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Wasserman I, Chieffe DJ, Gipson KS, Skotko BG, Hartnick CJ. Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea in a Young Child With Down Syndrome. Pediatrics 2024; 153:e2023063330. [PMID: 38602032 DOI: 10.1542/peds.2023-063330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 04/12/2024] Open
Abstract
Obstructive sleep apnea (OSA) is common in children with Down syndrome (DS). Adenoidectomy and/or tonsillectomy are the usual first interventions employed to treat OSA in children with DS but sometimes do not achieve adequate resolution of clinical signs. Positive airway pressure treatment is often used next, but this treatment is poorly tolerated by this population. Persistent OSA can adversely affect a child's health and cognitive development. Hypoglossal nerve stimulation (HGNS), previously shown to be safe and effective in adults with OSA, has been used in children as young as 10 years old with DS and has achieved measurable neurocognitive benefits. The US Food and Drug Administration recently lowered the age for HGNS implantation to 13 years for children with DS. However, questions remain regarding treatment of refractory OSA in younger children. Here, we report the case of a 4-year-old boy with DS and treatment-refractory OSA who underwent successful HGNS implantation. The decision to proceed with HGNS implantation in such a young child involved discussions about anatomic feasibility and potential neurocognitive benefits. The device was implanted without complication and with minimal postoperative bulk. This case suggests a possible treatment option that can be discussed in the course of shared decision-making between clinicians and families of young children with DS and treatment-refractory OSA.
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Affiliation(s)
- Isaac Wasserman
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Douglas J Chieffe
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Kevin S Gipson
- Department of Pediatric Pulmonary Medicine, Massachusetts General Hospital for Children, Boston, Massachusetts
- Division of Sleep Medicine
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Brian G Skotko
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
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Suresh K, Wu MP, Benboujja F, Christakis B, Newton A, Hartnick CJ, Cohen MS. AI Model Versus Clinician Otoscopy in the Operative Setting for Otitis Media Diagnosis. Otolaryngol Head Neck Surg 2023. [PMID: 37822130 DOI: 10.1002/ohn.559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023]
Abstract
Prior work has demonstrated improved accuracy in otitis media diagnosis based on otoscopy using artificial intelligence (AI)-based approaches compared to clinician evaluation. However, this difference in accuracy has not been shown in a setting resembling the point-of-care. In this study, we compare the diagnostic accuracy of a machine-learning model to that of pediatricians using standard handheld otoscopes. We find that the model is more accurate than clinicians (90.6% vs 59.4%, P = .01). This is a step towards validation of AI-based diagnosis under more real-world conditions. With further validation, for example on different patient populations and in deployment, this technology could be a useful addition to the clinician's toolbox in accurately diagnosing otitis media.
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Affiliation(s)
- Krish Suresh
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Michael P Wu
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Fouzi Benboujja
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Barbara Christakis
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alice Newton
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Michael S Cohen
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
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Larrow DR, Kadosh OK, Fracchia S, Radano M, Hartnick CJ. Harnessing the power of electronic health records and open natural language data mining to capture meaningful patient experience during routine clinical care. Int J Pediatr Otorhinolaryngol 2023; 173:111698. [PMID: 37597315 DOI: 10.1016/j.ijporl.2023.111698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION Electronic health records (EHR) are a rich data source for both quality improvement and clinical research. Natural language processing can be harnessed to extract data from these previously difficult to access sources. OBJECTIVE The objective of this study was to create and apply a natural language search query to extract EHR data to ask and answer quality improvement questions at a pediatric aerodigestive center. METHODS We developed a combined natural language search query to extract clinically meaningful data along with International Statistical Classification of Diseases (ICD10) and Current Procedural Terminology (CPT) code data. This search query was applied to a single pediatric aerodigestive center to answer key clinical questions asked by families. Data were extracted from EHR data from first clinic visit, operative note, microbiology lab report, and pathology report for all new patients from 2020 to 2021. Included as three queries were: 1) if I bring my child to a pediatric aerodigestive center, how often will my child obtain a medical diagnosis without needing an intervention? 2) if my child has a diagnostic procedure, how often will a diagnosis be made? 3) if a diagnosis is made, can it be addressed during that endoscopic intervention? RESULTS For the 711 new patients coming to the pediatric aerodigestive center from 2020 to 2021, only 26-32% required an interventional triple endoscopy (rigid/flexible bronchoscopy with esophagoduodenoscopy). Of these triple endoscopies, 75.7% resulted in a positive finding that enabled optimization of that child's care. Of the 221 patients who underwent diagnostic triple endoscopies, 40.7% underwent intervention at the same time for laryngeal cleft (injection or suture, dependent upon age). CONCLUSION Here we created an effective model of open language search query to extract meaningful metrics of patient experience from EHR data. This model easily allows the EHR to be harnessed to create retrospective and prospective databases that can be readily queried to answer clinical questions important to patients. Such databases are widely applicable not just to pediatric aerodigestive centers but to any clinical care setting using an EHR.
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Affiliation(s)
- Danielle R Larrow
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, USA; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
| | - Orna Katz Kadosh
- Department of Otolaryngology-Head and Neck Surgery, Dana-Dwek Children's Hospital, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shannon Fracchia
- Department of Pediatric Pulmonology, Massachusetts General Hospital, Boston, USA
| | - Marcella Radano
- Department of Pediatric Gastroenterology, Massachusetts General Hospital, Boston, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, USA; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA, USA.
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Suresh K, Cohen MS, Hartnick CJ, Bartholomew RA, Lee DJ, Crowson MG. Making Use of Artificial Intelligence-Generated Synthetic Tympanic Membrane Images. JAMA Otolaryngol Head Neck Surg 2023; 149:555-556. [PMID: 36995729 PMCID: PMC10064279 DOI: 10.1001/jamaoto.2023.0218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 03/31/2023]
Abstract
This diagnostic study examines the application of generative artificial intelligence in clinical tool research and development.
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Affiliation(s)
- Krish Suresh
- Department of Otolaryngology–Head & Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Cohen
- Department of Otolaryngology–Head & Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Hartnick
- Department of Otolaryngology–Head & Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ryan A. Bartholomew
- Department of Otolaryngology–Head & Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Daniel J. Lee
- Department of Otolaryngology–Head & Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Matthew G. Crowson
- Department of Otolaryngology–Head & Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
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5
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Miller AL, Xiao R, Rathi VK, Wang AA, Rutter MJ, Hartnick CJ, Sethi RKV. Hospital Prices for Pediatric Tympanostomy Tube Placement and Adenotonsillectomy in 2021. Laryngoscope 2023; 133:948-955. [PMID: 35678243 DOI: 10.1002/lary.30236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/27/2022] [Accepted: 05/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Hospital prices vary substantially for myringotomy with tympanostomy tube placement (M&T) and adenotonsillectomy (T&A). The Centers for Medicare and Medicaid Services recently implemented hospital price transparency requirements to help families make financially informed decisions about where to seek care. We sought to determine price availability and the extent of price variation for these procedures. METHODS We performed a cross-sectional analysis of the Turquoise Health Hospital Rates Data Platform, which extracts prices for facility fees from publicly available hospital chargemasters. We determined the proportion of hospitals serving pediatric patients that published payer-specific prices for M&T and T&A. We additionally characterized the extent of variation in payer-specific prices both across and within hospitals. RESULTS Approximately 40% (n = 909 of 2,266 hospitals) serving pediatric patients disclosed prices for M&T or T&A. Among disclosing hospitals, across-center ratios (adjusted for Medicare hospital wage indices) ranged from 11.0 (M&T; 10th percentile adjusted median price: $536.80 versus 90th percentile adjusted median price: $5,929.93) to 23.4 (revision adenoidectomy age >12 years; 10th percentile: $393.82 versus 90th percentile: $9,209.88). Median within-center price ratios for procedures ranged from 2.2 to 2.7, indicating that some private payers reimbursed the same hospital more than twice as much as other payers for the same procedure. CONCLUSION The majority of hospitals serving pediatric patients were non-compliant with federal requirements to disclose prices for M&T and T&A. Among disclosing hospitals, there was wide variation in payer-specific prices between and within institutions. Further research is necessary to understand whether disclosure of prices will enable families to make more financially informed decisions. LEVEL OF EVIDENCE 3 Laryngoscope, 133:948-955, 2023.
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Affiliation(s)
- Ashley L Miller
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Roy Xiao
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | | | - Michael J Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Rosh K V Sethi
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham Health, Boston, Massachusetts, USA
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Suresh K, Cohen MS, Hartnick CJ, Bartholomew RA, Lee DJ, Crowson MG. Generation of synthetic tympanic membrane images: Development, human validation, and clinical implications of synthetic data. PLOS Digit Health 2023; 2:e0000202. [PMID: 36827244 PMCID: PMC9956018 DOI: 10.1371/journal.pdig.0000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/24/2023] [Indexed: 02/25/2023]
Abstract
Synthetic clinical images could augment real medical image datasets, a novel approach in otolaryngology-head and neck surgery (OHNS). Our objective was to develop a generative adversarial network (GAN) for tympanic membrane images and to validate the quality of synthetic images with human reviewers. Our model was developed using a state-of-the-art GAN architecture, StyleGAN2-ADA. The network was trained on intraoperative high-definition (HD) endoscopic images of tympanic membranes collected from pediatric patients undergoing myringotomy with possible tympanostomy tube placement. A human validation survey was administered to a cohort of OHNS and pediatrics trainees at our institution. The primary measure of model quality was the Frechet Inception Distance (FID), a metric comparing the distribution of generated images with the distribution of real images. The measures used for human reviewer validation were the sensitivity, specificity, and area under the curve (AUC) for humans' ability to discern synthetic from real images. Our dataset comprised 202 images. The best GAN was trained at 512x512 image resolution with a FID of 47.0. The progression of images through training showed stepwise "learning" of the anatomic features of a tympanic membrane. The validation survey was taken by 65 persons who reviewed 925 images. Human reviewers demonstrated a sensitivity of 66%, specificity of 73%, and AUC of 0.69 for the detection of synthetic images. In summary, we successfully developed a GAN to produce synthetic tympanic membrane images and validated this with human reviewers. These images could be used to bolster real datasets with various pathologies and develop more robust deep learning models such as those used for diagnostic predictions from otoscopic images. However, caution should be exercised with the use of synthetic data given issues regarding data diversity and performance validation. Any model trained using synthetic data will require robust external validation to ensure validity and generalizability.
