Outcomes in Pediatric Transsphenoidal Pituitary Surgery Stratified by the Use of Image Guidance: An Analysis of the Kids' Inpatient Database from 1997 to 2016

Background  To evaluate the utilization of image guidance technology for pediatric transsphenoidal pituitary resection (TSPR) and analyze the complication rates, length of stay (LOS), and total cost for such surgeries as function of time and utilization of image guidance. Methods  The Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) was queried for all cases of TSPR between 1997 and 2016. Factors extracted included patient demographics, use of image guidance, LOS, total cost, and complications, including panhypopituitarism, diabetes insipidus (DI), cerebrospinal fluid (CSF) rhinorrhea, and cranial nerve (CN) III, IV, and VI palsies. Multivariate logistic regression was utilized to determine the odds ratio of developing panhypopituitarism, DI, CSF rhinorrhea, and CN palsies for image-guided versus nonimage-guided cases. A generalized linear model was used to determine the effect of image guidance on inflation-adjusted total cost and LOS. Results  A total of 1,297 cases of TSPR were included in the KID over this time period. The majority were female, Caucasian, and older than 15 years. Utilization of image guidance has rapidly increased since 2006. Complication rates were comparable, but when controlling for other factors, the use of image guidance showed a lower risk of postoperative DI ( p  = 0.05). The use of image guidance also resulted in a shorter LOS by 2.84 days ( p  < 0.001) with no associated increase in total cost ( p  = 0.663). Conclusion  The use of imaging guidance for pediatric TSPR has precipitously increased in recent years, as it is cost-effective, decreases LOS, and may lead to lower complication rates, such as DI.

Advanced practice providers and children's hospital-based pediatric otolarynology practices

INTRODUCTION

Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting.

METHODS

Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice.

RESULTS

A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale.

DISCUSSION

The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Protocol incorporating airway CT decreases negative bronchoscopy rates for suspected foreign bodies in pediatric patients

BACKGROUND

Foreign body aspiration (FBA) is the 4th leading cause of death in children between the ages 1-5. Although direct laryngoscopy and bronchoscopy (DL&B) is the reference standard for diagnosis of pediatric airway foreign bodies, there is a high negative bronchoscopy rate, exposing patients to unnecessary operative and anesthetic risks and costs.

METHODS

A clinical care protocol entailing the selective use of low-dose non-contrast airway computed tomography (CT) for children with an intermediate risk for FBA on the basis of clinical exam and chest radiography was implemented to decrease the negative DL&B rate. A retrospective review was conducted to compare negative bronchoscopy rates before and after implementation of the new protocol and the diagnostic performance characteristics of airway CT for airway foreign bodies were analyzed.

RESULTS

After implementation of the airway FB clinical care protocol entailing selective airway CT, the overall negative bronchoscopy rate decreased from an institutional historical rate of 37% (54/145) to 17% (10/56) (p = .06). The overall sensitivity, specificity, and positive and negative predictive value of airway CT for FB was 91%, 100%, 100%, and 97% respectively.

CONCLUSIONS

Low-dose non-contrast airway CT is highly sensitive and specific for airway foreign bodies, and its selective use in a clinical care protocol for children with suspected foreign body aspiration could greatly reduce the negative bronchoscopy rate, thereby decreasing operative risks and costs.

S265 – Tracheostomy in Bronchopulmonary Dysplasia

Objectives

To characterize pediatric patients undergoing tracheotomy for bronchopulmonary dysplasia (BPD). To examine the effects of tracheomalacia on tracheostomy outcomes in these patients.

Methods

The medical records of 95 patients with BPD who underwent tracheotomy in an academic tertiary care children's hospital over 8 years were evaluated for gestational age, birthweight, ethnicity, gender, co-morbid conditions, duration of ventilator support, duration of hospitalization, number of failed extubation attempts before tracheotomy, age at tracheotomy, and time to decannulation.

Results

The average gestational age was 28.9 weeks and the average postnatal age at tracheotomy was 27.6 weeks after having failed an average of 1.2 extubation attempts. The patients averaged 268.2 days of hospitalization, with 41.6% still requiring ventilator support and 57.1% still having tracheostomy at the end of the study. Of 27 patients with tracheomalacia, 4 (15%) were eventually decannulated vs. 36 of 68 patients without tracheomalacia (53%). The average time to decannulation among patients with tracheomalacia was 27.4 months and without tracheomalacia was 25.7 months. Decreased gestational age correlated with increased time to decannulation (Cox regression analysis, p=0.035). Of patients with genetic anomalies, 22.7% were eventually decannulated vs. 49.3% of patients without genetic anomalies (p = 0.027).

