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Presidential keynote address and new research highlights from the American Society of Pediatric Otolaryngology meeting

San Diego, CA - The American Society of Pediatric Otolaryngology (ASPO) will hold its annual meeting, April 18 April 22, during the 2012 Combined Otolaryngology Spring Meetings (COSM) - a joint meeting of eight otolaryngological societies in San Diego, CA.

During the ASPO meeting, hundreds of pieces of new research and dozens of scientific sessions featuring expert panelists will be presented focusing on children's ear, nose, and throat health. National health statistics reveal that pediatric ear, nose, and throat disorders remain among the primary reasons children visit a physician, with ear infections ranking as the number one reason for an appointment. All sessions are embargoed until date and time of presentation. Here are some of the lectures and sessions that will be unveiled during the meeting:

Presidential Keynote Lecture - Variation in Practice - Unwarranted Interference or Personalized Medicine?
Speaker: Martin Burton, MD
Date: Friday, April 20, 2012
Time: 1:10 1:55pm

San Diego, CA Martin Burton, MD, Director of the United Kingdom Cochrane Centre, the unit responsible for supporting the activities Cochrane contributors in the UK, Ireland and the Middle East will give the Presidential Keynote Lecture, "Variation in Practice - Unwarranted Interference or Personalized Medicine?" at the American Society of Pediatric Otolaryngology annual meeting in San Diego, CA.

Dr. Burton is a Consultant Otolaryngologist at the Oxford University Hospitals NHS Trust, based at the John Radcliffe Hospital in Oxford, and also Senior Clinical Lecturer at the University of Oxford and Lecturer in Clinical Medicine at Balliol College. He was the founding coordinating editor of the Cochrane Ear, Nose & Throat Disorders Group ( and Clinical Lead of the ENT & Audiology Library of the UK's National Library for Health.

He trained as a medical student at Cambridge and Oxford Universities and did his early clinical training in Oxford and Bristol. He was a Fulbright Scholar and undertook research training at the Kresge Hearing Research Institute at the University of Michigan. Following a period as lecturer in otolaryngology at the University of Melbourne, he completed his doctoral thesis on the safety of cochlear implantation in small children. His higher surgical training was completed in London and as Fellow in otology, neurotology & skull base surgery at Johns Hopkins University in Baltimore, MD (USA).

His clinical practice is otological - particularly middle ear surgery, tinnitus and balance disorders. He is interested in the application of evidence (and wisdom) based medicine in otolaryngology and in otolaryngological epistemology and heuristics.

Systematic Review on Dilatation as Primary Therapy for Pediatric Laryngotracheal Stenosis
Speaker: Kristelle Chueng, MD
Date: Friday, April 20, 2012
Time: 1:55 2:02pm

San Diego, CA Balloon catheters are more effective than rigid dilators and are more effective as primary therapy for laryngotracheal stenosis (LTS) in pediatric patients.

Study results show balloon dilatation alone (4 studies, n=8) and with adjuvant therapy (7 studies, n=37), success rates were 50% and 76%, respectively. In studies using rigid dilatation alone (5 studies, n=80) and with adjuvant therapy (5 studies, n=108), success rates were 56% and 60%, respectively. Treatment algorithms based on level, type and grade of LTS were proposed.

Two independent reviewers selected original studies on primary dilatation therapy for LTS in patients younger than 18 years old. Studies on tracheobronchial stenosis or stents for tracheomalacia were excluded. Study results show, 25 of 340 identified studies (7%) met the inclusion criteria.

While examining the data, two reviewers independently appraised the level of evidence of each study, using the Oxford Clinical Evidence-Based Medicine guidelines, and extracted raw data using a standardized form developed a priori.

Overall, the data synthesis revealed the patient population consisted of grades I to III and rarely grade IV LTS. Some studies used adjuvant therapy including laser or topical agents. The outcomes of success were achievement of a functional airway or decannulation without open surgery.

Children with Sensorineural Hearing Loss after Passing Newborn Hearing Screen
Speaker: Kavita Dedhia, MD
Date: Friday, April 20, 2012
Time: 2:25 2:32pm

San Diego, CA In 2000, 921 children who passed their newborn hearing screen (NHS) test were subsequently found to have childhood hearing loss.

"This is the largest study to characterize children with hearing loss that passed NHS. In our review parental concerns and school screening were the most common method of diagnosis hearing loss after passing NHS," said study author Kavita Dedhia, MD. "Families and primary care physicians may have a false sense of security when patients pass NHS and overlook symptoms of hearing loss. This study raises the question whether further screens would identify hearing loss in children after passing the NHS."

Seventy-seven patients were included in our study. The diagnosis of hearing loss in patients who passed the NHS was most often from parental concerns (35%) and failed school screenings (31%). Speech/language delay and failed PCP screening accounted for 18% and 12% respectively. Laterality was bilateral symmetric (53%), bilateral asymmetric (21%) and unilateral (26%) loss. Forty-eight percent of patients had severe or profound hearing loss. The etiology was unknown in 55% of the cohorts; the remaining was attributed to structural abnormality (14%), genetics (14%), acquired perinatal (12%), and auditory neuropathy (5%).

