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Perspectives on paediatric sleep-disordered breathing in the UK: a qualitative study. The Journal of Laryngology & Otology 2022; 136:520-526. [DOI: 10.1017/s0022215121004242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveThere is limited understanding of treatment pathways for paediatric sleep-disordered breathing. This study explored current UK pathways and what is important to well-being for parents and children.MethodThe study comprised in-depth qualitative interviews (n = 22) with parents of children (2–9 years) with symptoms of sleep-disordered breathing referred to a regional ENT clinic (n = 11), general practitioners who might refer these children to ENT (n = 5) and hospital doctors involved in treating these children (n = 6). Interviews were audio recorded, transcribed verbatim, anonymised and analysed thematically.ResultsGeneral practitioners rarely identify seeing children with sleep-disordered breathing; conversely hospital doctors identify unsuspected issues. Parents are worried their child will stop breathing, but routes to referral and diagnosis are not straightforward. Modern technology can aid investigation and diagnosis. Patient weight is an issue for general practitioners and hospital doctors. Adenotonsillectomy is the treatment of choice, and information on paediatric sleep-disordered breathing is needed.ConclusionGuidelines for the management of paediatric sleep-disordered breathing are needed.
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Pecha PP, Chew M, Andrews AL. Racial and Ethnic Disparities in Utilization of Tonsillectomy among Medicaid-Insured Children. J Pediatr 2021; 233:191-197.e2. [PMID: 33548260 PMCID: PMC8154654 DOI: 10.1016/j.jpeds.2021.01.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/18/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine racial differences in tonsillectomy with or without adenoidectomy (T&A) for sleep-disordered breathing (SDB) among Medicaid-insured children. STUDY DESIGN Retrospective analysis of the 2016 MarketScan Multistate Medicaid Database was performed for children ages 2 to <18 years with a diagnosis of SDB. Patients with medical complexity and infectious indications for surgery were excluded. Racial groups were categorized into non-Hispanic White, non-Hispanic Black, Hispanic, and other. Adjusted multivariate logistic regression was used to determine if race/ethnicity was a significant predictor of obtaining T&A, polysomnography, and time to intervention. RESULTS There were 83 613 patients with a diagnosis of SDB that met inclusion criteria, of which 49.2% were female with a mean age of 7.9 ± 3.8 years. The cohort consisted of White (49.2%), Black (30.0%), Hispanic (8.0%), and other (13.2%) groups. Overall, 15.4% underwent T&A. Black (82.2%) and Hispanic (82.3%) children had significantly higher rates of no intervention and White patients had the lowest rate of no intervention (76.9%; P < .0001) and the highest rate of T&A (18.7%; P < .0001). Mean time to surgery was shortest in White compared with Black children (P < .0001). Logistic regression adjusting for age and sex showed that Black children had 45% reduced odds of surgery (95% CI 0.53-0.58), Hispanic 38% (95% CI 0.58-0.68), and other 35% (95% CI 0.61-0.70) compared with White children with Medicaid insurance. CONCLUSIONS Racial and ethnic disparities exist in the utilization of T&A for children with SDB enrolled in Medicaid. Future studies that investigate possible sources for these differences and more equitable care are warranted.