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Affiliation(s)
- Krish Suresh
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, United States of America
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Michael S. Cohen
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, United States of America
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christopher J. Hartnick
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, United States of America
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ryan A. Bartholomew
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, United States of America
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel J. Lee
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, United States of America
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Matthew G. Crowson
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts, United States of America
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
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Crowson MG, Gipson KS, Kadosh OK, Hartnick E, Grealish E, Keamy DG, Kinane TB, Hartnick CJ. Paediatric sleep apnea event prediction using nasal air pressure and machine learning. J Sleep Res 2023:e13851. [PMID: 36807952 PMCID: PMC10363180 DOI: 10.1111/jsr.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/23/2023]
Abstract
Sleep-disordered breathing is an important health issue for children. The objective of this study was to develop a machine learning classifier model for the identification of sleep apnea events taken exclusively from nasal air pressure measurements acquired during overnight polysomnography for paediatric patients. A secondary objective of this study was to differentiate site of obstruction exclusively from hypopnea event data using the model. Computer vision classifiers were developed via transfer learning to either normal breathing while asleep, obstructive hypopnea, obstructive apnea or central apnea. A separate model was trained to identify site of obstruction as either adeno-tonsillar or tongue base. In addition, a survey of board-certified and board-eligible sleep physicians was completed to compare clinician versus model classification performance of sleep events, and indicated very good performance of our model relative to human raters. The nasal air pressure sample database available for modelling comprised 417 normal, 266 obstructive hypopnea, 122 obstructive apnea and 131 central apnea events derived from 28 paediatric patients. The four-way classifier achieved a mean prediction accuracy of 70.0% (95% confidence interval [67.1-72.9]). Clinician raters correctly identified sleep events from nasal air pressure tracings 53.8% of the time, whereas the local model was 77.5% accurate. The site of obstruction classifier achieved a mean prediction accuracy of 75.0% (95% confidence interval [68.7-81.3]). Machine learning applied to nasal air pressure tracings is feasible and may exceed the diagnostic performance of expert clinicians. Nasal air pressure tracings of obstructive hypopneas may "encode" information regarding the site of obstruction, which may only be discernable by machine learning.
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Affiliation(s)
- Matthew G Crowson
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin S Gipson
- Department of Pediatric Pulmonary Medicine, Mass General Hospital for Children, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Orna Katz Kadosh
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Ellen Grealish
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donald G Keamy
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Bernard Kinane
- Department of Pediatric Pulmonary Medicine, Mass General Hospital for Children, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Jayawardena AD, Redmann A, Roby BB, Chinnadurai S, Caloway CL, Hartnick CJ. Response to: Objective Improvement After Frenotomy for Posterior Tongue Tie: A Prospective Randomized Trial. Otolaryngol Head Neck Surg 2022:1945998221112324. [DOI: 10.1177/01945998221112324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hersh CJ, Sorbo J, Moreno JM, Hartnick E, Fracchia MS, Hartnick CJ. Aspiration does not mean the end of a breast-feeding relationship. Int J Pediatr Otorhinolaryngol 2022; 161:111263. [PMID: 35947926 DOI: 10.1016/j.ijporl.2022.111263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/24/2022] [Accepted: 07/29/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Breastfeeding is widely recommended as optimal nutrition for infants. However, there are no known publications on the impact of prandial aspiration of breast milk fed infants with dysphagia. The goal of this study was to assess pulmonary outcomes in infants with dysphagia who were given medical clearance for intake of breast milk. METHODS This retrospective cohort study included review of 80 infants examined between August 2016 to March 2021. Patients were evaluated by an interdisciplinary team of providers in a tertiary pediatric aerodigestive center. Patient inclusion criteria included a VFSS with documented aspiration or penetration with thin liquids. Participants met inclusion criteria if given medical clearance for intake of breast milk despite aspiration risk. Pulmonary health was monitored for three months following medical clearance for the consumption of breast milk. Pulmonary illness was defined as development of bronchiolitis, wheezing, unexplained stridor during feeding, croup, pneumonia, or persistent bacterial bronchitis requiring medical intervention. RESULTS Forty-three males (54%) and 37 females (46%) enrolled in the study with an age range of 1 month-6 months corrected age. Mean age at initial VFSS was 3.6 months. Twenty-six out of 80 (32.5%) had a report of a mild cough but did not require intervention. Eight out of 80 (10%) received a diagnosis of a pulmonary illness. Seventy-two out of 80 (90%) did not report pulmonary illness. CONCLUSION This pilot study reveals that the majority (90%) of this single institution, small sample size cohort of breast milk fed infants with documented oropharyngeal dysphagia remained healthy despite continued intake of breast milk. Prospective investigation is warranted to follow pulmonary health outcomes longitudinally and a head to head comparative study would be helpful to identify whether there were indeed significant changes to pulmonary health according to differential feeding regimens offered and followed.
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Affiliation(s)
- Cheryl J Hersh
- Department of Speech Language and Swallowing Disorders, Massachusetts General Hospital, MGH Professional Office Building, 3rd Floor, 275 Cambridge St., Boston, MA, 02114, USA
| | - Jessica Sorbo
- Department of Speech Language and Swallowing Disorders, Massachusetts General Hospital, MGH Professional Office Building, 3rd Floor, 275 Cambridge St., Boston, MA, 02114, USA
| | - Juan Manuel Moreno
- Universidad de Los Andes, Colombia, School of Medicine, Mass Eye & Ear Infirmary, 243 Charles Street, Boston, MA, 02114, USA
| | - Elizabeth Hartnick
- Brown University, Providence, RI, 101 Revere St., Boston, MA, 02114, USA
| | - M Shannon Fracchia
- Department of Pediatric Pulmonology, Massachusetts General Hospital, Boston, MA, MGH Professional Office Building, 5th Floor, 75 Cambridge St., Boston, MA, 02114, USA
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, Mass Eye & Ear Infirmary, 243 Charles St., Boston, MA, 02114, USA.
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Crowson MG, Bates DW, Suresh K, Cohen MS, Hartnick CJ. "Human vs Machine" Validation of a Deep Learning Algorithm for Pediatric Middle Ear Infection Diagnosis. Otolaryngol Head Neck Surg 2022:1945998221119156. [PMID: 35972815 PMCID: PMC9931938 DOI: 10.1177/01945998221119156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We compared the diagnostic performance of human clinicians with that of a neural network algorithm developed using a library of tympanic membrane images derived from children taken to the operating room with the intent of performing myringotomy and possible tube placement for recurrent acute otitis media (AOM) or otitis media with effusion (OME). STUDY DESIGN Retrospective cohort study. SETTING Tertiary academic medical center from 2018 to 2021. METHODS A training set of 639 images of tympanic membranes representing normal, OME, and AOM was used to train a neural network as well as a proprietary commercial image classifier from Google. Model diagnostic prediction performance in differentiating normal vs nonpurulent vs purulent effusion was scored based on classification accuracy. A web-based survey was developed to test human clinicians' diagnostic accuracy on a novel image set, and this was compared head to head against our model. RESULTS Our model achieved a mean prediction accuracy of 80.8% (95% CI, 77.0%-84.6%). The Google model achieved a prediction accuracy of 85.4%. In a validation survey of 39 clinicians analyzing a sample of 22 endoscopic ear images, the average diagnostic accuracy was 65.0%. On the same data set, our model achieved an accuracy of 95.5%. CONCLUSION Our model outperformed certain groups of human clinicians in assessing images of tympanic membranes for effusions in children. Reduced diagnostic error rates using machine learning models may have implications in reducing rates of misdiagnosis, potentially leading to fewer missed diagnoses, unnecessary antibiotic prescriptions, and surgical procedures.
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Affiliation(s)
- Matthew G. Crowson
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Massachusetts
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Krish Suresh
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Massachusetts
| | - Michael S. Cohen
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Massachusetts
| | - Christopher J. Hartnick
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Massachusetts
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11
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Yu PK, Stenerson M, Ishman SL, Shott SR, Raol N, Soose RJ, Tobey A, Baldassari C, Dedhia RC, Pulsifer MB, Grieco JA, Abbeduto LJ, Kinane TB, Keamy DG, Skotko BG, Hartnick CJ. Evaluation of Upper Airway Stimulation for Adolescents With Down Syndrome and Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2022; 148:522-528. [PMID: 35446411 PMCID: PMC9026239 DOI: 10.1001/jamaoto.2022.0455] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patients with Down syndrome have a high incidence of persistent obstructive sleep apnea (OSA) and limited treatment options. Upper airway hypoglossal stimulation has been shown to be effective for adults with OSA but has not yet been evaluated for pediatric populations. Objective To evaluate the safety and effectiveness of upper airway stimulation for adolescent patients with Down syndrome and severe OSA. Design, Setting, and Participants This prospective single-group multicenter cohort study with 1-year follow-up was conducted between April 1, 2015, and July 31, 2021, among a referred sample of 42 consecutive adolescent patients with Down syndrome and persistent severe OSA after adenotonsillectomy. Intervention Upper airway stimulation. Main Outcomes and Measures The prespecified primary outcomes were safety and the change in apnea-hypopnea index (AHI) from baseline to 12 months postoperatively. Polysomnographic and quality of life outcomes were assessed at 1, 2, 6, and 12 months postoperatively. Results Among the 42 patients (28 male patients [66.7%]; mean [SD] age, 15.1 [3.0] years), there was a mean (SD) decrease in AHI of 12.9 (13.2) events/h (95% CI, -17.0 to -8.7 events/h). With the use of a therapy response definition of a 50% decrease in AHI, the 12-month response rate was 65.9% (27 of 41), and 73.2% of patients (30 of 41) had a 12-month AHI of less than 10 events/h. The most common complication was temporary tongue or oral discomfort, which occurred in 5 patients (11.9%). The reoperation rate was 4.8% (n = 2). The mean (SD) improvement in the OSA-18 total score was 34.8 (20.3) (95% CI, -42.1 to -27.5), and the mean (SD) improvement in the Epworth Sleepiness Scale score was 5.1 (6.9) (95% CI, -7.4 to -2.8). The mean (SD) duration of nightly therapy was 9.0 (1.8) hours, with 40 patients (95.2%) using the device at least 4 hours a night. Conclusions and Relevance Upper airway stimulation was able to be safely performed for 42 adolescents who had Down syndrome and persistent severe OSA after adenotonsillectomy with positive airway pressure intolerance. There was an acceptable adverse event profile with high rates of therapy response and quality of life improvement. Trial Registration ClinicalTrials.gov Identifier: NCT02344108.
