Multiple surgeries in pediatric otolaryngology patients and associated anesthesia risks

Can growing patients with end-stage TMJ pathology be successfully treated with alloplastic temporomandibular joint reconstruction? - A systematic review

INTRODUCTION

The use of alloplastic total temporomandibular joint reconstruction (TMJR) in growing patients is controversial, mainly due to immature elements of the craniomaxillofacial skeleton. The aim of this systematic review was to evaluate the use of alloplastic TMJR in growing patients, focusing on the patient's clinical presentation, surgical and medical history and efficacy of alloplastic TMJR implantation.

MATERIALS AND METHODS

The literature search strategy was based on the Population, Intervention, Comparator, Outcomes and Study type (PICOS) framework. We searched Pubmed, Google Scholar, Dimension, Web of Science, X-mol, Semantic Scholar and Embase to January 2023, without any restriction on the type of publication reporting alloplastic TMJR in growing patients (age ≤ 18 years for boys and age ≤ 15 years for girls).

RESULTS

A total of 15 studies (case reports: 09, case series: 02, cohort studies: 04) met the inclusion criteria, documenting 73 patients of growing age from 07 countries. Thirty-eight (~ 52%) cases were female. The mean ± SD (range) age and follow-up of patients in all studies was 13.1 ± 3.2 (0-17) years and 34.3 ± 21.5 (7-96) months, respectively. A total of 22 (30%) patients were implanted with bilateral alloplastic TMJR. Over half of the studies (n = 10) were published in the last 3 years. All patients underwent multiple surgeries prior to implantation of alloplastic TMJR. In extreme cases, patients underwent a total of 17 surgeries. Different types of studies reporting inconsistent variables restricted our ability to perform quality assessment measures for evidence building.

CONCLUSIONS

Clinical experience with alloplastic TMJR in growing patients is limited to cases showing poor prognosis with other types of reconstruction. Nevertheless, studies show promising results for the use of alloplastic TMJR in growing patients, highlighting the need for well-controlled prospective studies with long-term follow-up.

Helping Children with Special Needs: Who Receives Tympanostomy Tubes?

OBJECTIVES

Tympanostomy tubes can prevent sequelae of otitis media that adversely affect long term hearing and language development in children. These negative outcomes compound the existing difficulties faced by children who are already diagnosed with developmental disorders. This study aims to characterize this subset of children with developmental disorders undergoing myringotomy and tympanostomy tube insertion.

METHODS

A retrospective review using the Kids' Inpatient Database (KID) was conducted, with codes from International Classification of Diseases, Ninth Revision used to query data from the years 2003 to 2012 to determine a study group of children with a diagnosis of a developmental disorder undergoing myringotomy and tympanostomy insertion. This group was compared statistically to patients undergoing these procedures who did not have a diagnosed developmental disorder.

RESULTS

In total, 21 945 cases of patients with myringotomy with or without tympanostomy tube insertion were identified, of which 1200 (5.5%) had a diagnosis of a developmental disorder. Children with developmental disorders had a higher mean age (3.3 years vs 2.9 years, P = .002) and higher mean hospital charges ($43 704.77 vs $32 764.22, P = .003). This cohort also had higher proportions of black (17.6% vs 12.3%, P < .001) and Hispanic (23.9% vs 20.6%, P = .014) patients, and had lower rates of private insurance coverage (39.6% vs 49%, P < .001).

CONCLUSION

The population of children with developmental disorders undergoing myringotomy or tympanostomy tube placement has a different demographic composition than the general population and faces distinct financial and insurance coverage burdens. Further study should be done to assess if these differences impact long term outcomes.

General anesthesia risk across pediatric surgical specialties: Low in otolaryngology

PURPOSE

To determine the relevance of the Food and Drug Administration (FDA) warning regarding general anesthesia (GA) in children under 3 years of age for procedures lasting longer than 3 h, by surgical specialty and for otolaryngology specifically.

METHODS

A one-year retrospective review was conducted at a tertiary-care medical center for all children younger than 3 years undergoing surgical procedures with durations greater than 3 h. De-identified data related to age, surgical service, procedure types, American Society of Anesthesiologists (ASA) physical status classification, and general anesthesia time were collected and examined.

RESULTS

During 2017, 430 of 11,757 patients (3.7%) met the age and duration of anesthesia criteria. Procedures performed by the cardiothoracic surgery service were mostly likely to result in duration of surgery greater than 3 h (46.6%), followed by neurosurgery (12.9%), cardiology (9.3%), plastic surgery (7.1%), general surgery (6.6%), and urology (5.1%). Less than 2% of patients undergoing ophthalmology (1.9%), orthopedic surgery (1.7%), and otolaryngology (0.5%) procedures required anesthesia greater than 3 h.

CONCLUSION

Less than 4% of patients younger than 3 years undergoing surgery required general anesthesia for longer than 3 h. The theoretical risks of general anesthesia per the FDA warning are discussed and must be balanced against the known functional and neurodevelopmental consequences of not performing critical and time-sensitive surgery on children in this age group. A strategy for addressing parental and provider concerns is discussed.

Preventing unnecessary tympanostomy tube placement in children

OBJECTIVE

In 2013 the American Academy of Otolaryngology published tympanostomy tube guidelines for children; Action Statement 6 recommends against tube placement without middle ear effusion (MEE) at time of assessment. To date, little research has directly evaluated this recommendation in reducing the need for ear tubes. We evaluated the effectiveness of this recommendation and potential risk factors that influence the success of watchful waiting.

METHODS

Retrospective chart review collecting demographics, daycare status, smoking exposure, and time of year of visit. Children aged 6 months to 12 years without MEE on presentation, but with 3 or more episodes of acute otitis media (AOM) in 6 months or 4 or more episodes in 12 months, were assigned to watchful waiting (WW) treatment. These patients were followed every 4 months or returned sooner with additional infections. Any continued AOM, or MEE on follow up leading to tube placement, defined WW failure.

RESULTS

123 patients met criteria, with 81 still in WW to date (66% success rate). 42 children failed WW and received tympanostomy tubes (34% failure rate). There were no statistically significant associations between age, race, gender, smoking exposure, daycare, or month of presentation between children who failed WW compared to children receiving tubes.

CONCLUSIONS

Tympanostomy tube guidelines mitigate unnecessary tube placement in a majority of children with recurrent AOM without MEE. To our knowledge, this is the first study supporting the 2013 recommendations, with a 66% success rate. Additionally, no significant associations between modifying risk factors in those who failed watchful waiting were identified.