Conclusions

This study describes the characteristics of patients undergoing tracheotomy for BPD and begins to clarify the relationship between BPD and tracheomalacia. The presence of tracheomalacia in patients with BPD correlates with decreased likelihood of decannulation, but does not significantly affect time to decannulation. As such, tracheomalacia may be an independent risk factor for worse tracheostomy prognosis.

Pediatric lymphedema caused by diffuse cervical lymphadenopathy: A case report and review of the literature

Pediatric head and neck lymphedema is rare and there have not been any reported cases in children. Here we discuss severe, diffuse head and neck lymphedema in a child caused by compression of the internal jugular veins by lymphadenopathy from Kawasaki's disease. With steroid and intravenous immunoglobulin treatment, the lymphadenopathy improved and facial edema slowly resolved. In review of the literature, complications of head and neck lymphedema including airway obstruction and blindness are discussed. This case highlights the importance of the pediatric otolaryngologist considering lymphedema as a cause for facial swelling and monitoring for complications of lymphedema.

Intraorbital and intracranial extension of sinusitis: comparative morbidity

OBJECTIVES

We hypothesized that intracranial extension of sinusitis carries greater morbidity than extension confined to the orbit and that presenting features can raise suspicion for intracranial extension.

STUDY DESIGN

A retrospective review (1997 to 2006) identified 118 children with sinusitis complicated by intracranial extension or intraorbital extension. Presenting features and infecting organisms were compared using χ(2) or Fisher exact tests. Outcomes included duration of hospitalization, length of therapy and sequelae.

RESULTS

Thirty-three children had intracranial extension and 85 had intraorbital extension. Children with intracranial extension were older (11.4 versus 7.6 years; P ≤ .001), had more preadmission encounters (1.9 versus 1.3; P = .012), longer headache duration (9.5 versus 2.8 days; P = .009), and presented more often with vomiting (73% versus 28%; P < .001) than those with intraorbital extension. Children with intracranial extension also were hospitalized (26 versus 10 days; P < .001) and treated (36 versus 24 days; P = .001) longer. Four children (3%) had persistent sequelae.

CONCLUSIONS

Children with intracranial extension are hospitalized and treated longer than those with intraorbital extension of sinusitis but persistent sequelae are uncommon. Prolonged headache and protracted vomiting at presentation should alert caregivers to consider intracranial extension.

Multimodality imaging of tracheobronchial disorders in children

The trachea and bronchial airways in children are subject to compromise by a number of extrinsic and intrinsic conditions, including congenital, inflammatory, infectious, traumatic, and neoplastic processes. Stridor, wheezing, and respiratory distress are the most common indications for imaging of the airway in children. Frontal and lateral chest and/or neck radiography constitute the initial investigations of choice in most cases. Options for additional imaging include airway fluoroscopy, contrast esophagography, computed tomography (CT), and magnetic resonance (MR) imaging. Advanced imaging techniques such as dynamic airway CT, CT angiography, MR angiography, and cine MR imaging are valuable for providing relevant vascular and functional information in certain settings. Postprocessing techniques such as multiplanar reformatting, volume rendering, and virtual bronchoscopy assist in surgical planning by providing a better representation of three-dimensional anatomy. A systematic approach to imaging the airway based on clinical symptoms and signs is essential for the prompt, safe, and accurate diagnosis of tracheobronchial disorders in children.

Airway foreign bodies and brain abscesses: report of two cases and review of the literature

We report two cases of intracranial abscess in pediatric patients secondary to aspirated foreign bodies. Although foreign bodies are a significant cause of morbidity and mortality in the pediatric population, only four previous cases have been reported that resulted in a brain abscess. Our patients presented with neurological symptoms, and both were found to have a sharp foreign body in the bronchus. Both had brain abscesses caused by bacteria that normally colonize the aerodigestive tract with no other source of bacterial foci. When respiratory flora are isolated from brain abscesses in the absence of other possible sources, intrabronchial foreign body should be considered in evaluation of the etiology.

Opening plugged tympanostomy tubes

OBJECTIVE

To determine the most effective solvents for dissolving plugged tympanostomy tubes.

STUDY DESIGN

In vitro laboratory study.