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Affiliation(s)
- Phoebe K Yu
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston
| | | | - Stacey L Ishman
- Department of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sally R Shott
- Department of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nikhila Raol
- Department of Otolaryngology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ryan J Soose
- Division of Sleep Surgery, Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Allison Tobey
- Division of Sleep Surgery, Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cristina Baldassari
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Eastern Virginia Medical School, Norfolk
| | - Raj C Dedhia
- CPAP Alternatives Clinic, Division of Sleep Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Margaret B Pulsifer
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston.,Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Julie A Grieco
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Leonard J Abbeduto
- MIND Institute, Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento
| | - Thomas B Kinane
- Department of Pediatrics, Massachusetts General Hospital, Boston
| | - Donald G Keamy
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston
| | - Brian G Skotko
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston
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12
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Stenerson ME, Yu PK, Kinane TB, Skotko BG, Hartnick CJ. Long-term stability of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea in children with Down syndrome. Int J Pediatr Otorhinolaryngol 2021; 149:110868. [PMID: 34371294 DOI: 10.1016/j.ijporl.2021.110868] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/12/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
IMPORTANCE Obstructive sleep apnea (OSA) occurs in 55-97% of people with Down syndrome (DS). Even after adenotonsillectomy, residual OSA often persists into adulthood due, in part, to tongue base collapse. Implantable hypoglossal nerve stimulators are being investigated in children and young adults with DS and persistent, moderate to severe OSA. However, the long-term necessity for such an intervention-especially as patients mature and voltage adjustment becomes warranted-has not been previously reported in the pediatric DS population. OBJECTIVE To assess the long-term need for implantable hypoglossal nerve stimulators and the necessity for voltage adjustment in children and young adults with Down syndrome. DESIGN This is a case series from an ongoing clinical trial assessing safety and efficacy of hypoglossal nerve stimulation among 42 children and young adults with DS and persistent OSA, despite adenotonsillectomy and trialed positive airway pressure (PAP) therapy. We focus here on the first 4 participants who have undergone implantation by age 13 and have completed at least 44 months of follow-up. PARTICIPANTS 4 participants (2 male, 2 female; ages 10-13 years) with DS and persistent, severe OSA (AHI > 10 events/h) underwent hypoglossal nerve stimulator implantation and were followed for 44-58 months. SETTING Participants completed in-lab sleep studies at baseline (before implantation), 1 year postoperatively, and 44-58 months postoperatively. During their most recent follow-up, 2 participants completed split-night sleep studies in which assessment was done with the device both on and off. INTERVENTIONS Hypoglossal nerve stimulator implantation. MAIN OUTCOMES AND MEASURES Stability in titrated and untitrated OSA as measured by the apnea-hypopnea index (AHI); growth measures including BMI; and quality of life as measured by the OSA-18 questionnaire. RESULTS Compared to baseline, all 4 participants maintained reductions of at least 50% in AHI over the course of follow-up. At recent follow-up, two participants had persistent, moderate OSA despite stimulation therapy. The other two participants achieved 100% reductions in AHI with stimulation therapy; when they underwent split-night sleep studies, the severe OSA persisted with the device turned off. Improvement in OSA-18 quality of life scores was observed in three of the four participants. CONCLUSION and Relevance: Hypoglossal nerve stimulation continues to effectively control OSA in children with DS as they mature, while their underlying untitrated OSA appears to persist into adulthood. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT2344108.
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Affiliation(s)
- Matthew E Stenerson
- Division of Pediatric Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA
| | - Phoebe K Yu
- Division of Pediatric Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Thomas B Kinane
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Brian G Skotko
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA; Down Syndrome Program, Division of Medical Genetics and Metabolism, Massachusetts General Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Christopher J Hartnick
- Division of Pediatric Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
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13
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Jayawardena ADL, Ghersin ZJ, Guzman LJ, Bonilla JA, Abrego S, Aguilar A, Ramos D, Zablah E, Callans K, Macduff M, Cayer M, Gallagher TQ, Vangel MG, Peikin MH, Yager PH, Hartnick CJ. A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units. Int J Pediatr Otorhinolaryngol 2021; 149:110857. [PMID: 34343831 DOI: 10.1016/j.ijporl.2021.110857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU. METHODS This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was $1.32 per child. PICU mortality was evaluated as an exploratory outcome. RESULTS Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28-0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17-0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24-0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is $30.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44. CONCLUSION This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.
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Affiliation(s)
- Asitha D L Jayawardena
- Children's Minnesota, Department of Otolaryngology, Minneapolis, MN, USA; Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA
| | - Zelda J Ghersin
- Massachusetts General Hospital, Pediatric Intensive Care Unit, Boston, MA, USA
| | - Luis Jose Guzman
- Benjamin Bloom Hospital, Pediatric Intensive Care, San Salvador, El Salvador
| | - Jose A Bonilla
- Benjamin Bloom Hospital, Department of Otolaryngology San Salvador, El Salvador
| | - Susana Abrego
- Benjamin Bloom Hospital, Pediatric Anesthesia, San Salvador, El Salvador
| | - Alejandra Aguilar
- Benjamin Bloom Hospital, Respiratory Therapy, San Salvador, El Salvador
| | - Daniel Ramos
- Benjamin Bloom Hospital, Department of Otolaryngology San Salvador, El Salvador
| | - Evelyn Zablah
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; The Benjamin Harry Peikin Foundation, Boston, MA, USA
| | - Kevin Callans
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; Massachusetts General Hospital for Children, Boston, MA, USA
| | - Megan Macduff
- Massachusetts General Hospital, Department of Respiratory Care Services, Boston, MA, USA
| | - Makara Cayer
- Massachusetts Eye and Ear Infirmary, Department of Anesthesia, Boston, MA, USA
| | - Thomas Q Gallagher
- Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Department of Otolaryngology-Head and Neck Surgery, Pediatric Otolaryngology, 601 Children's Lane, 2nd Floor, Norfolk, VA, 23507, USA
| | - Mark G Vangel
- Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Mark H Peikin
- The Benjamin Harry Peikin Foundation, Boston, MA, USA
| | - Phoebe H Yager
- Massachusetts General Hospital, Pediatric Intensive Care Unit, Boston, MA, USA
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14
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Mokhtari TE, Miller LE, Chen JX, Hartnick CJ, Varvares MA. Opioid prescribing practices in academic otolaryngology: A single institutional survey. Am J Otolaryngol 2021; 42:103038. [PMID: 33878642 DOI: 10.1016/j.amjoto.2021.103038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Opioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing. METHODS This quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents. RESULTS A total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively). CONCLUSION There was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
| | - Lauren E Miller
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Jenny X Chen
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
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15
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Grieco JA, Hartnick CJ, Skotko BG, Yu PK, Pulsifer MB. Preliminary Neurocognitive Results Post Hypoglossal Nerve Stimulation in Patients With Down Syndrome. Laryngoscope 2021; 131:2830-2833. [PMID: 34363400 DOI: 10.1002/lary.29808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/28/2021] [Accepted: 07/27/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Julie A Grieco
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Christopher J Hartnick
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Brian G Skotko
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Phoebe K Yu
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Margaret B Pulsifer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
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16
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McHugh CI, Mokhtari TE, Cohen MS, Hartnick CJ. Unilateral Facial Paralysis. J Pediatr 2021; 235:293-295. [PMID: 33894264 DOI: 10.1016/j.jpeds.2021.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Christopher I McHugh
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology and, Harvard Medical School, Boston, MA
| | - Tara E Mokhtari
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology and, Harvard Medical School, Boston, MA
| | - Michael S Cohen
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology and, Harvard Medical School, Boston, MA
| | - Christopher J Hartnick
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology and, Harvard Medical School, Boston, MA
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17
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Crowson MG, Hartnick CJ, Diercks GR, Gallagher TQ, Fracchia MS, Setlur J, Cohen MS. Machine Learning for Accurate Intraoperative Pediatric Middle Ear Effusion Diagnosis. Pediatrics 2021; 147:peds.2020-034546. [PMID: 33731369 DOI: 10.1542/peds.2020-034546] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Misdiagnosis of acute and chronic otitis media in children can result in significant consequences from either undertreatment or overtreatment. Our objective was to develop and train an artificial intelligence algorithm to accurately predict the presence of middle ear effusion in pediatric patients presenting to the operating room for myringotomy and tube placement. METHODS We trained a neural network to classify images as " normal" (no effusion) or "abnormal" (effusion present) using tympanic membrane images from children taken to the operating room with the intent of performing myringotomy and possible tube placement for recurrent acute otitis media or otitis media with effusion. Model performance was tested on held-out cases and fivefold cross-validation. RESULTS The mean training time for the neural network model was 76.0 (SD ± 0.01) seconds. Our model approach achieved a mean image classification accuracy of 83.8% (95% confidence interval [CI]: 82.7-84.8). In support of this classification accuracy, the model produced an area under the receiver operating characteristic curve performance of 0.93 (95% CI: 0.91-0.94) and F1-score of 0.80 (95% CI: 0.77-0.82). CONCLUSIONS Artificial intelligence-assisted diagnosis of acute or chronic otitis media in children may generate value for patients, families, and the health care system by improving point-of-care diagnostic accuracy. With a small training data set composed of intraoperative images obtained at time of tympanostomy tube insertion, our neural network was accurate in predicting the presence of a middle ear effusion in pediatric ear cases. This diagnostic accuracy performance is considerably higher than human-expert otoscopy-based diagnostic performance reported in previous studies.
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Affiliation(s)
- Matthew G Crowson
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts; .,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Gillian R Diercks
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Thomas Q Gallagher
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Mary S Fracchia
- Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jennifer Setlur
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Michael S Cohen
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
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18
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Miller AL, McCarty JC, Bergmark RW, Gadkaree SK, Cohen MS, Diercks GR, Keamy DJ, Mankarious LA, Hartnick CJ. Association of perioperative ibuprofen exposure with post-tonsillectomy bleeding requiring operative management. Int J Pediatr Otorhinolaryngol 2021; 142:110627. [PMID: 33477013 DOI: 10.1016/j.ijporl.2021.110627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/21/2020] [Accepted: 01/10/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Pediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not. METHODS Retrospective cohort study of patients 0-18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred. RESULTS A total of 4098 patients with a median age of 6 years old (IQR 4-10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3-8) in the non-ibuprofen group. CONCLUSIONS No difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy.
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Affiliation(s)
- Ashley L Miller
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA.
| | - Justin C McCarty
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Regan W Bergmark
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Shekhar K Gadkaree
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA
| | - Michael S Cohen
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA
| | - Gillian R Diercks
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA
| | - Donald J Keamy
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA
| | - Leila A Mankarious
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA
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19
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Patel KR, Partain M, Ryan DP, Hersh C, Goldenberg P, Hartnick CJ. Carotid artery mobilization prior to pharyngeal flap inset for patients with 22q11.2 deletion syndrome. Int J Pediatr Otorhinolaryngol 2021; 141:110573. [PMID: 33359933 DOI: 10.1016/j.ijporl.2020.110573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/01/2022]
Abstract
The management of velopharyngeal insufficiency (VPI) in patients with 22q11.2 deletion syndrome (22q11DS) poses a significant clinical challenge due to presence of a large velopharyngeal gap and a relatively high rate of internal carotid artery (ICA) medialization. To our knowledge, we are the first group to have successfully managed VPI in a series of seven pediatric patients with 22q11DS with medialized ICAs via a novel surgical technique involving carotid artery mobilization followed by pharyngeal flap insertion. Thus far, we have found this technique to be reliably safe with no significant morbidity and caregivers have reported postoperative improvement in speech, swallowing and nasal regurgitation symptoms. Herein, we provide a detailed description of our novel surgical approach, including an instructional video, for correction of VPI in patients with medialized ICAs, who have previously had limited management options.