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Affiliation(s)
- Phayvanh P. Pecha
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Marshall Chew
- Department of Healthcare Leadership and Management, Medical University of South Carolina College of Health Professions, Charleston, SC
| | - Anne L. Andrews
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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Lushington K, Biggs S, Martin AJ, Kennedy JD. Sleep disordered breathing in children: which symptoms do parents consider a problem? Sleep Med 2021; 81:33-41. [PMID: 33636542 DOI: 10.1016/j.sleep.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE Parents tend to under-report symptoms suggestive of sleep disordered breathing (SDB) at medical consultation. It is thought that a contributing factor may be whether parents view SDB symptoms as a problem. The aim of the study was to examine to what extent parents view SDB symptoms as a problem in children recruited from the general community and especially in children who currently have symptoms suggestive of SDB. METHODS Parents of 1639 children aged 5-10 y attending middle school in South Australia completed a questionnaire which included demographics and assessed the frequency over the previous school week of 32 sleep habits including six SDB sleep habit items. The sample was restricted to typically developing children and excluded children with medical problems likely to impact SDB. The final sample included 1610 children without a prior diagnosis of SDB and 29 with a prior diagnosis and/or treatment of SDB. Parents were asked to rate children's sleep habits using a 4-pt scale (never, rarely, sometimes and usually) and if the sleep habit was perceived to be a problem (yes/no). Children who sometimes or usually reported a sleep habit item were labelled as symptomatic. RESULTS Parents of children with, compared to those without, a prior diagnosis of SDB, were more likely to report the presence of SDB symptoms which were more frequently viewed as a problem. In children without a prior diagnosis of SDB, parents of symptomatic children viewed most SDB symptoms as a problem ranging from 91% for apnoea, 63% snorted/gasped, 63% watched child breathing at night, 58% snored loudly, 49% snored to 32% breathing heavily at night. Additional analyses in the combined sample revealed that a prior diagnosis of SDB, gender, socioeconomic status and ethnicity were weak predictors of whether parents viewed SDB sleep symptoms as a problem. CONCLUSION In children with symptoms suggestive of SDB, most parents viewed most SDB symptoms as a problem especially apnoea. The high frequency is contrary to that expected given the under-reporting of SDB symptoms at medical consultation. This suggests that additional factors other than whether parents consider SDB symptoms as a problem might better explain the under-reporting of SDB symptoms at medical consultation. Given the important impact on child health and medical service provision, future studies examining the factors that prompt parents to discuss SDB symptoms at medical consultation are warranted.
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Affiliation(s)
| | - Sarah Biggs
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Alfred James Martin
- University of Adelaide, Adelaide, Australia; Women's and Children's Hospital Adelaide, Australia
| | - John Declan Kennedy
- University of Adelaide, Adelaide, Australia; Women's and Children's Hospital Adelaide, Australia
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Chan KH, Misseri R, Cain MP, Whittam B, Szymanski K, Kaefer M, Rink R, Cockrum B, Moore C, Wiehe S. Provider perspectives on shared decision-making regarding hypospadias surgery. J Pediatr Urol 2020; 16:307-315. [PMID: 32307325 PMCID: PMC8562057 DOI: 10.1016/j.jpurol.2020.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/19/2020] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Many parents experience decisional conflict and decisional regret around hypospadias surgery. The utilization of a shared decision-making (SDM) process may mitigate these issues, however addressing the principal components of the SDM process is a complex task that requires the investment of providers. OBJECTIVE The purpose of this study was to facilitate a discussion about SDM anchored on hypospadias with pediatric urology and general pediatric providers to explore perspectives, clinical applications and barriers to adopting SDM in clinical practice. STUDY DESIGN We conducted two focus groups in order to engage pediatric urology and general pediatric providers in guided discussions about SDM anchored on hypospadias. All activities were audio recorded and professionally transcribed. The transcripts were analyzed by three coders using directed qualitative content analysis techniques to identify themes and relationships between themes to inform the development of an affinity diagram (Extended Summary Figure). RESULTS Two focus groups were held; one with seven pediatric urology providers in November 2018 and one with ten general pediatric providers in January 2019 (median age 51 years, 88.2% Caucasian, 58.8% female, 70.6% physicians and 29.4% nurse practitioners). Both groups identified some of the key components of SDM including engaging families in decision-making, informing them about treatment options and clarifying values/preferences (Extended Summary Figure). They thought that SDM was useful for discussing preference-sensitive conditions (e.g. hypospadias) and addressing parental compliance. General pediatric providers also suggested that SDM helped them avoid unnecessary referrals to specialists. Both groups identified parental, provider and systemic barriers to the adoption of SDM: a) desire for paternalism, b) misperceptions about medical evidence, c) completion of parental decision-making prior to the clinical visit, d) provider bias/lack of interest and e) time constraints/productivity pressures. DISCUSSION Providers who care for hypospadias patients are knowledgeable about SDM and its potential clinical applications. They identified several potentially modifiable barriers to the adoption of a SDM process about hypospadias surgery in a pediatric clinical setting. CONCLUSIONS Based on feedback from providers, we plan to implement a hypospadias decision aid early in the parental decision-making process about hypospadias such as in the postpartum unit and at well-child visits in the newborn period and provide a provider training session about SDM to address the identified knowledge gaps.
