Documentation in Pediatric Microlaryngoscopy/Bronchoscopy: International Modified Delphi Consensus

BACKGROUND

Complete and accurate documentation of surgical procedures is essential for optimizing patient care, yet significant variation in operative notes persists within and across institutions. We sought to reach consensus on the most important components of an operative note for pediatric microlaryngoscopy and bronchoscopy.

METHODS

A modified Delphi consensus process was used. A checklist for operative documentation, created by fellowship-trained pediatric otolaryngologists-head and neck surgeons, was sent to surgeons identified as experts in pediatric laryngoscopy and bronchoscopy. In the first round, items were rated as "keep" or "remove". In the second round, each item was rated on a 7-point Likert scale for importance. The mean score of each item was calculated to determine if consensus was reached.

RESULTS

Overall, 43/74 (58.1%) surgeons responded to our survey. After two rounds of editing, 28 components reached consensus, 24 were near consensus, and 26 did not reach consensus. Items that reached final consensus had mean (SD) ratings of 6.12 (0.94) (range, 5.31-6.72).

CONCLUSION

Pediatric otolaryngologists identified as bronchoscopy experts were able to create a checklist of essential components of an operative note for pediatric laryngoscopy and bronchoscopy using a Delphi method. Items reaching consensus included procedure name, description of breathing, grade of airway view, description of normal anatomic structures, grade of subglottic stenosis if present, presence and description of tracheobronchomalacia, presence of fistulae, cleft and rings, and several special cases including foreign body and tracheostomy management, as well as end of procedure disposition and complications.

LEVEL OF EVIDENCE

5 Laryngoscope, 2022.

Anticholinergic treatment for sialorrhea in children: A systematic review

Background

Sialorrhea in children can be associated with adverse physical and social effects. Treatment using anticholinergic medications has been shown to offer symptomatic relief, but there is no consensus regarding which treatment is the most efficacious.

Objective

To examine the effectiveness of anticholinergic medications for sialorrhea in children.

Methods

A systematic review was carried out in Medline, EMBASE, Cochrane, Scopus, and the Web of Science from inception until April 29, 2020. Studies reporting original data on the efficacy of anticholinergic medications in the management of sialorrhea in children aged 0 to 17 years of age were included. This review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. Data on study design, setting, population, pharmacologic intervention(s), comparator(s), outcomes, and results were extracted and summarized.

Results

The search strategy identified 2,800 studies of which 27 articles were included in the synthesis, including five randomized controlled trials. Each anticholinergic undergoing experimental study (glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine) showed evidence of efficacy. Adverse side effects were common. Significant heterogeneity exists in the studies' methodology and the variability of outcome measures used between studies precluded a meta-analysis.

Conclusions

Glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine have all shown efficacy in the treatment of sialorrhea in children. The small number of reports and the variability in study design precluded a meta-analysis. More studies are needed with uniformity in outcome measures to help guide evidence-based decision making. A guidance table is presented.

Overprescription of opioid analgesia is common following ambulatory Otolaryngology—Head and Neck surgery procedures: A multicenter study

Background

The rise in the use of prescription opioids for postoperative analgesia within surgery has mirrored an increased trend of opioid‐related morbidity within Canada and the United States. This study prospectively studied daily pain levels and medication requirements postoperatively in patients undergoing elective Otolaryngology—Head and Neck surgery procedures.

Methods

Patients were asked to prospectively document their pain level and medication use daily for 7 days postoperatively. A final survey was used to quantify unused medication left at home and clarify each patient's disposal plan. We included patients undergoing elective outpatient or short stay surgeries from three tertiary care centers in Toronto, Ontario from September 2016 to September 2017. Previous opioids users or patients suffering from chronic pain were excluded.

Results

A final cohort of 56 eligible adult patients were included in the study. The most common procedures were thyroidectomy (n = 19), endoscopic sinus surgery (n = 10), tympanoplasty/ossiculoplasty (n = 7), and cochlear implant (n = 5). Most patients received a prescription for acetaminophen/codeine (n = 29, 51.8%) or acetaminophen/oxycodone (n = 22, 39.3%) and used on average 29% of their initial prescription. Patients most commonly opted to keep their unused narcotics at home (n = 23, 41%). A total of 710 tablets of narcotics were overprescribed in our study population, 351 of which were kept in patients' home for future use.