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Affiliation(s)
- Krupa R Patel
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Matthew Partain
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Daniel P Ryan
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl Hersh
- Pediatric Airway, Voice and Swallowing Center, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Paula Goldenberg
- Division of Medical Genetics, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
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20
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Patel KR, Zablah E, Yager PH, Hartnick CJ. Leveraging telemedicine to preserve pediatric global health missions in the era of COVID-19. Int J Pediatr Otorhinolaryngol 2021; 140:110494. [PMID: 33213961 PMCID: PMC7658589 DOI: 10.1016/j.ijporl.2020.110494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 12/23/2022]
Abstract
This paper outlines the use of a global telehealth program to leverage the potential of telehealth to not only 1) preserve the previous progress of our pediatric surgical airway global teaching mission, but also: 2) to provide rapid, international dissemination of information related to care of pediatric COVID-19 patients; 3) to virtually support the attainment of self-sufficiency of our host countries in relation to our teaching mission; and 4) to inspire host countries to be local champions for each other during the COVID-19 crisis.
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Affiliation(s)
- Krupa R. Patel
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Evelyn Zablah
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Phoebe H. Yager
- Pediatric Intensive Care Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher J. Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA,Corresponding author. MS Department of Otolaryngology—Head and Neck Surgery Massachusetts Eye and Ear Infirmary, Harvard Medical School 243 Charles Street, Boston, MA, 02114, USA
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21
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Yu PK, Jayawardena ADL, Stenerson M, Pulsifer MB, Grieco JA, Abbeduto L, Dedhia RC, Soose RJ, Tobey A, Raol N, Ishman SL, Shott SR, Cohen MS, Skotko BG, Kinane TB, Keamy DG, Hartnick CJ. Redefining Success by Focusing on Failures After Pediatric Hypoglossal Stimulation in Down Syndrome. Laryngoscope 2020; 131:1663-1669. [PMID: 33264427 DOI: 10.1002/lary.29290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/04/2020] [Accepted: 11/17/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS Patients with Down syndrome have a high incidence of obstructive sleep apnea (OSA) and limited treatment options. Hypoglossal stimulation has shown efficacy but has not yet been approved for pediatric populations. Our objective is to characterize the therapy response of adolescent patients with down syndrome and severe OSA who underwent hypoglossal stimulation. STUDY DESIGN Prospective longitudinal trial. METHODS We are conducting a multicenter single-arm trial of hypoglossal stimulation for adolescent patients with Down syndrome and severe OSA. Interim analysis was performed to compare objective sleep and quality of life outcomes at 12 months postoperatively for the first 20 patients. RESULTS The mean age was 15.5 and baseline AHI 24.2. Of the 20 patients, two patients (10.0%) had an AHI under 1.5 at 12 months; nine patients of 20 (45.0%) under five; and 15 patients of 20 (75.0%) under 10. The mean decrease in AHI was 15.1 (P < .001). Patients with postoperative AHI over five had an average baseline OSA-18 survey score of 3.5 with an average improvement of 1.7 (P = .002); in addition, six of these patients had a relative decrease of apneas compared to hypopneas and seven had an improvement in percentage of time with oxygen saturation below 90%. CONCLUSIONS Patients with persistently elevated AHI 12 months after hypoglossal implantation experienced improvement in polysomnographic and quality of life outcomes. These results suggest the need for a closer look at physiologic markers for success beyond reporting AHI as the gold standard. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1663-1669, 2021.
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Affiliation(s)
- Phoebe K Yu
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Asitha D L Jayawardena
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Matthew Stenerson
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Margaret B Pulsifer
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Julie A Grieco
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Leonard Abbeduto
- MIND Institute and Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, California, U.S.A
| | - Raj C Dedhia
- CPAP Alternatives Clinic and Division of Sleep Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Ryan J Soose
- Department of Otolaryngology and Division of Sleep Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Allison Tobey
- Department of Otolaryngology and Division of Sleep Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Nikhila Raol
- Department of Otolaryngology, Children's Healthcare of Atlanta, Atlanta, Georgia, U.S.A
| | - Stacey L Ishman
- Department of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Sally R Shott
- Department of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Michael S Cohen
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Brian G Skotko
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Thomas B Kinane
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Donald G Keamy
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
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22
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Diercks GR, Hersh CJ, Baars R, Sally S, Caloway C, Hartnick CJ. Factors associated with frenotomy after a multidisciplinary assessment of infants with breastfeeding difficulties. Int J Pediatr Otorhinolaryngol 2020; 138:110212. [PMID: 32738672 DOI: 10.1016/j.ijporl.2020.110212] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Frenotomy for ankyloglossia has increased nearly 10-fold over the past few decades despite insufficient evidence that the procedure improves breastfeeding outcomes. There is no universally accepted method for identifying patients who may benefit from the procedure. The objective of this study is to determine if comprehensive feeding evaluations and targeted interventions can identify children who should undergo procedures, and to identify factors associated with lip or tongue frenotomy to treat breastfeeding difficulties. METHODS This observational quality improvement study followed infant-mother dyads between March 2018 and December 2019 referred to our tertiary care center for breastfeeding difficulties. Speech and language pathologists performed comprehensive feeding evaluations on infants prior to surgical consultation for frenotomy. Infants' oral anatomy and function and their ability to breast and bottle feed were assessed, and techniques for mothers to address feeding difficulties without a procedure were offered prior to surgical consultation. Infants either found success over a short observation period or underwent procedures (lip and/or tongue frenotomy). RESULTS 153 patients (mean age 47.0 days (stdev 39.0 days, 56.2% male) were referred for surgical division of the lingual frenulum. Following development of a program utilizing pediatric speech language pathologists to perform feeding evaluations prior to surgical consultation, 69.9% of patients subsequently did not undergo surgical procedures. 11 (23.9%) underwent labial frenotomy alone and 30 (65.2%) underwent both labial and lingual frenotomies. Frenotomy was associated with significantly increased worry subscale of the Feeding Swallow Impact Survey (FSIS) and decreased mean Breastfeeding Self Efficacy Scale score (p = 0.0001, p = 0.006, respectively). Tongue appearance was significantly associated with having a procedure, while lip appearance was not. The Bristol Breastfeeding Assessment Tool (BBAT) was lower in children undergoing tongue and/or lip frenotomy (p = 0.0006), while the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) appearance and function scores were lower in children undergoing lingual frenotomy with or without lip frenotomy (p = 0.0008, p = 0.0009, respectively). CONCLUSIONS The majority of patients referred for ankyloglossia may benefit from nonsurgical intervention strategies based on findings from comprehensive feeding evaluation. Frenotomy is associated with higher maternal feeding-related worry and reduced breastfeeding self-efficacy scores. While tongue appearance is associated with frenotomy, functional assessment is critical for identifying patients who may also benefit from lip frenotomy.
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Affiliation(s)
| | | | | | - Sarah Sally
- Massachusetts General Hospital, Boston, MA, USA
| | - Christen Caloway
- Massachusetts Eye and Ear Infirmary, Boston, MA, USA; St. Barnabas Medical Center, Livingston, NJ, USA
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23
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Faucett EA, Wolter NE, Balakrishnan K, Ishman SL, Mehta D, Parikh S, Nguyen LHP, Preciado D, Rutter MJ, Prager JD, Green GE, Pransky SM, Elluru R, Husein M, Roy S, Johnson KE, Friedberg J, Johnson RF, Bauman NM, Myer CM, Deutsch ES, Gantwerker EA, Willging JP, Hart CK, Chun RH, Lam DJ, Ida JB, Manoukian JJ, White DR, Sidell DR, Wootten CT, Inglis AF, Derkay CS, Zalzal G, Molter DW, Ludemann JP, Choi S, Schraff S, Myer CM, Cotton RT, Vijayasekaran S, Zdanski CJ, El-Hakim H, Shah UK, Soma MA, Smith ME, Thompson DM, Javia LR, Zur KB, Sobol SE, Hartnick CJ, Rahbar R, Vaccani JP, Hartley B, Daniel SJ, Jacobs IN, Richter GT, de Alarcon A, Bromwich MA, Propst EJ. Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus. Laryngoscope 2020; 131:1168-1174. [PMID: 33034397 DOI: 10.1002/lary.29126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/19/2020] [Accepted: 09/10/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN Blinded modified Delphi consensus process. SETTING Tertiary care center. METHODS A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE 5. Laryngoscope, 131:1168-1174, 2021.
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Affiliation(s)
- Erynne A Faucett
- Division of Otolaryngology, Head and Neck Surgery, Phoenix Children's Hospital, Department of Child Health, University of Arizona, Tucson, Arizona, U.S.A.,College of Medicine, Department of Otolaryngology, Mayo College of Medicine and Science, Phoenix, Arizona, U.S.A
| | - Nikolaus E Wolter
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Karthik Balakrishnan
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Stacey L Ishman
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Deepak Mehta
- Department of Pediatric Otolaryngology, Texas Children's Hospital, Houston, Texas, U.S.A
| | - Sanjay Parikh
- Division of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Lily H P Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Diego Preciado
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, Washington, District of Columbia, U.S.A
| | - Michael J Rutter
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Jeremy D Prager
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Glenn E Green
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan, U.S.A
| | - Seth M Pransky
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, U.S.A
| | - Ravi Elluru
- Division of Otolaryngology, Dayton Children's Hospital, Dayton, Ohio, U.S.A
| | - Murad Husein
- Department of Otolaryngology - Head and Neck Surgery, Victoria Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Soham Roy
- Department of Otorhinolaryngology, University of Texas at Houston McGovern Medical School, Houston, Texas, U.S.A
| | - Kaalan E Johnson
- Division of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jacob Friedberg
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Romaine F Johnson
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Nancy M Bauman
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, Washington, District of Columbia, U.S.A
| | - Charles M Myer
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Ellen S Deutsch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.,Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Eric A Gantwerker
- Department of Otolaryngology - Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, U.S.A
| | - J Paul Willging
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Catherine K Hart
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Robert H Chun
- Department of Otolaryngology, Children's Hospital of Wisconsin-Milwaukee Campus, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Derek J Lam
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Pediatric Otolaryngology, Doernbecher Children's Hospital, Portland, Oregon, U.S.A
| | - Jonathan B Ida
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - John J Manoukian
- Department of Otolaryngology - Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - David R White
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Douglas R Sidell
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Christopher T Wootten
- Division of Otolaryngology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
| | - Andrew F Inglis
- Division of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Craig S Derkay
- Department of Otolaryngology - Head and Neck Surgery Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - George Zalzal
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, Washington, District of Columbia, U.S.A
| | - David W Molter
- Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, U.S.A
| | - Jeffrey P Ludemann
- Pediatric Otolaryngology, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sukgi Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Scott Schraff
- Arizona Otolaryngology Consultants, Phoenix, Arizona, U.S.A
| | - Charles M Myer
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Robin T Cotton
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Shyan Vijayasekaran
- Department of Otolaryngology, Head and Neck Surgery, Perth Children's Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - Carlton J Zdanski
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Hamdy El-Hakim
- Division of Pediatric Surgery and Otolaryngology - Head and Neck Surgery, Departments of Surgery and Pediatrics, The Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Udayan K Shah
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, U.S.A
| | - Marlene A Soma
- Department of Paediatric Otolaryngology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Marshall E Smith
- Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Dana M Thompson
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Luv Ram Javia
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Karen B Zur
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Steven E Sobol
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School Boston, Boston, Massachusetts, U.S.A
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Jean-Philippe Vaccani
- Division of Otolaryngology, Department of Surgery, CHEO, University of Ottawa, Ottawa, Ontario, Canada
| | - Benjamin Hartley
- Department of Otolaryngology, Great Ormond Street Hospital, London, United Kingdom
| | - Sam J Daniel
- Department of Otolaryngology - Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Ian N Jacobs
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Gresham T Richter
- Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, Arkansas, U.S.A
| | - Alessandro de Alarcon
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Matthew A Bromwich
- Division of Otolaryngology, Department of Surgery, CHEO, University of Ottawa, Ottawa, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
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24
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Jayawardena ADL, Fracchia MS, Bartley BL, Yonker LM, Lapey A, Virgin F, Hartnick CJ. Working towards consensus in the management of pediatric chronic rhinosinusitis in cystic fibrosis. Int J Pediatr Otorhinolaryngol 2020; 135:110047. [PMID: 32446041 DOI: 10.1016/j.ijporl.2020.110047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The prevalence of chronic rhinosinusitis (CRS), defined by mucosal thickening on imaging, approaches 100% in the cystic fibrosis (CF) population. CRS is associated with significant morbidity in CF, including its ability to trigger pulmonary exacerbations. CRS in CF is typically managed by pediatricians, otolaryngologists and pulmonologists. This survey evaluates the variance in practice patterns of CRS in CF amongst specialists. METHODS This is a cross-sectional, electronic survey in which maximum variation purposive sampling was used by a multi-disciplinary group of pediatric, otolaryngology and pulmonology providers in order to select a survey population with expertise in CRS in CF patients. The survey was distributed to 381 practitioners from September to October 2019. RESULTS 175 participants responded (45% response rate). Ten (of 54) statements achieved 75% consensus agreement. Consensus statements included: The decision to pursue surgical intervention for CRS in CF is a multi-disciplinary approach (94%; n = 146); maximal medical management should include nasal saline irrigation (93%; n = 142), topical steroids (75%; n = 117), maximal medical management should not include intravenous steroids (79%; n = 122); image guidance in surgery is necessary for all surgery involving the frontal sinuses (77%; n = 43), and all revision surgery(80%, n = 45); the appropriate setting for sinus surgery in a CF patient varies depending on patient presentation (89%; n = 133); post-operative regimen should include nasal saline (93%; n = 137); but does depend on the severity of disease discovered intra-operatively (84%; n = 124); post-operative antibiotics should be guided by intra-operative culture data (82%; n = 121). CONCLUSIONS There is a great deal of variation amongst specialists in the treatment of CRS in CF, however 10 statements met consensus criteria and should be considered when forming clinical care guidelines in this population.