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Affiliation(s)
- Katherine H Chan
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Pediatrics, Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Rosalia Misseri
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Mark P Cain
- Department of Urology, University of Washington, Seattle, WA, USA.
| | - Benjamin Whittam
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Konrad Szymanski
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Martin Kaefer
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Richard Rink
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Brandon Cockrum
- Research Jam, Indiana Clinical and Translational Sciences Institute, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Courtney Moore
- Research Jam, Indiana Clinical and Translational Sciences Institute, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Sarah Wiehe
- Research Jam, Indiana Clinical and Translational Sciences Institute, Indiana University School of Medicine, Indianapolis, IN, USA.
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Heller MA, Lind MN, Boss EF, Cooper JN. Differences in Tonsillectomy Use by Race/Ethnicity and Type of Health Insurance Before and After the 2011 Tonsillectomy Clinical Practice Guidelines. J Pediatr 2020; 220:116-124.e3. [PMID: 32171561 DOI: 10.1016/j.jpeds.2020.01.061] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/02/2020] [Accepted: 01/29/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate whether differences in pediatric tonsillectomy use by race/ethnicity and type of insurance were impacted by the American Academy of Otolaryngology-Head and Neck Surgery's 2011 tonsillectomy clinical practice guidelines. STUDY DESIGN We included children aged <15 years from Florida or South Carolina who underwent tonsillectomy in 2004-2017. Annual tonsillectomy rates within groups defined by race/ethnicity and type of health insurance were calculated using US Census data, and interrupted time series analyses were used to compare the guidelines' impact on utilization across groups. RESULTS The average annual tonsillectomy rate was greater among non-Hispanic white children (66 procedures per 10 000 children) than non-Hispanic black (38 procedures per 10 000 children) or Hispanic children (41 procedures per 10 000 children) (P < .001). From the year before to the year after the guidelines' release, tonsillectomy use decreased among non-Hispanic white children (-11.1 procedures per 10 000 children), but not among non-Hispanic black (-0.9 procedures per 10 000 children) or Hispanic children (+3.9 procedures per 10 000 children) (P < .05). Use was greater among publicly than privately insured children (75 vs 52 procedures per 10 000 children, P < .001). The guidelines were associated with a reversal of the upward trend in use seen in 2004-2010 among publicly insured children (-5.5 procedures per 10 000 children per year, P < .001). CONCLUSIONS Tonsillectomy use is greatest among white and publicly insured children. However, the American Academy of Otolaryngology-Head and Neck Surgery's 2011 clinical practice guideline statement was associated with an immediate decrease and change in use trends in these groups, narrowing differences in utilization by race/ethnicity and type of insurance.
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Affiliation(s)
- Margaret A Heller
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Meredith N Lind
- Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH; Department of Otolaryngology, The Ohio State University College of Medicine, Columbus, OH
| | - Emily F Boss
- Department of Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH.