METHODS

Twelve solvents (including ototopical antibiotics and water) were applied to fluoroplastic tympanostomy tubes (n = 260) plugged with dried mucoid middle ear effusion in an ear canal-tympanic membrane model. Time to clearance of the tympanostomy tubes was both visually and tympanometrically determined.

RESULTS

Vinegar (P =.0030) and hyaluronidase solutions (P =.0030) were significantly better solvents than water.

CONCLUSION

Vinegar and hyaluronidase solutions are more likely to clear plugged tympanostomy tubes than water and ototopical antibiotics, but vinegar is the preferred solution because of its known relative safety for use in the ear.

Defining tympanostomy tube plugs

OBJECTIVES

To define the composition of tympanostomy tube plugs because selecting or developing effective solvents depends on such knowledge.

STUDY DESIGN

Prospective, in vitro laboratory study.

METHODS

Luminal contents of 105 plugged, microscopically removed tympanostomy tubes were expressed, pooled, acid hydrolyzed, and passed through a high-performance liquid chromatography column. Retention times were compared with high-performance liquid chromatography standards to develop free amino acid and monosaccharide profiles. Cerumen, blood, and chronic mucoid effusion (collected during myringotomy) were pooled and subjected to the same analysis. The elution profiles of each substance were compared to determine which substance most closely matched the plugs.

RESULTS

High-performance liquid chromatography amino acid and monosaccharide analysis demonstrated greatest similarity between tympanostomy tube plugs and mucoid effusion.

CONCLUSIONS

Tympanostomy tube plug composition is more similar to mucoid effusion than to blood or cerumen. Solvents to open plugged tympanostomy tubes should be directed against the components of mucoid effusion.

Ocular motility complications after endoscopic sinus surgery with powered cutting instruments

OBJECTIVE

The purpose of this study was to describe 2 unique cases of ocular motility dysfunction after powered endoscopic sinus surgery and identify potential risk factors for extraocular muscle injury.

STUDY DESIGN

Interventional case series.

RESULTS

Patient 1 developed a restrictive global ophthalmoplegia after inadvertent entry into the medial orbit during powered endoscopic sinus surgery. Patient 2 had complete loss of adduction of the left eye as a result of transection of the medial rectus muscle by a powered cutting instrument.

CONCLUSIONS

Despite advances in endoscopic sinus surgery technique and instrumentation, serious ophthalmic complications may still occur. Inadvertent entry into the medial orbital wall can result in ocular motility complications. Furthermore, it is possible that attraction of orbital contents into the tip of a powered cutting instrument may occur without significant entry into the orbital cavity.

SIGNIFICANCE

It is important for endoscopic sinus surgeons to be aware of the intimate anatomical relationship between the orbit and sinuses, as well as the potential risks of the current instruments used in endoscopic sinus surgery.

Impact of resistant pneumococcus on rates of acute mastoiditis

OBJECTIVE

To determine whether the rate of acute mastoiditis is rising, specifically as a result of antibiotic-resistant strains of Streptococcus pneumoniae.

METHODS

A retrospective chart review of all patients with a discharge diagnosis of acute mastoiditis between July 1, 1987, and June 30, 1997, was performed at our academic, tertiary-care medical center. There were no interventions, and the main outcome measures included the number of cases of acute or coalescent mastoiditis, stratified by pathogen, per year.

RESULTS

The rate of acute mastoiditis as a proportion of yearly otorhinolaryngology admissions increased linearly over time (P = 0. 024). Pneumococcal-related rates of acute mastoiditis, expressed as a proportion of yearly hospital and otorhinolaryngology admissions, increased linearly over time (P = 0.002, P = 0.002). All but 1 case of pneumococcal mastoiditis during the past 3 years were caused by penicillin-resistant strains.

CONCLUSIONS

The emergence of antibiotic-resistant S pneumoniae may be responsible for an increasing rate of acute mastoiditis.

Intracranial complications of sinusitis

Intracranial suppurative complications of sinusitis remain a challenging and contemporary topic. To determine the prevalence of sinogenic sources in intracranial infectious complications, we reviewed the records at a large public hospital between 1985 and 1995. There were 203 patients with 212 suppurative intracranial infections. Sinogenic sources were identified in 12 patients with 19 infections. Most patients had ethmoid or frontal sinusitis. We discuss the presentation, microbiology, diagnosis, treatment, and clinical course of these 12 cases. The diagnosis of intracranial complications of sinusitis requires a high index of suspicion and radiographic imaging of the head and paranasal sinuses. The mean hospital stay was 31.4 days and all 12 patients survived, although three patients had significant neurologic sequelae.