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Affiliation(s)
- Asitha D L Jayawardena
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology Head and Neck Surgery, Boston, MA, USA
| | - M Shannon Fracchia
- Massachusetts General Hospital, Department of Pediatric Pulmonology, Boston, MA, USA
| | - Bethany L Bartley
- Massachusetts General Hospital, Department of Pediatric Pulmonology, Boston, MA, USA
| | - Lael M Yonker
- Massachusetts General Hospital, Department of Pediatric Pulmonology, Boston, MA, USA
| | - Allen Lapey
- Massachusetts General Hospital, Department of Pediatric Pulmonology, Boston, MA, USA
| | - Frank Virgin
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher J Hartnick
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology Head and Neck Surgery, Boston, MA, USA.
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25
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Angulo C, Jayawardena ADL, Caruso PA, Ramos D, Bonilla JA, Zablah E, Hartnick CJ. Congenital nasal piriform aperture atresia: A case report and novel finding. Int J Pediatr Otorhinolaryngol 2020; 135:110124. [PMID: 32512323 DOI: 10.1016/j.ijporl.2020.110124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 11/29/2022]
Abstract
Congenital nasal piriform aperture stenosis and choanal atresia are types of nasal obstructions that can be life threatening to infants if left untreated. While there has been numerous reports on both of them there has not been a single reported case of congenital nasal piriform aperture atresia. Here, we present the first case of piriform aperture atresia that includes the diagnostic and clinical approach.
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Affiliation(s)
- Camila Angulo
- Tecnológico de Monterrey, Medical School, Guadalajara, Mexico
| | - Asitha D L Jayawardena
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology Head and Neck Surgery, Boston, MA, USA
| | - Paul A Caruso
- Massachusetts Eye and Ear Infirmary, Department of Radiology, Boston, MA, USA
| | - Daniel Ramos
- Hospital Nacional de Niños Benjamín Bloom, Department of of Otolaryngology Head and Neck Surgery, San Salvador, El Salvador
| | - José A Bonilla
- Hospital Nacional de Niños Benjamín Bloom, Department of of Otolaryngology Head and Neck Surgery, San Salvador, El Salvador
| | - Evelyn Zablah
- Benjamin Harry Peikin Foundation, Mission Coordination of Operation Airway, Boston, MA, USA
| | - Christopher J Hartnick
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology Head and Neck Surgery, Boston, MA, USA.
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26
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Jayawardena ADL, Liu T, Pereira B, Wang Y, Baker L, Leary R, Mirambeaux M, Zablah E, Sabatos-Peyton CA, Hartnick CJ. Immune Signature Variation in Twins With Clinically Different Recurrent Respiratory Papillomatosis. Laryngoscope 2020; 131:E1335-E1338. [PMID: 32722845 DOI: 10.1002/lary.28930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/04/2020] [Accepted: 06/21/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Tingyu Liu
- Novartis Institutes of BioMedical Research, Cambridge, MA, USA
| | - Bernard Pereira
- Novartis Institutes of BioMedical Research, Cambridge, MA, USA
| | - Ye Wang
- Novartis Institutes of BioMedical Research, Cambridge, MA, USA
| | - Lisa Baker
- Novartis Institutes of BioMedical Research, Cambridge, MA, USA
| | - Rebecca Leary
- Novartis Institutes of BioMedical Research, Cambridge, MA, USA
| | - Marcos Mirambeaux
- Department of Otolaryngology, Roberto Reid Cabral, Santa Domingo, Dominican Republic
| | - Evelyn Zablah
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | | | - Christopher J Hartnick
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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27
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Jayawardena ADL, Ghersin ZJ, Mirambeaux M, Bonilla JA, Quiñones E, Zablah E, Callans K, Hartnick M, Sahani N, Cayer M, Hersh C, Gallagher TQ, Yager PH, Hartnick CJ. A Sustainable and Scalable Multidisciplinary Airway Teaching Mission: The Operation Airway 10-Year Experience. Otolaryngol Head Neck Surg 2020; 163:971-978. [PMID: 32600113 DOI: 10.1177/0194599820935042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy. STUDY DESIGN Consecutive case series with chart review. SETTING This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic. METHODS Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes. RESULTS A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded. CONCLUSION This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.
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Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Zelda J Ghersin
- Pediatric Intensive Care Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marcos Mirambeaux
- Department of Otolaryngology, Roberto Reid Cabral, Santa Domingo, Dominican Republic
| | - Jose A Bonilla
- Department of Otolaryngology, Benjamin Bloom Hospital, San Salvador, El Salvador
| | - Ernesto Quiñones
- Hospital de los Valles, Universidad San Francisco de Quito, Quito, Ecuador
| | - Evelyn Zablah
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Kevin Callans
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | - Marina Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Nita Sahani
- Department of Anesthesia, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Makara Cayer
- Department of Anesthesia, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Cheryl Hersh
- Pediatric Airway, Voice and Swallowing Center, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | - Thomas Q Gallagher
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Phoebe H Yager
- Pediatric Intensive Care Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Mokhtari TE, Miller LE, Jayawardena ADL, Sadow PM, Hardy SC, Rothman D, Hartnick CJ. Eosinophilic Granulomatosis With Polyangiitis: An Unusual Case of Pediatric Subglottic Stenosis. Laryngoscope 2020; 131:656-659. [PMID: 32562500 DOI: 10.1002/lary.28848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/14/2020] [Accepted: 05/25/2020] [Indexed: 12/27/2022]
Abstract
Systemic disease is an uncommon cause of subglottic stenosis (SGS). We report a case of severe SGS due to underlying eosinophilic granulomatosis with polyangiitis (EGPA) in a child presenting with isolated stridor. EGPA is a rare systemic vasculitis with very limited cases reported in the pediatric population. While surgical intervention was required given the degree of stenosis in this case, medical management of the underlying systemic disease process is critical when there is clinical suspicion of SGS in the context of systemic vasculitis. Laryngoscope, 131:656-659, 2021.
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Affiliation(s)
- Tara E Mokhtari
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Lauren E Miller
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Asitha D L Jayawardena
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Peter M Sadow
- Department of Pathology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Stephen C Hardy
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Deborah Rothman
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
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Jayawardena ADL, Romano S, Callans K, Fracchia MS, Hartnick CJ. Family-Centered Information Dissemination: A Multidisciplinary Virtual COVID-19 "Town Hall". Otolaryngol Head Neck Surg 2020; 163:929-930. [PMID: 32513062 DOI: 10.1177/0194599820935419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Significant misinformation about COVID-19 has been spread on the internet. Parents of children with complex aerodigestive problems have a hard time understanding the information they encounter on the internet and the news media and interpreting how it relates to their child's complex needs. Our multidisciplinary team, at the suggestion of a parent, hosted 3 virtual "town halls" in which families could ask questions directly of pediatric otolaryngology, pediatric pulmonology and case management in order to efficiently obtain factual evidence-based up-to-date advice. The information discussed at the town halls was then annotated and disseminated via active, parent-run aerodigestive social media forums. The information disseminated via the town halls reached 4787 Facebook participants.