Conclusion

There is a clear tendency to overestimate postoperative pain resulting in significant overprescription of opioids among Otolaryngologists.

Surgeons tend to overestimate post‐operative opioid analgesic requirements, leading to over‐prescription.

Less than half of the 56 participants in this study used non‐opioid analgesia during their post‐operative course, indicating a lack of counselling.

Most commonly, patients elected to keep unused opioids at home for future use – a known risk factor for opioid diversion.

Changes to the practice of pediatric otolaryngology as a consequence of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has shifted medical practice globally. The objective of this study was to examine the changes to the practice of pediatric otolaryngology internationally due to the COVID-19 pandemic and examine potential contributors.

METHOD

An online survey was designed to assess practice demographics, patterns of COVID-19 related restrictions in communities, and changes to practice and referrals. This was disseminated via an international Covid-19 WhatsApp™ group of pediatric otolaryngologists.

RESULTS

There were 45 respondents of 177 group members (25.4%) from 15 countries. The mean estimated time spent under strictest lockdown measures was 16.2 (±10.7) weeks (range: 1-45 weeks). Operating room time was reduced for 82.9%, with an average reported reduction of 41.5%. Almost all (>75%) of respondents reported reduced referrals for five common conditions: otitis media with effusion (average reported decrease - 56.1%); acute otitis media (average decrease 62.8%); acute mastoiditis (average decrease 66.6%); recurrent pharyngotonsillitis (average decrease 51.0%); and peritonsillar abscess (average decrease 52.1%). COVID-19 cases per million population significantly influenced the acuity of referrals received (p < .05). No conditions were reported as increased in frequency and the acuity of most conditions was reported as unchanged by the majority of respondents.

CONCLUSION

The measures taken to reduce the spread of COVID-19 have resulted in many changes to pediatric otolaryngology practice and the referral patterns of common conditions. Some of these changes may have enduring sequelae.

149 Virtual Care: A Quality Improvement Project on the Experience of Paediatricians during the COVID-19 Pandemic

Primary Subject area

Practice/Office Management

Background

Prior to the COVID-19 pandemic, in-person visits were the standard of care for paediatricians at our centre. With the pandemic onset, virtual care (VC) was adopted at an unprecedented scale and pace. Studies have reported positive patient VC experience; however, few have explored physician experience. This quality improvement (QI) initiative sought to qualify the VC experience of local paediatricians during the pandemic, with the intention of implementing VC clinical practice changes at the department level.

Objectives

To determine key factors that have supported and challenged the adoption of, and that will support integration of, VC in the future.

Design/Methods

The Donabedian model for healthcare QI was used to evaluate VC experience through an online survey with a focus on structure, process, and outcome measures. All physicians affiliated with the Department of Paediatrics (generalists and subspecialists in medicine and surgery) were invited to participate via email. Three reminder emails were sent at 2-week intervals. Descriptive statistics were reported.

Results

The response rate was 32.3% (63 of 195 physicians). The majority of respondents were subspecialists (84.1%), and at academic centres (87.5%) (Table 1). Pre-pandemic, only 30.1% used VC and saw &lt;10% of patients virtually. During March-May 2020, 93.8% transitioned to VC, with &gt; 50% seeing over 75% of patients virtually. By summer 2020, VC use declined, but remained higher than pre-pandemic (53.6% seeing &lt; 25% of patients). OTN and telephone were platforms most used (32.8% and 28.6%, respectively). Most conducted visits from their work location (55.2%) versus home (44.8%).

VC experience was considered positive by most physicians (73.6%), and only 18.8% found VC difficult to use despite technical difficulties reported by 41.5% (Figure 1). Physicians with ≤ 5 years in practice were most likely to find VC convenient (93.8%). Challenges with VC included lack of physical exam, diagnostic uncertainty, lower patient volumes, and poor patient VC etiquette. Regardless of practice location, specialty, years in practice, and prior experience, 96% would continue VC to 25% of patients, ideally for patients who live far away (26.4%) and for follow-ups of patients with established diagnoses (21.4%).