The study methods highlighted patients that were retrieved from an Institutional Review Board approved database. We identified 921 children with hearing loss from 2000 to present. Patients who passed NHS with subsequent hearing loss were included.

Perioperative Dexamethasone and The Risk of Bleeding in Pediatric Tonsillectomy: A Prospective, Randomized, Double Blind Trial
Speaker: Thomas Gallagher, DO
Date: Saturday, April 21, 2012
Time: 8:00 8:07am

San Diego, CA One-time perioperative dexamethasone administration prior to tonsillectomy is equivalent to saline placebo with regards to risk of post-operative bleeding in the pediatric population.

"The purpose of this study was to determine if perioperative dexamethasone affected the post-tonsillectomy hemorrhage rate in children," said study author Thomas Gallagher, DO.

This was a multicenter, prospective, randomized, double-blind, placebo-controlled study of 306 patients ages 3-18 undergoing tonsillectomy for either obstructive sleep apnea or recurrent tonsillitis. The chief outcome measure was defined as whether or not there was bleeding in the post-operative period significant enough to return to the operating room for control. A non-inferiority statistical design was chosen in order to demonstrate whether dexamethasone has equivalent bleeding rates compared with placebo. The non-inferiority margin was set at 5% based on a review of the literature as well as in accordance with our historical tonsillectomy bleeding rate. The study group received a one-time, perioperative dose of dexamethasone 0.5mg/kg (max 20mg). The placebo group received volume equivalent 0.9% saline. The post-operative time period was 14 days. All investigators performed tonsillectomy in a standardized fashion using electrocautery on similar power settings.

The summary of results show post-operative bleeding was stratified into three levels of severity. There were 153 children enrolled in each arm. The mean age of the children enrolled was 6 years with a standard deviation of 3.4. Overall, there were 5 level 3 bleeds (return to operating room). We found the difference in post-operative hemorrhage rates between the two arms to be less than the non-inferiority margin.

Risk Factors for Pediatric Post-Tonsillectomy Hemorrhage
Speaker: Zorik Spektor, MD
Date: Saturday, April 21, 2012
Time: 8:07 8:14am

San Diego, CA The risk of post-tonsillectomy hemorrhage is significantly increased in older children and those with recurrent tonsillitis, obesity and ADHD.

"The main objective of the study was to determine significant pre-operative risk factors for post-tonsillectomy secondary hemorrhage in children, and quantify the magnitude of their risk," said Zorik Spektor, MD.

All of our pediatric tonsillectomy patients experiencing post-operative bleeding from 2005-2010 were identified. The 91 cases were matched with 151 controls that underwent tonsillectomy by the same surgeon on the same day as an identified case. All charts were reviewed, and 41 pre-operative variables were extracted and statistically analyzed.

In the study results, four significant predictors of post-operative bleeding were identified. Performing a tonsillectomy on a child with recurrent tonsillitis (vs. other indications) increased the risk of post-operative hemorrhage by 4.5 times (p<0.0001, 95% confidence intervals 2.41-8.38). Performing a tonsillectomy on a child with attention deficit hyperactivity disorder (ADHD) increased the risk by 8.7 times (p=0.029, 95%CI 1.4-53.6), and obese children increased their bleeding risk by 2.5 times (p=0.044, 95%CI 1.000649-6.76). Older children were more predisposed to post-operative bleeding. For every increase in age by one year, the hemorrhage risk increased by 1.1 times (p=0.0025, 95%CI 1.032-1.162). Children 11 years of age and older had double the risk of bleeding compared to younger children (odds ratio 1.98, p=0.0381, 95%CI 1.04-3.79). None of the remaining 37 variables showed significant differences between cases and controls.

Is Tonsillectomy A Risk Factor for Childhood Obesity?
Speaker: Jessica Levi, MD
Date: Saturday, April 21, 2012
Time: 8:14 8:21am

San Diego, CA Children, particularly younger ones, gain weight after tonsillectomy but the odds of a child being overweight or obese after tonsillectomy was no different than before surgery.

Research methods were carried out on 200 children ages 2-12 undergoing tonsillectomy. All children had a pre-operative body mass index (BMI) recorded and a post-operative BMI recorded 6-18 months after surgery. Two hundred age and gender matched controls were selected for comparison. The Body mass index percentile for age (BMI %) was analyzed between and within groups. A Wilcoxon matched-pairs test was used to analyze BMI% pre and post tonsillectomy, and a Mann-Whitney test was used to compare BMI% between the study and control groups. An odds ratio was used to compare overweight (85%) and obese (95%) patients pre and post-operatively. A correlation analysis was used to examine the relationship between age and weight gain.

Study results concluded the BMI% between the study and control groups did not differ significantly prior to tonsillectomy (p = 0.1380). The BMI% in the study group increased significantly post tonsillectomy (p < 0.0001). Although they had a higher BMI% pre-operatively than age matched controls, older children had a smaller change in BMI% after tonsillectomy than younger children (p=0.0042). The odds of a child being overweight (85%) (Odds ratio= 1.226; p=0.3641) or obese (95%) (Odds ratio= 1.439; p= 0.1237) was not significantly different before or after tonsillectomy.