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Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Sarah Romano
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Kevin Callans
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - M Shannon Fracchia
- Department of Pediatric Pulmonology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Jayawardena AD, Randolph GW, Hartnick CJ. Ansa-to-Recurrent Laryngeal Nerve Anastomosis Aided by Vagal Nerve Evoked Electromyography: Surgical Technique. VideoEndocrinology 2020. [DOI: 10.1089/ve.2020.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Asitha D.L. Jayawardena
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Greg W. Randolph
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Christopher J. Hartnick
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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31
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Moser PT, Gerli M, Diercks GR, Evangelista-Leite D, Charest JM, Gershlak JR, Ren X, Gilpin SE, Jank BJ, Gaudette GR, Hartnick CJ, Ott HC. Creation of Laryngeal Grafts from Primary Human Cells and Decellularized Laryngeal Scaffolds. Tissue Eng Part A 2020; 26:543-555. [DOI: 10.1089/ten.tea.2019.0128] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Philipp T. Moser
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Mattia Gerli
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Great Ormond Street Institute of Child Health, University College London Medical School, London, United Kingdom
| | - Gillian R. Diercks
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | | | - Jonathan M. Charest
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Gershlak
- Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Xi Ren
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Sarah E. Gilpin
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bernhard J. Jank
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology, Medical University of Vienna, Vienna, Austria
| | - Glenn R. Gaudette
- Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Christopher J. Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Harald C. Ott
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Thoracic Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Jayawardena ADL, Burks CA, Hartnick CJ. Bioabsorbable Microplates as an External Stent for Suprastomal Collapse: A Retrospective Review. Laryngoscope 2020; 131:E631-E634. [PMID: 32330306 DOI: 10.1002/lary.28699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 03/16/2020] [Accepted: 04/07/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE/HYPOTHESIS To assess the long-term decannulation outcomes of bioresorbable microplates as an external stent for pediatric tracheostomy patients with suprastomal collapse. STUDY DESIGN Retrospective cohort study. METHODS Hospital records of all patients who underwent a bioresorbable microplate for suprastomal collapse from 2016 to 2019 were reviewed at a single institution. The primary outcome measure was tracheostomy decannulation. RESULTS A total of nine patients underwent placement of bioabsorbable microplates to treat suprastomal collapse. After initial tracheostomy, four patients received a laryngotracheal reconstruction prior to their external stent placement, and one patient received a mandibular distraction. The average age at the time of external stent placement was 32 (±21) months, excluding one patient who received a stent at the age of 29 years. Eight patients (88.9%) were successfully decannulated following the procedure. Decannulated patients were followed for an average of 21 (±12.5) months postoperatively, and all these patients have remained decannulated since their initial procedure. This is a total of 173 months (14.4 years) of observation postprocedure in which these patients have remained decannulated. One patient experienced postoperative crepitus requiring washout but still maintained decannulation. CONCLUSION Bioabsorbable microplates have a reasonable chance of long-term successful decannulation when an appropriate patient is selected. Decannulation is maintained beyond the 6-month time frame in which the 85:15 poly(L-lactide-co-glycolide) polymer that comprises the external stent takes to bioabsorb. This procedure should be considered for the often difficult problem of pediatric tracheostomy with isolated suprastomal collapse. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E631-E634, 2021.
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Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Ciersten A Burks
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
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Jayawardena ADL, Randolph GW, Hartnick CJ. Pediatric Modifications to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: How I Do It. Laryngoscope 2020; 131:423-424. [PMID: 32271464 DOI: 10.1002/lary.28661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/05/2020] [Accepted: 03/14/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Greg W Randolph
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Christopher J Hartnick
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
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Jayawardena ADL, Bouhabel S, Sheridan RL, Hartnick CJ. Laryngotracheal Reconstruction in the Pediatric Burn Patient: Surgical Techniques and Decision Making. J Burn Care Res 2020; 41:882-886. [PMID: 32112103 DOI: 10.1093/jbcr/iraa032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multidisciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific LTR techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus, and neck contractures-the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision making regarding pursuing single-stage LTR, double-stage LTR, and 1.5-stage LTR can be challenging-the authors recommend 1.5-stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include obtaining intravenous access, securing the airway, and intravenous induction-the authors recommend peripherally inserted central catheter when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the TBSA covered by the burn injury-the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric LTR in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision making.
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Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
| | - Sarah Bouhabel
- Department of Otolaryngology-Head and Neck Surgery, McGill University Health Center, Montréal, Canada
| | | | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
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35
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Ghersin ZJ, Yager P, Cummings BM, Hersh M C, Cayer M, Callans KM, Zablah EJ, Gallagher T, Abrego S, Bonilla J, Vela OS, Guzman L, Aguilar A, Hartnick CJ. A multidisciplinary, video-based, curriculum for management of the intubated and surgical airway patient for a pediatric hospital in El Salvador. Int J Pediatr Otorhinolaryngol 2020; 128:109732. [PMID: 31644996 DOI: 10.1016/j.ijporl.2019.109732] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/13/2019] [Accepted: 10/13/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Primary objective is to determine the rate of intubation with inappropriately sized endotracheal tubes (ETTs) in a pediatric intensive care unit (PICU) in El Salvador. Secondary objective is to determine effectiveness of a video-based curriculum to teach local providers on pediatric advanced airway management and surgical approach to patients requiring airway reconstruction. METHODS Data for 296 intubated pediatric patients was collected over a six month period in a 16-bed PICU in El Salvador. Results of a learning behavior assessment survey completed by local healthcare workers informed a curriculum to complement on-site education during annual surgical airway mission trips. The video-based curriculum addressed proper sizing and use of cuffed endotracheal tubes, care of the intubated child and perioperative considerations of the surgical airway patient. Providers completed pre and post-curriculum quizzes to measure knowledge acquisition. RESULTS Over 6-months, 281 patients were intubated. Sixty-three percent had improperly sized ETTs. Thirty-one percent had a failed or accidental extubation. All-cause mortality was 24%. One hundred and fifty-nine Salvadorian providers completed a learning behavior survey informing a video-based curriculum. Sixty-four providers completed the curriculum. Post-curriculum quiz scores increased by 18.7%. Surgeons, anesthesiologist, intensivists and speech pathologists demonstrated significant improvement (p < 0.05). CONCLUSION Nearly two-thirds of intubated patients in a PICU in El Salvador have improperly sized ETTs and one-third require reintubation following planned or accidental extubation. The development of this first of its kind video-based curriculum for critical care and surgical training regarding how to properly care for the intubated child is coupled with the development of a longitudinal database to record pediatric airway related morbidity and mortality in the largest pediatric hospital in El Salvador. This model and system can be used to track the reduction in airway related morbidity and mortality directly related to a systems based intervention both in El Salvador and then elsewhere.
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Affiliation(s)
- Zelda J Ghersin
- Massachusetts General Hospital for Children, Boston, MA, USA.
| | - Phoebe Yager
- Massachusetts General Hospital for Children, Boston, MA, USA.
| | | | - Cheryl Hersh M
- Massachusetts General Hospital for Children, Boston, MA, USA.
| | | | | | | | | | - Susana Abrego
- Hospital de Niños Benjamin Bloom, San Salvador, El Salvador.
| | - Jose Bonilla
- Hospital de Niños Benjamin Bloom, San Salvador, El Salvador.
| | | | - Luis Guzman
- Hospital de Niños Benjamin Bloom, San Salvador, El Salvador.
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Miller AL, Caloway C, Hersh CJ, Hartnick CJ. Long-term swallowing outcomes following type 1 laryngeal cleft injection. Int J Pediatr Otorhinolaryngol 2020; 128:109731. [PMID: 31648159 DOI: 10.1016/j.ijporl.2019.109731] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/11/2019] [Accepted: 10/12/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Interarytenoid injection augmentation (IIA) during initial diagnostic endoscopy for aspiration and dysphagia has been described as both a diagnostic and therapeutic technique in the evaluation of type 1 laryngeal cleft (LC-1). IIA is additionally hypothesized to be a temporizing measure that facilitates improvement of swallowing function and potentially obviates the need for future formal endoscopic suture repair of LC-1. However, long-term (>6 month) outcomes of IIA for LC-1 remain largely unknown. The objective of this study was to evaluate the effect of IIA on long-term swallowing outcomes and need for formal endoscopic suture repair in patients with LC-1. METHODS This is a retrospective cohort study of patients age ≤24 months with pharyngeal phase dysphagia on preoperative videofluoroscopic swallow study (VFSS) who underwent IIA for LC-1 during diagnostic laryngoscopy and bronchoscopy at a single tertiary care academic subspecialty hospital from June 2017 to May 2018. Included patients underwent VFSS within 30 days of IIA and had documented SLP follow up at 6 months or more post-procedure. Exclusion criteria included prior cleft repair, gastrostomy tube dependence, additional procedures at the time of IIA, or lack of documented follow up. A total of 34 patients underwent LC-1 during study period with 24 included in final analyses. The primary outcome measure was improvement in safely swallowed consistency at 6 months or greater following injection. Secondary outcomes included need for formal suture LC-1 repair following IIA and comparison of 30-day and long-term swallowing function. RESULTS Median [range] age at injection was 15.3 [10.3-19.1] months and 50% were female (n = 12). Improvement was noted in 12 (50%) patients within 30 days of IIA, with 11 of 12 demonstrating sustained improvement at long-term follow up (10.3 [9.3-14.0] months). Among all patients, 15 of 24 (63%) demonstrated improvement compared to preoperative baseline. Six of 24 (25%) required formal suture repair of LC-1. CONCLUSIONS IIA is a safe procedure that may result in both immediate and long-term improvement in dysphagia in select patients with LC-1. Additional studies are required to determine impact of IIA on pulmonary complications and hospital utilization and as well as patient- and caregiver-related outcome measures.
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Affiliation(s)
- Ashley L Miller
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Christen Caloway
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
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Caloway CL, Bouhabel S, Hartnick CJ. Lessons learned to aid the successful outcome of pediatric recurrent laryngeal nerve reinnervation. Int J Pediatr Otorhinolaryngol 2020; 128:109742. [PMID: 31677453 DOI: 10.1016/j.ijporl.2019.109742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 11/25/2022]
Abstract
While Ansa to recurrent laryngeal nerve reinnervation is gaining popularity in the treatment of unilateral vocal fold immobility, little has been reported on commonly encountered surgical challenges with this procedure. Here, we present a cohort of 21 pediatric patients who underwent this procedure with a full description of techniques used to overcome common challenges with this procedure. We report vocal and swallowing outcomes for these patients, with an overall success rate of 19/21 (90.5%) patients, with success defined as improvement of a half-consistency or resolution of vocal issues.
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Affiliation(s)
- Christen L Caloway
- Department of Otolaryngology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Propst EJ, Wolter NE, Ishman SL, Balakrishnan K, Deonarain AR, Mehta D, Zalzal G, Pransky SM, Roy S, Myer CM, Torre M, Johnson RF, Ludemann JP, Derkay CS, Chun RH, Hong P, Molter DW, Prager JD, Nguyen LHP, Rutter MJ, Myer CM, Zur KB, Sidell DR, Johnson LB, Cotton RT, Hart CK, Willging JP, Zdanski CJ, Manoukian JJ, Lam DJ, Bauman NM, Gantwerker EA, Husein M, Inglis AF, Green GE, Javia LR, Schraff S, Soma MA, Deutsch ES, Sobol SE, Ida JB, Choi S, Uwiera TC, Shah UK, White DR, Wootten CT, El-Hakim H, Bromwich MA, Richter GT, Vijayasekaran S, Smith ME, Vaccani JP, Hartnick CJ, Faucett EA. Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus. Laryngoscope 2019; 130:2700-2707. [PMID: 31821571 DOI: 10.1002/lary.28461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/08/2019] [Accepted: 11/21/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Create a competency-based assessment tool for pediatric tracheotomy. STUDY DESIGN Blinded, modified, Delphi consensus process. METHODS Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items. RESULTS The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus. CONCLUSIONS It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure. LEVEL OF EVIDENCE 5 Laryngoscope, 130:2700-2707, 2020.