Conclusion

A rapid transition to VC during the COVID-19 pandemic was associated with challenges but also positive experiences. Willingness to continue VC was high. VC experience could be improved with greater patient education and focus on select patient populations. Future research is needed to improve practice efficiency and to inform regulatory guidelines for VC at a local level.

Choosing Wisely Canada - pediatric otolaryngology recommendations

The Choosing Wisely Canada campaign raises awareness amongst physicians and patients regarding unnecessary or inappropriate tests and treatments. Using an online survey, members of the Pediatric Otolaryngology Subspecialty Group within the Canadian Society of Otolaryngology – Head & Neck Surgery developed a list of nine evidence based recommendations to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations: (1) Don’t routinely order a plain film x-ray in the evaluation of nasal fractures; (2) Don’t order imaging to distinguish acute bacterial sinusitis from an upper respiratory infection; (3) Don’t place tympanostomy tubes in most children for a single episode of otitis media with effusion of less than 3 months duration; (4) Don’t routinely prescribe intranasal/systemic steroids, antihistamines or decongestants for children with uncomplicated otitis media with effusion; (5) Don’t prescribe oral antibiotics for children with uncomplicated tympanostomy tube otorrhea or uncomplicated acute otitis externa; (6) Don’t prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children; (7) Don’t administer perioperative antibiotics for elective tonsillectomy in children; (8) Don’t perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years; and (9) Don’t perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy.

Rapid standardized operating rooms (RAPSTOR) in thyroid and parathyroid surgery

OBJECTIVE

To evaluate the impact of a high efficiency rapid standardized OR (RAPSTOR) for hemithyroid/parathyroid surgery using standardized equipment sets (SES) and consecutive case scheduling (CCS) on turnover times (TOT), average case volumes, patient outcomes, hospital costs and OR efficiency/stress.

METHODS

Patients requiring hemithyroidectomy (primary or completion) or unilateral parathyroidectomy in a single surgeon's practice were scheduled consecutively with SES. Retrospective control groups were classified as sequential (CS) or non-sequential (CNS). A survey regarding OR efficiency/stress was administered. Phenomenography and descriptive statistics were conducted for time points, cost and patient outcome variables. Hospital cost minimization analysis was performed.

RESULTS

The mean TOT of RAPSTOR procedures (16 min; n = 27) was not significantly different than CS (14 min, n = 14) or CNS (17 min, n = 6). Mean case number per hour was significantly increased in RAPSTOR (1.2) compared to both CS (0.9; p < 0.05) and CNS (0.7; p < 0.05). Average operative time was significantly reduced in RAPSTOR (32 min; n = 28) compared to CNS (48 min; p < 0.05) but not CS (33 min; p = 0.06). Time to discharge was reduced in RAPSTOR (595 min) compared to CNS (1210 min, p < 0.05). There was no difference in complication rate between all groups (p = 0.27). Survey responses suggested improved efficiency, teamwork and workflow. Furthermore, there is associated decrease in direct operative costs for RAPSTOR vs. CS.

CONCLUSION

A high efficiency standardized OR for hemithyroid and parathyroid surgery using SES and CCS is associated with improved efficiency and, in this study, led to increased capacity at reduced cost without compromising patient safety.

LEVEL OF EVIDENCE

Level 2.

Quality indicators for the diagnosis and management of pediatric tonsillitis

INTRODUCTION

Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options.

METHODS

A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology - head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology.

RESULTS

Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care.

CONCLUSIONS

This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

International Pediatric Otolaryngology Group (IPOG): Juvenile-onset recurrent respiratory papillomatosis consensus recommendations

OBJECTIVES

To develop consensus recommendations for the evaluation and management of juvenile-onset recurrent respiratory papillomatosis (JORRP) in pediatric patients.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.