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Links AR, Callon W, Wasserman C, Walsh J, Tunkel DE, Beach MC, Boss EF. Parental role in decision-making for pediatric surgery: Perceptions of involvement in consultations for tonsillectomy. PATIENT EDUCATION AND COUNSELING 2020; 103:944-951. [PMID: 31866196 DOI: 10.1016/j.pec.2019.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/20/2019] [Accepted: 12/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Parental role in decision-making has implications for quality of care. We describe roles of parent participation in decision-making for tonsillectomy. METHODS Parents reported preferred role in decision-making before consultations for tonsillectomy and the role they experienced after their consult. Parents completed questionnaires, including items evaluating clinician/parent communication. Clinicians rated perception of parents' preferred role in decision-making. Congruence between parent and clinician responses was evaluated via kappa analysis. Logistic regression identified associations between decision-making roles and socioemotional and communication factors. RESULTS Consults between 63 parents and 8 otolaryngologists were analyzed.There was inadequate agreement between clinician and parent ratings of preferred roles (37%, p = 0.6, 95% CI [-0.09, 0.001]). Parents perceived greater involvement when clinicians discussed reasons to have (OR = 4.3, p = 0.03) or not have (OR = 4.1, p = 0.005) surgery. Parents perceived less involvement when clinicians used jargon (OR = 0.1, p = 0.03), and when parents trusted clinicians (OR = 0.4, p = 0.049), or experienced greater decisional conflict (OR = 0.9, p = 0.03). CONCLUSIONS Parents and clinicians perceived parental preference for decision-making involvement differently during consultations for tonsillectomy. Clinician information-sharing, jargon use, and parent trust in clinician predicted extent of perceived engagement. PRACTICE IMPLICATIONS Findings may enhance understanding of strategies to effectively communicate and engage parents in shared decision-making for pediatric surgical care.
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Affiliation(s)
- Anne R Links
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA.
| | - Wynne Callon
- Harvard Medical School, Boston Children's Hospital, Boston, USA
| | - Carly Wasserman
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Jonathan Walsh
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
| | - Mary Catherine Beach
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Emily F Boss
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
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Kannan S, Seo J, Riggs KR, Geller G, Boss EF, Berger ZD. Surgeons' Views on Shared Decision-Making. J Patient Cent Res Rev 2020; 7:8-18. [PMID: 32002443 PMCID: PMC6988707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
PURPOSE Shared decision-making (SDM) has a significant role in surgical encounters, where decisions are influenced by both clinician and patient preferences. Herein, we sought to explore surgeons' practices and beliefs about SDM. METHODS We performed a qualitative study consisting of semi-structured individual interviews with 18 surgeons from private practice and academic surgery practices in Baltimore, Maryland. We purposively sampled participants to maximize diversity of practice type (academic vs private), surgical specialty, gender, and experience level. Interview topics included benefits and challenges to patient involvement in decision-making, communicating uncertainty to patients, and use of decision aids. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes. RESULTS Surgeons were supportive of patients being involved in decision-making, particularly in cases with uncertainty about treatment options. However, surgeons identified SDM as being more appropriate for patients whom surgeons perceived as interested in decision-making involvement and for decisions in which surgeons did not have strong preferences. Additionally, surgeons reported typically presenting only a subset of available options, remaining confident in their ability to filter less suitable options based on intuitive risk assessments. Surgeons differed in their approach to making recommendations, with some guiding patients towards what they saw as the correct or optimal decision while others sought to maintain neutrality and support of the patients' chosen decision. CONCLUSIONS Many surgeons do not believe SDM is universally optimal for every surgical decision. They instead use assessments of patient disposition or potential clinical uncertainty to guide their perceived appropriateness of using SDM.