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Affiliation(s)
- Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stacey L Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Karthik Balakrishnan
- Department of Otolaryngology and Mayo Children's Center, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, U.S.A
| | - Ashley R Deonarain
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Deepak Mehta
- Department of Pediatric Otolaryngology, Texas Children's Hospital, Houston, Texas, U.S.A
| | - George Zalzal
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, DC, U.S.A
| | - Seth M Pransky
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, U.S.A
| | - Soham Roy
- Department of Otorhinolaryngology, University of Texas at Houston McGovern Medical School, Houston, Texas, U.S.A
| | - Charles M Myer
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Michele Torre
- Airway Unit, Scientific Institute for Research and Healthcare, Giannina Gaslini Institute, Genoa, Italy
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Jeffrey P Ludemann
- Pediatric Otolaryngology, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig S Derkay
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Robert H Chun
- Department of Otolaryngology, Children's Hospital of Wisconsin-Milwaukee Campus, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Paul Hong
- Division of Otolaryngology, Dalhousie University, Izaak Walton Killam Health Centre, Halifax, Nova Scotia, Canada
| | - David W Molter
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jeremy D Prager
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Lily H P Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Michael J Rutter
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Charles M Myer
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Karen B Zur
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Douglas R Sidell
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Liane B Johnson
- Division of Otolaryngology, Dalhousie University, Izaak Walton Killam Health Centre, Halifax, Nova Scotia, Canada
| | - Robin T Cotton
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Catherine K Hart
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - J Paul Willging
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Carlton J Zdanski
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - John J Manoukian
- Department of Otolaryngology-Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Derek J Lam
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Pediatric Otolaryngology, Doernbecher Children's Hospital, Portland, Oregon, U.S.A
| | - Nancy M Bauman
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, DC, U.S.A
| | - Eric A Gantwerker
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, U.S.A
| | - Murad Husein
- Department of Otolaryngology-Head and Neck Surgery, Victoria Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Andrew F Inglis
- Division of Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Glenn E Green
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan, U.S.A
| | - Luv Ram Javia
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Scott Schraff
- Arizona Otolaryngology Consultants, Phoenix, Arizona, U.S.A
| | - Marlene A Soma
- Department of Pediatric Otolaryngology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Ellen S Deutsch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Steven E Sobol
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Jonathan B Ida
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Sukgi Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Trina C Uwiera
- Divisions of Pediatric Surgery and Otolaryngology-Head and Neck Surgery, Departments of Surgery and Pediatrics, The Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Udayan K Shah
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, U.S.A
| | - David R White
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Christopher T Wootten
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Hamdy El-Hakim
- Divisions of Pediatric Surgery and Otolaryngology-Head and Neck Surgery, Departments of Surgery and Pediatrics, The Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Matthew A Bromwich
- Division of Otolaryngology, Department of Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Gresham T Richter
- Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, Arkansas, U.S.A
| | - Shyan Vijayasekaran
- Department of Otolaryngology-Head and Neck Surgery, Perth Children's Hospital, University of Western Australia, Nedlands, Western Australia, Australia
| | - Marshall E Smith
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Jean-Philippe Vaccani
- Division of Otolaryngology, Department of Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Erynne A Faucett
- Department of Pediatric Otolaryngology, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
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Shembel AC, Hartnick CJ, Bunting G, Ballif C, Shaiman S, de Guzman V, Abbott KV. Perceptual Clinical Features in Exercise-Induced Laryngeal Obstruction (EILO): Toward Improved Diagnostic Approaches. J Voice 2019; 33:880-893. [DOI: 10.1016/j.jvoice.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/17/2018] [Indexed: 10/28/2022]
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40
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Caloway C, Hersh CJ, Baars R, Sally S, Diercks G, Hartnick CJ. Association of Feeding Evaluation With Frenotomy Rates in Infants With Breastfeeding Difficulties. JAMA Otolaryngol Head Neck Surg 2019; 145:817-822. [PMID: 31294774 DOI: 10.1001/jamaoto.2019.1696] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Inpatient surgical release of lingual frenulums rose 10-fold between 1997 and 2012 despite insufficient evidence that frenotomy for ankyloglossia is associated with improvements in breastfeeding. Clear indications for surgical release remain murky, and best practice guidelines have yet to be developed. Objective To determine whether infants referred for frenotomy to treat breastfeeding difficulties should undergo procedures after comprehensive feeding examination, during which the primary cause of feeding issues was identified, and targeted intervention was provided. Design, Setting, and Participants This observational quality improvement study followed mother-infant dyads between March and December of 2018 who were referred to our tertiary care center for difficulty with breastfeeding. All infants underwent a comprehensive feeding evaluation by speech and language pathologists who examined the infants' ability to breastfeed prior to a surgical consultation for initial frenotomy. Data analysis was performed between January 2019 and May 2019. Interventions A multidisciplinary feeding evaluation that examined infants' oral structure and function and their ability to breastfeed and that offered techniques for mothers to address any feeding difficulties prior to surgical intervention was developed. Infants either found success in feeding and weight gain through this program or underwent procedures. Main Outcomes and Measures The primary outcome was the percentage of frenotomy procedures following implementation of a multidisciplinary feeding team evaluation. The secondary outcome was the percentage of infants referred for lingual frenotomy who later had either combined lingual and labial frenotomy or labial frenotomy alone. Results Included in the study were 115 patients (median age, 34 days [interquartile range, 19-56 days], 68 (59%) were male) referred for surgical division of the lingual frenum. Following the development of a program with feeding examination with a pediatric speech and language pathologist, 72 (62.6%) patients subsequently did not undergo surgical procedures. Although all of the referrals were for lingual frenotomy, 10 (8.7%) underwent labial frenotomy alone and 32 (27.8%) underwent both labial and lingual frenotomy. Conclusions and Relevance The majority of patients referred for ankyloglossia may benefit from alternative intervention strategies following comprehensive feeding evaluation. Close collaboration and formation of multidisciplinary teams are imperative for treating these children.
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Affiliation(s)
| | | | - Rebecca Baars
- Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah Sally
- Massachusetts General Hospital, Boston, Massachusetts
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Caloway CL, Diercks GR, Randolph G, Hartnick CJ. Vagal stimulation and laryngeal electromyography for recurrent laryngeal reinnervation in children. Laryngoscope 2019; 130:747-751. [DOI: 10.1002/lary.28135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/13/2019] [Accepted: 05/28/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Christen L. Caloway
- Department of OtolaryngologyMassachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
- Department of Otology and LaryngologyHarvard Medical School Boston Massachusetts U.S.A
| | - Gillian R. Diercks
- Department of OtolaryngologyMassachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
- Department of Otology and LaryngologyHarvard Medical School Boston Massachusetts U.S.A
| | - Gregory Randolph
- Department of OtolaryngologyMassachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
- Department of Otology and LaryngologyHarvard Medical School Boston Massachusetts U.S.A
| | - Christopher J. Hartnick
- Department of OtolaryngologyMassachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
- Department of Otology and LaryngologyHarvard Medical School Boston Massachusetts U.S.A
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Nourmahnad A, Benboujja F, Hartnick CJ. Using intraoperative optical coherence tomography to image pediatric unilateral vocal fold paralysis. Int J Pediatr Otorhinolaryngol 2019; 121:72-75. [PMID: 30877978 DOI: 10.1016/j.ijporl.2019.02.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Unilateral vocal fold paralysis (UVFP) impairs communication and reduces academic performance and social interactions in children. Deciding between temporary, permanent, or potentially destructive surgical interventions can be challenging, as there currently exists no reliable means of predicting vocal fold recovery or assessing the presence of vocal fold atrophy. Regarding vocal fold atrophy, optical coherence tomography (OCT) has been shown to be an appealing non-invasive alternative for accessing vocal fold structures. This study describes UVFP microanatomy and identifies possible vocal fold atrophy using OCT. METHODS Three UVFP patients (ages 1, 11, and 17 years) underwent bilateral OCT imaging using a handheld probe while under general anesthesia for direct laryngoscopy, and the laryngoscopic images were compared with images obtained from OCT. Structural morphological features were extracted and compared to a healthy patients' cohort. RESULTS While endoscopy showed no evidence of vocal fold atrophy in two of three cases, OCT images revealed distinct differences between the lamina propria of the paralyzed and functional vocal folds in all patients. In two cases, the paralyzed vocal fold morphology was similar to a healthy patient at the age of nerve injury. The third case exhibited extensive scarring in the lamina propria of the paralyzed vocal fold. CONCLUSION This pilot study characterizes and compares vocal fold microanatomy in three UVFP patients. In most cases, lamina propria development halted at the age of paralysis, suggesting that lamina propria maturation may be dependent on vocal fold functionality. OCT shows potential to aid UVFP assessment and treatment decisions by evaluating the presence of atrophy.
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Affiliation(s)
| | - Fouzi Benboujja
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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43
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Bowe SN, Wentland CJ, Hartnick CJ. Pediatric laryngeal electromyography technique for vocal fold immobility using bipolar double hookwire electrodes. Int J Pediatr Otorhinolaryngol 2019; 119:75-78. [PMID: 30684689 DOI: 10.1016/j.ijporl.2019.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Abstract
Vocal fold immobility (VFI) is a common cause of dysphonia and dysphagia in children. Laryngeal electromyography (LEMG) is an important adjunctive test in its diagnosis and treatment. In this study, we present an alternative technique in which bipolar double hookwire electrodes allow simultaneous placement and recordings from the bilateral thyroarytenoid and posterior cricoarytenoid muscles. Details of the technique are shown for a 5 y/o F with history of Neurofibromatosis Type 2 with left VFI and aspiration and dysphonia. This modified technique for pediatric LEMG has the potential to be a useful tool in predicting return of laryngeal function.
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Affiliation(s)
- Sarah N Bowe
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, MA, USA
| | - Carissa J Wentland
- Department of Otolaryngology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, MA, USA; Department of Otology & Laryngology, Harvard Medical School, Boston, MA, USA.
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Bowe SN, Colaianni CA, Yamasaki A, Cummings BM, Hartnick CJ. Reevaluating a Standardized Sedation Weaning Protocol for Pediatric Laryngotracheal Reconstruction for Continuous Quality Improvement. JAMA Otolaryngol Head Neck Surg 2019; 145:321-327. [PMID: 30763412 DOI: 10.1001/jamaoto.2018.4348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation. Objective Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR). Design, Setting, and Participants A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients. Main Outcomes and Measures The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission. Results The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS. Conclusions and Relevance Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.