RESULTS

Consensus recommendations including diagnostic considerations, surgical management, systemic adjuvant therapies, postoperative management, surveillance, and voice evaluation. These recommendations are based on the collective opinion of the IPOG members and are targeted for otolaryngologists, primary care providers, pulmonologists, infectious disease specialists, and any other health care providers that manage patients with JORRP.

CONCLUSIONS

Pediatric JORRP consensus recommendations are aimed at improving care and outcomes in this patient population.

Opioid prescribing practices following elective surgery in Otolaryngology-Head & Neck Surgery

BACKGROUND

Prescription opioid abuse has become a major issue across the world and especially in North America. Canada has the second highest number of opioid prescriptions per capita in the world, second only to the United States, with numbers continuing to rise in recent years. Surgeons play a critical role in this discussion as they are responsible for the management of post-operative pain in their patients. The objective of this study is to evaluate the opioid prescribing practices of Otolaryngologists-Head and Neck Surgeons in Canada and determine factors that may influence these practices.

METHODS

The online survey was distributed to members of the Canadian Society of Otolaryngology-Head and Neck Surgery. Questions surveyed the respondents' demographics and opioid prescribing practices for common pediatric and adult elective surgeries.

RESULTS

The survey was sent to 670 surgeons and trainees and 121 responses were received (18%). There was representation across all subspecialties with a mix of community and academic surgeons. The most commonly prescribed opioid was Codeine/Acetaminophen, 48.2% (n = 53), in the adult population, and Morphine, 47.1% (n = 41), in the pediatric population. The median total oral morphine equivalents prescribed across all adult surgeries was 123.75 mg (24.75 doses). The surgery with the highest oral morphine equivalents prescribed was tonsillectomy/adenoidectomy for both adult and pediatric patients, with a median of 150 mg (30 doses) for adults and 4.5 mg/kg (23 doses) for pediatrics. Gender, training years, year in residency, or reported level of conservatism did not predict the dose prescribed to either adult or pediatric patients. Due to the relatively low response rate, the generalizability of these results is unclear.

CONCLUSIONS

Our study demonstrates a wide variability in opioid prescriptions across procedures and within each individual procedure. This variability reflects the lack of guidelines available for post-operative opioid prescribing and suggests that some Otolaryngologists may be prescribing higher doses of opioids than required. Opportunities for improving patient safety and resource stewardship regarding optimal prescribing practices should be explored.

International Pediatric ORL Group (IPOG) laryngomalacia consensus recommendations

OBJECTIVE

To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG).

RESULTS

Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy.

CONCLUSION

Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

Relationship between sputum eosinophilia and sinus disease in patients with eosinophilic bronchitis

BACKGROUND

Sinus disease is commonly seen in patients with asthma, and several studies have been published describing the relationship between sinus disease and the inflammation seen in the sputum of asthmatic subjects. In this article, we expand on this knowledge by studying patients with eosinophilic bronchitis with and without asthma.

METHODS

We describe the relationship between the severity of sinus disease determined by the Lund-Mackay score and sputum eosinophilia. Comparisons with blood eosinophil and total immunoglobulin (IgE) measurements are made.

RESULTS

We have shown that the severity of sinus disease is positively correlated with sputum eosinophil counts, and the site of sinus disease affected the level of eosinophilia. There was a positive correlation between sputum eosinophils and blood eosinophils, but there was no relationship with blood total IgE levels.

CONCLUSIONS

We have confirmed that there is a link between upper and lower airway inflammation and that this is not limited to patients with asthma. The process is associated with systemic inflammation as evidenced by increased blood eosinophils but appears to be independent of IgE.

Sialendoscopy for the management of juvenile recurrent parotitis: a systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness and safety of sialendoscopy for the treatment of juvenile recurrent parotitis (JRP). The study was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

A comprehensive search strategy in MEDLINE, EMBASE, the Cochrane library, and Google Scholar was completed and limited to studies published in English. Relevant reference lists were reviewed.

