores for the sites accessed through the most popular search engines.

Introduction: Laryngomalacia is a common diagnosis in children but is often difficult for parents to comprehend. As information available on the internet is unregulated, the quality and readability of this information may vary.

Methods: An advanced search on Google, Yahoo, and Bing was conducted using the terms "laryngomalacia" OR "soft larynx" OR "floppy voice box." The first ten websites meeting inclusion and exclusion criteria were evaluated, for each search engine. Quality and readability were assessed using the DISCERN criteria and the Flesch reading ease scoring (FRES) and Flesch-Kincaid grade level (FKGL) tests, respectively.

Results: The top 10 hits on each search engine yielded 15 unique web pages. The median DISCERN score (out of a possible high-score of 80) was 48.5 (SD 12.6). The median USA grade-level estimated by the FKGL was 11.3 (SD 1.4). Only one website (6.7%), had a readability score in the optimal range of 6th to 8th grade reading level. DISCERN scores did not correlate with FKGL scores (r = 0.10).

Conclusion: Online information discussing laryngomalacia often varies in quality and may not be easily comprehensible to the public. It is important for healthcare professionals to understand the quality of health information accessible to patients as it may influence medical decision-making by patient families.
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http://dx.doi.org/10.1016/j.ijporl.2018.02.036DOI Listing
May 2018

Cervical Spine Injury From Unrecognized Craniocervical Instability in Severe Pierre Robin Sequence Associated With Skeletal Dysplasia.

Cleft Palate Craniofac J 2018 05 28;55(5):773-777. Epub 2018 Feb 28.

1 Division of Pediatric Plastic Surgery, University of Pittsburgh School of Medicine, Pennsylvania, PA, USA.

Pierre Robin Sequence (PRS) can be associated with skeletal dysplasias, presenting with craniocervical instability and devastating spinal injury if unrecognized. The authors present the case of an infant with PRS and a type II collagenopathy who underwent multiple airway-securing procedures requiring spinal manipulation before craniocervical instability was identified. This resulted in severe cervical cord compression due to odontoid fracture and occipitoatlantoaxial instability. This case highlights the importance of early cervical spine imaging and cautious manipulation in infants with PRS and suspected skeletal dysplasia.
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http://dx.doi.org/10.1177/1055665618758102DOI Listing
May 2018

Diagnosing Tongue Base Obstruction in Pierre Robin Sequence Infants: Sleep vs Awake Endoscopy.

Cleft Palate Craniofac J 2018 05 15;55(5):692-696. Epub 2018 Feb 15.

4 Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Objective: To investigate whether awake endoscopy can diagnose base-of-tongue obstruction as reliably as sleep endoscopy in infants with Pierre Robin sequence (PRS).

Design: The study was retrospective with the clinicians blinded to patient identity. Endoscopy findings were assessed and measured by the performing pediatric otolaryngologist.

Setting: Tertiary care children's hospital.

Patients: All infants with PRS managed between January 2005 and July 2015 were included. There were 141 patients, of which 35 underwent both awake endoscopy (AE) and drug-induced sleep endoscopy (DISE).

Interventions: Bedside AE and DISE in the operating room.

Main Outcome Measures: Presence of moderate or severe base-of-tongue collapse was assessed. Sensitivity, specificity, and positive likelihood ratio of AE findings as well as intertest differences between AE and DISE were calculated.

Results: AE had 50.0% sensitivity (95% confidence interval [CI] 27.2%-72.8%) and 86.7% specificity (95% CI 59.5%-98.3%) for detecting base-of-tongue obstruction compared to DISE; false negative rate was 50.0% (n = 10). Positive likelihood ratio was 3.75 (CI 0.96-14.65). Compared to AE, DISE demonstrated significantly more cases of base-of-tongue obstruction ( P = .039).

Conclusions: Bedside AE has low sensitivity for detecting base-of-tongue collapse in infants with PRS. Because of the substantial false negative rate, AE may not be a reliable diagnostic modality for ruling out base-of-tongue obstruction in this susceptible population. DISE may be indicated in high-risk patients to avoid underdiagnosing upper airway obstruction.
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http://dx.doi.org/10.1177/1055665618756706DOI Listing
May 2018

Should Children With Cleft Palate Receive Early Long-Term Tympanostomy Tubes: One Institution's Experience.

Cleft Palate Craniofac J 2018 03 14;55(3):389-395. Epub 2017 Dec 14.

1 Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Objectives: To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes.

Design: Retrospective cohort study.

Setting: Tertiary care children's hospital.

Participants: Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained.

Main Outcome Measure: Number of tubes.

Results: Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P = .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P = .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years).

Conclusion: Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population.
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http://dx.doi.org/10.1177/1055665617736775DOI Listing
March 2018

Reducing rates of operative intervention for pediatric post-tonsillectomy hemorrhage.

Laryngoscope 2018 08 4;128(8):1958-1962. Epub 2018 Jan 4.

Department of Otolaryngology, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A.

Objectives/hypothesis: The aims of this study were to determine the frequency of rebleeding in patients admitted for observation after presentation for nonactive hemorrhage in the post-tonsillectomy period, compare rebleeding rates between patients managed with observation versus initial operative control, and describe the complication profile associated with observation as a management strategy for post-tonsillectomy bleeding.

Study Design: Case series with retrospective review of patients.

Methods: Patients presenting from September 1, 2013 to August 31, 2015 for post-tonsillectomy hemorrhage to a tertiary pediatric care center were evaluated for inclusion in the study. Inclusion criteria included patients ≤18 years of age without active bleeding at the time of the initial examination. Proportions were compared using χ and Fisher exact tests, whereas continuous data were compared using the Wilcoxon rank sum test.

Results: Of 3,866 tonsillectomy patients, 285 (7.4%) presented with concern for oropharyngeal bleeding in the postoperative period, of whom 224 were admitted for nonactive bleeding. Of patients with nonactive bleeding, 203 (90.6%) were managed with observation and 21 (9.4%) with operative intervention. Rate of rebleeding was 26/203 (12.8%) after inpatient observation and 3/21 (14.3%) after operative intervention (P = 1.000). Frequency of rebleeding requiring operative control in patients undergoing initial observation was 14/203 (6.9%).

Conclusions: In our pilot study, rates of rebleeding in patients observed for nonactive post-tonsillectomy hemorrhage was not statistically different than those managed with initial operative exploration. Although preliminary in nature, our data suggest observation may have comparable safety and efficacy when compared to operative management for pediatric patients presenting with nonactive post-tonsillectomy bleeding. Further data collection to establish an optimal management algorithm is ongoing.

Level Of Evidence: 4 Laryngoscope, 1958-1962, 2018.
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http://dx.doi.org/10.1002/lary.27076DOI Listing
August 2018