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Affiliation(s)
- Sarah N Bowe
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts
| | - C Alessandra Colaianni
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts
| | - Alisa Yamasaki
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts
| | - Brian M Cummings
- Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts.,Department of Otology & Laryngology, Harvard Medical School, Boston, Massachusetts
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Woo J, Prince JL, Stone M, Xing F, Gomez AD, Green JR, Hartnick CJ, Brady TJ, Reese TG, Wedeen VJ, El Fakhri G. A Sparse Non-Negative Matrix Factorization Framework for Identifying Functional Units of Tongue Behavior From MRI. IEEE Trans Med Imaging 2019; 38:730-740. [PMID: 30235120 PMCID: PMC6422735 DOI: 10.1109/tmi.2018.2870939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Muscle coordination patterns of lingual behaviors are synergies generated by deforming local muscle groups in a variety of ways. Functional units are functional muscle groups of local structural elements within the tongue that compress, expand, and move in a cohesive and consistent manner. Identifying the functional units using tagged-magnetic resonance imaging (MRI) sheds light on the mechanisms of normal and pathological muscle coordination patterns, yielding improvement in surgical planning, treatment, or rehabilitation procedures. In this paper, to mine this information, we propose a matrix factorization and probabilistic graphical model framework to produce building blocks and their associated weighting map using motion quantities extracted from tagged-MRI. Our tagged-MRI imaging and accurate voxel-level tracking provide previously unavailable internal tongue motion patterns, thus revealing the inner workings of the tongue during speech or other lingual behaviors. We then employ spectral clustering on the weighting map to identify the cohesive regions defined by the tongue motion that may involve multiple or undocumented regions. To evaluate our method, we perform a series of experiments. We first use two-dimensional images and synthetic data to demonstrate the accuracy of our method. We then use three-dimensional synthetic and in vivo tongue motion data using protrusion and simple speech tasks to identify subject-specific and data-driven functional units of the tongue in localized regions.
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Affiliation(s)
- Jonghye Woo
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School
| | - Jerry L. Prince
- Department of Electrical and Computer Engineering at Johns Hopkins University
| | | | - Fangxu Xing
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School
| | - Arnold D. Gomez
- Department of Electrical and Computer Engineering at Johns Hopkins University
| | | | | | - Thomas J. Brady
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School
| | - Timothy G. Reese
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School
| | - Van J. Wedeen
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School
| | - Georges El Fakhri
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School
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46
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Miller AL, Hersh CJ, Johnson KE, Hartnick CJ. Short-term swallowing outcomes following type 1 laryngeal cleft injection. Int J Pediatr Otorhinolaryngol 2019; 116:159-163. [PMID: 30554689 DOI: 10.1016/j.ijporl.2018.10.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/16/2018] [Accepted: 10/28/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Interarytenoid injection augmentation at the time of initial diagnostic endoscopy for aspiration and dysphagia may result in near-immediate improvement in swallowing function, potentially obviating the need for future formal endoscopic repair of type 1 laryngeal cleft. Interarytenoid injection augmentation may also address physiologic aspiration. Early treatment of type 1 laryngeal cleft may allow for expedited liberalization of feedings. The objective of this study was to evaluate the effect of interarytenoid injection augmentation (IIA) for type 1 laryngeal clefts (LC-1) on short-term swallowing function assessed by videofluoroscopic swallowing study (VFSS). METHODS This was a retrospective cohort study of patients age ≤24 months with dysphagia on preoperative VFSS who underwent IIA with calcium hydroxyapatite for LC-1 during direct laryngoscopy and bronchoscopy from June to October 2017 at a tertiary care academic subspecialty hospital. Exclusion criteria included prior endoscopic or open LC repair (n = 1), gastrostomy tube dependence (n = 1), additional procedures at the time of IIA (supraglottoplasty, frenulectomy, n = 1). Children without postoperative VFSS within 30 days of injection were excluded (n = 2). Fifteen children met inclusion criteria for analysis. The primary endpoint was improvement in safely swallowed consistency as defined by recommendation to liberalize diet by at least a half-consistency (e.g. half-honey to nectar thick liquid). Secondary endpoints included clinical assessment of dysphagia and postoperative respiratory events. RESULTS Median [range] age at injection was 15.2 [7.7-24.3] months and 67% of patients were female (n = 10). The majority (13/15) of patients were full-term and 80% of patients (n = 12) had documented gastroesophageal reflux disease (GERD). Median time from injection to VFSS was 16 [9-29] days. Improvement in safely swallowed consistency was noted in 60% (n = 9) of patients. Aspiration completely resolved in two patients. Swallow function was unchanged in 40% of patients (n = 6); no patients experienced worsening dysphagia. No respiratory complications were documented during inpatient observation. CONCLUSION IIA is a safe procedure that may result in immediate improvement in dysphagia in select patients with LC-1. IIA does not address neurologic, developmental, or other anatomic etiologies of dysphagia. Additional studies are required to determine long-term efficacy of IIA on dysphagia and pulmonary complications, as well as the patient- and caregiver-related outcome measures.
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Affiliation(s)
- Ashley L Miller
- Massachusetts Eye and Ear, Department of Otolaryngology, Boston, MA, USA
| | - Cheryl J Hersh
- Massachusetts Eye and Ear, Department of Otolaryngology, Boston, MA, USA; Massachusetts General Hospital for Children, Boston, MA, USA
| | - Kaalan E Johnson
- Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, WA, USA; Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's, Seattle, WA, USA
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McGill M, Raol N, Gipson KS, Bowe SN, Fulk-Logan J, Nourmahnad A, Chung JY, Whalen MJ, Kaplan DL, Hartnick CJ. Preclinical assessment of resorbable silk splints for the treatment of pediatric tracheomalacia. Laryngoscope 2018; 129:2189-2194. [PMID: 30408198 DOI: 10.1002/lary.27540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tracheomalacia is characterized by weakness of the tracheal wall resulting in dynamic airway collapse during respiration; severe cases often require surgical intervention. Off-label external splinting with degradable implants has been reported in humans; however, there remains a need to develop splints with tunable mechanical properties and degradation profiles for the pediatric population. The objective of this pilot study is to assess the safety and efficacy of silk fibroin-based splints in a clinically relevant preclinical model of tracheomalacia. METHODS Silk splints were evaluated in a surgically induced model of severe tracheomalacia in N = 3 New Zealand white rabbits for 17, 24, and 31 days. An image-based assay was developed to quantify the dynamic change in airway area during spontaneous respiration, and histopathology was used to study the surrounding tissue response. RESULTS The average change in area in the native trachea was 23% during spontaneous respiration; surgically induced tracheomalacia resulted in a significant increase to 86% (P < 0.001). The average change in airway area after splint placement was reduced at all terminal time points (17, 24, and 31 days postimplantation), indicating a clinical improvement, and was not statistically different than the native trachea. Histopathology showed a localized inflammatory reaction characterized by neutrophils, eosinophils, and mononuclear cells, with early signs suggestive of fibrosis at the splint and tissue interface. CONCLUSION This pilot study indicates that silk fibroin splints are well tolerated and efficacious in a rabbit model of severe tracheomalacia, with marked reduction in airway collapse following implantation and good tolerability over the studied time course. LEVEL OF EVIDENCE NA Laryngoscope, 129:2189-2194, 2019.
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Affiliation(s)
- Meghan McGill
- Department of Biomedical Engineering, Tufts University, Medford
| | - Nikhila Raol
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,the Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Kevin S Gipson
- Department of Pediatrics, Division of Pediatric Pulmonology the Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah N Bowe
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | | | - Anahita Nourmahnad
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joon Yong Chung
- Department of Pediatrics, Division of Pediatric Pulmonology the Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael J Whalen
- Department of Pediatrics, Division of Pediatric Pulmonology the Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - David L Kaplan
- Department of Biomedical Engineering, Tufts University, Medford
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
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48
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Shembel AC, Hartnick CJ, Bunting G, Ballif C, Vanswearingen J, Shaiman S, Johnson A, de Guzman V, Verdolini Abbott K. The Study of Laryngoscopic and Autonomic Patterns in Exercise-Induced Laryngeal Obstruction. Ann Otol Rhinol Laryngol 2018; 127:754-762. [PMID: 30187760 DOI: 10.1177/0003489418796524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES (1) Identify laryngeal patterns axiomatic to exercise-induced laryngeal obstruction (EILO) and (2) investigate the role of autonomic function in EILO. METHODS Twenty-seven athletic adolescents (13 EILO, 14 control) underwent laryngoscopy at rest and exercise. Glottal configurations, supraglottic dynamics, systolic blood pressure responses, and heart rate recovery were compared between conditions and groups. RESULTS Inspiratory glottal angles were smaller in the EILO group than the control group with exercise. However, group differences were not statistically significant ( P > .05), likely due to high variability of laryngeal responses in the EILO group. Expiratory glottal patterns showed statistically greater abductory responses to exercise in the control group ( P = .001) but not the EILO group ( P > .05). Arytenoid prolapse occurred variably in both groups. Systolic blood pressure responses to exercise were higher in the control group, and heart rate recovery was faster in the EILO group. However, no significant differences were seen between the 2 groups on either autonomic parameter ( P > .05). CONCLUSIONS "Paradoxical" inspiratory and blunted expiratory vocal fold pattern responses to exercise best characterize EILO. Group differences were only seen with exercise challenge, thus highlighting the utility of provocation and control groups to identify EILO.
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Affiliation(s)
- Adrianna C Shembel
- 1 Department of Otolaryngology, NYU Langone Medical Center, Voice Center, New York, New York, USA.,2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA.,3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher J Hartnick
- 2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA
| | - Glenn Bunting
- 4 Massachusetts Eye and Ear, Voice and Speech Laboratory, Boston, Massachusetts, USA
| | - Catherine Ballif
- 4 Massachusetts Eye and Ear, Voice and Speech Laboratory, Boston, Massachusetts, USA
| | - Jessie Vanswearingen
- 3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Susan Shaiman
- 3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aaron Johnson
- 1 Department of Otolaryngology, NYU Langone Medical Center, Voice Center, New York, New York, USA
| | - Vanessa de Guzman
- 2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA
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Rathi VK, Naunheim MR, Varvares MA, Holmes K, Gagliano N, Hartnick CJ. The Merit-based Incentive Payment System (MIPS): A Primer for Otolaryngologists. Otolaryngol Head Neck Surg 2018; 159:410-413. [DOI: 10.1177/0194599818774033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Following passage of the 2015 Medicare Access and CHIP Reauthorization Act, most clinicians caring for Medicare Part B patients were required to participate in a new value-based reimbursement system known as the Merit-based Incentive Payment System (MIPS) beginning in 2017. The MIPS adjusts payment rates to providers based on a composite score of performance across 4 categories: quality, advancing care information, clinical practice improvement activities, and resource use. However, factors such as practice size, setting, informational capabilities, and patient population may pose challenges as otolaryngologists endeavor to adapt to this broad-reaching payment reform. Given potential barriers to adoption, otolaryngologists should be aware of several important initiatives to help optimize their performance, including advocacy efforts by the American Academy of Otolaryngology—Head and Neck Surgery, the development of otolaryngology-specific MIPS quality measures, and the launch of a Centers for Medicare & Medicaid Services–qualified otolaryngology clinical data registry to facilitate reporting.
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Affiliation(s)
- Vinay K. Rathi
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R. Naunheim
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark A. Varvares
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Nancy Gagliano
- Culbert Healthcare Solutions, Woburn, Massachusetts, USA
| | - Christopher J. Hartnick
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Kempfle JS, Diercks GR, Kinane TB, Skotko B, Keamy D, Hartnick CJ. 0769 Polysomnographic Analysis Of Post-stimulation Titration In Children With Down Syndrome And Hypoglossal Nerve Implant. Sleep 2018. [DOI: 10.1093/sleep/zsy061.768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J S Kempfle
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - G R Diercks
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - T B Kinane
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - B Skotko
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - D Keamy
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - C J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
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