STUDY SELECTION

Two independent reviewers selected prospective or retrospective studies of pediatric patients treated with interventional sialendoscopy for the management of JRP. Outcome measures included rates of successful treatment (no further episodes of parotid swelling or need for further sialendoscopy) and complications,

DATA EXTRACTION

Two reviewers appraised the level of evidence using the Oxford Clinical Evidence-based Medicine (OCEBM) guidelines, extracted data, and resolved discrepancies by consensus. Weighted pooled proportion, 95% confidence interval (CI), and test results for heterogeneity and publication bias are reported.

RESULTS

Seven studies were included. Levels of evidence varied from OCEBM level 3 to 4. The weighted pooled proportion of success rates for no further episodes by patient (n = 120) was 73% (95% CI: 64%-82%) and by gland (n = 165) 81% (95% CI: 75%-87%). The weighted pooled proportion of success rates for no further sialendoscopy by patient was 87% (95% CI: 81%-93%). Heterogeneity was low, and publication bias was not detected. There were no major complications reported. Surgical techniques and endoscopic findings are summarized.

CONCLUSIONS

The results from this analysis suggest that sialendoscopy is effective and safe for the treatment of JRP and may be offered to appropriate patients.

LEVEL OF EVIDENCE

NA

YouTube as a Source of Pediatric Tonsillectomy Information

Objective: Tonsillectomy is a common surgery performed on pediatric patients. Patients and their caregivers may search the Internet for information related to this procedure, and YouTube is a popular Web site that they may consult. We investigated YouTube as an information source on pediatric tonsillectomy.

Method: YouTube was searched on February 17, 2012, for videos containing relevant information about tonsillectomies in pediatric patients using the keywords pediatric tonsillectomy, tonsillectomy and tonsil surgery. Non-English videos were excluded. Two physician reviewers watched each video and assessed for content (useful, misleading, personal experience). The StatsDirect software will analyze measures.

Results: The search for each keyword identified over 2555 videos (pediatric tonsillectomy = 91, tonsillectomy = about 1800, tonsil surgery = 664). The first 200 videos were screened for each keyword on the assumption that most users would not go beyond the first 10 pages. Therefore, 491 videos were screened for inclusion and exclusion criteria, and duplicates were removed. At the time of abstract submission, final data analysis was not yet available. Outcomes included content assessment and characteristics, and video total viewership, number of days since upload, total duration, viewer rating, and source of upload. Reviewer degree of agreement and relevant statistical analysis will be reported.

Conclusion: YouTube has a substantial number of videos on pediatric tonsillectomy with a variety of content ranging from useful to misleading. Health care professionals must recognize the potential influence that these user-generated video Web sites may have on the attitudes of patients and their caregivers.

Purely endoscopic transsphenoidal surgery versus traditional microsurgery for resection of pituitary adenomas: systematic review

OBJECTIVE

To determine, in a systematic review, whether purely endoscopic transsphenoidal resection of pituitary adenomas offers improved outcomes and decreased complications compared to the traditional microscopic approach.

DESIGN

Systematic review.

SETTING

The literature was searched using Medline, EMBASE, and the Cochrane Library (inception to October 2009) by two independent review authors.

METHODS

Studies were included if they compared the two surgical approaches for the management of pituitary adenomas and at least one main outcome measure.

MAIN OUTCOME MEASURES

Gross tumour resection (GTR), recurrence, visual field improvement, hormone resolution, mean blood loss, mean operative time, mean hospital length of stay, cerebrospinal fluid (CSF) leak, hormone deterioration, vision deterioration, nasal complications, meningitis, and death.

RESULTS

Ten studies met the inclusion criteria (one prospective and nine retrospective) and involved 687 patients. The purely endoscopic approach was associated with less mean blood loss, shorter hospital stays and operative times, and fewer nasal complications. There was also a trend toward better GTR and decreased incidence of postoperative diabetes insipidus. However, a higher incidence of postoperative CSF leak was also noted with the endoscopic approach. Other outcomes and complication rates appeared to be similar between the two groups.

CONCLUSIONS

Purely endoscopic transsphenoidal resection of pituitary adenomas seems to be safe and efficacious when compared to the traditional microscopic approach and may offer some benefit.