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Affiliation(s)
- Suraj Kannan
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jayhyun Seo
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin R. Riggs
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL
- Birmingham VA Medical Center, Birmingham, AL
| | - Gail Geller
- Division of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily F. Boss
- Pediatric Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zackary D. Berger
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Aaronson NL, Cox CT, Boss EF. Parental health literacy in pediatric otolaryngology: A pilot study. Int J Pediatr Otorhinolaryngol 2019; 125:87-91. [PMID: 31271973 DOI: 10.1016/j.ijporl.2019.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Pediatric otolaryngology bears the highest frequency of elective surgical cases in children, but little is known regarding the health literacy of these children's parents. In a questionnaire-based pilot study, we assessed parental health literacy in our pediatric otolaryngology clinic and evaluated its relation to personal demographics. We also evaluated postoperative and diagnosis-based leaflets for readability using validated measures. METHODS Parents completed the Short Assessment of Health Literacy-English (SAHL-E) and were defined as low (0-14) or high (>14) literacy based on mean scores. RESULTS Fifty parents participated (mean SAHL-E score, 17.6), and all scored >14, indicating proficient health literacy. No differences existed in mean or median scores based on demographics. Continued education after high school was associated with higher scores (P = 0.003) and was the only significant variable in multivariable linear regression. All leaflets were at or below the recommended reading level for public health information. CONCLUSIONS Parents generally had high health literacy.
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Affiliation(s)
- Nicole Leigh Aaronson
- Nemours/Alfred I. duPont Hospital for Children, Department of Surgery, Section of Otolaryngology, Wilmington, DE, USA; Thomas Jefferson University School of Medicine, Departments of Otolaryngology and Pediatrics, Philadelphia, PA, USA.
| | - Courtney T Cox
- Nemours/Alfred I. duPont Hospital for Children, Department of Surgery, Section of Otolaryngology, Wilmington, DE, USA.
| | - Emily F Boss
- Johns Hopkins University Departments of Otolaryngology and Health Policy & Management, Baltimore, MD, USA.
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Hairston TK, Links AR, Harris V, Tunkel DE, Walsh J, Beach MC, Boss EF. Evaluation of Parental Perspectives and Concerns About Pediatric Tonsillectomy in Social Media. JAMA Otolaryngol Head Neck Surg 2019; 145:45-52. [PMID: 30452510 PMCID: PMC6439813 DOI: 10.1001/jamaoto.2018.2917] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/27/2018] [Indexed: 01/06/2023]
Abstract
Importance Tonsillectomy is common in children, but little is known about parental preferences and values concerning this surgical procedure. Twitter offers an opportunity to evaluate parental understanding and experience of tonsillectomy care. Objective To identify parental perspectives about tonsillectomy in children that may not be apparent in a routine clinical encounter. Design, Setting, and Participants In this qualitative study, social media platform Twitter was searched for posts (tweets) published between January 1, 2008, and December 31, 2017, by US-based parents about their child's tonsillectomy. Modified grounded theory was applied to develop a coding taxonomy to classify the tweets. Tweets were assessed for thematic synthesis and classification, and descriptive statistics were obtained for each theme. Main Outcomes and Measures Themes of parental experiences and perspectives about their child's tonsillectomy. Results Of the 5801 total tweets retrieved, 782 (13.5%) satisfied the inclusion criteria. Tweets were categorized under 2 overarching themes: procedural concerns (549 tweets [70.2%]) and attitudes or experiences (498 [63.7%]). Common tweets under procedural concerns mentioned surgical indication for tonsillectomy (55 tweets [7.0%]); eg, "strep-I think it's tonsil removing time…") and recovery (227 tweets [29.0%]), including child's attitude (89 tweets [11.4%]; eg, "so hard to get my daughter to eat") and parental experience (87 tweets [11.1%]; eg, "tonsillectomy recovery sucks for the parent as much as the kid!"). Common tweets regarding attitudes or experiences included the tenor of overall care (225 tweets [28.6%]; eg, "Tonsillectomy is a bear") and fears or apprehensions (209 tweets [26.6%]). Conclusions and Relevance These social media findings may be used to guide clinicians in educating and counseling parents as well as further engaging parents and children in shared decision making for tonsillectomy.
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Affiliation(s)
- Tai Kyung Hairston
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anne R. Links
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vandra Harris
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E. Tunkel
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Walsh
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Emily F. Boss
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Affiliation(s)
- Jennifer A. Villwock
- Department of Otolaryngology, Division of Rhinology and Skull Base Surgery, University of Kansas Medical Center, Kansas City, Kansas
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