Effect of Obesity and Medical Comorbidities on Polysomnographic Outcomes After Adjunct Surgery in Adenotonsillectomy Failures
Speaker: Dylan Chan, MD
Date: Saturday, April 21, 2012
Time: 11:00 11:07am

San Diego, CA Lingual tonsillar hypertrophy and occult laryngomalacia are two important causes of residual obstructive sleep apnea syndrome (OSAS) after adenotonsillectomy.

"The goal of this research study was to evaluate the effect of obesity and medical comorbidities on outcomes after lingual tonsillectomy and supraglottoplasty performed for obstructive sleep apnea syndrome (OSAS) caused by lingual tonsillar hypertrophy and occult laryngomalacia," said Dylan Chan, MD.

Study results 82 children with persistent OSAS after adenotonsillectomy who underwent either lingual tonsillectomy (N = 58), supraglottoplasty (N = 16) or both (N = 8). Compared to children with lingual tonsillar hypertrophy, children with occult laryngomalacia were younger, half as likely to be obese, and twice as likely to have a medical comorbidity. Overall, both operations significantly improved the apnea-hypopnea index (AHI); however, children with comorbidities had significantly higher post-operative AHI after supraglottoplasty than those without, and obese children had significantly higher post-operative AHI after lingual tonsillectomy than those of normal weight. Post-operative AHI had a direct, though weak correlation with BMI among children undergoing lingual tonsillectomy. In contrast, comorbidities and obesity had no statistically significant effect on outcomes after lingual tonsillectomy and supraglottoplasty, respectively.

In conclusion, Lingual tonsillar hypertrophy and occult laryngomalacia are two important causes of residual OSAS after adenotonsillectomy. However, they tend to affect distinct populations of children, and though appropriate surgical correction can improve AHI, cure rates are significantly worse for obese children undergoing lingual tonsillectomy and for children with medical comorbidities undergoing supraglottoplasty.

Obstructive Sleep Apnea, Behavioral Problems and Quality of Life in Children
Speaker: Manasa Tripuraneni, BA
Date: Saturday, April 21, 2012
Time: 11:14 11:21am

San Diego, CA The degree of obesity does not predict obstructive sleep apnea (OSA) severity in children. Obese children have worse OSA, behavioral problems and quality of life than normal weight children. In normal weight children with a sleep disturbance behavioral and quality of life scores are similar regardless of the severity of the sleep disorder.

Seventy-three patients were included in the study. Thirty-five children had OSA and obesity (48%), 21 were normal-weight with OSA (29%), and 17 were controls (23%). There was no correlation between the degree of obesity and OSA severity. AHI was significantly higher for OSA obese versus OSA normal weight children (20 versus 9; p = 0.02) The OSA-18 total score, and BASC-2 mean score was worse for the OSA-obese than the OSA normal weight group (p=0.01, for both). There was no difference in quality of life or behavioral scores between the OSA normal weight and control groups.

Caregivers were asked to complete a consent document. Demographic and polysomnograpic data was collected as well as BASC-2 and OSA-18 questionnaires completed by caregivers. Children were assigned to one of three groups: obese with OSA, normal-weight with OSA, and a control group (normal weight with no OSA). The correlation between OSA severity and the degree of obesity as well behavior and quality of life measures were compared between the 3 groups. A p-value .05 was considered significant.

Patient Experience in the Pediatric Otolaryngology Clinic: Does the Teaching Setting Influence Parent Satisfaction?
Speaker: Emily Boss, MD
Date: Saturday, April 21, 2012
Time: 3:15 3:22pm

San Diego, CA Patient experience scores are increasingly recognized as a chief indicator of healthcare quality. This report evaluates outpatient pediatric otolaryngology patient satisfaction in the teaching and non-teaching setting. 4,704 surveys were analyzed, with 1,984 (42%) from the teaching setting. For the teaching setting, mean scores were lower overall (88.1 v. 89.0; p<0.001) and in domains of access (includes scheduling ease, promptness in returning calls; 86.7 vs. 89.4; p<0.001) and personal issues (includes office hour convenience, sensitivity to needs; 87.0 v. 88.5; p<0.001). Children in the teaching setting were less likely to have HI-SCORES overall (OR 0.78; 95%CI 0.65-0.95; p=0.011) and for access (OR 0.8; 95% CI 0.67-0.95; p=0.012); probability of HI-SCORES was similar for the two settings for all other domains.

Survey methods were stratified by teaching/non-teaching affiliation. The survey has 29 Likert-scaled questions which comprise an overall score and subscores in 6 domains: access, visit, nursing, provider, personal issues, and assessment. The item likelihood-to-recommend was measured to indicate practice loyalty. Mean scores were compared by Kruskal-Wallis rank test. Multivariate logistic regression was performed to evaluate the association of teaching status with receipt of highest scores (HI-SCORES).

In conclusion, parents of pediatric otolaryngology patients seen in the teaching setting report lower satisfaction related to access to care, but similar scores for care provision and practice loyalty. Academic otolaryngology practices should focus on access issues to improve overall experience for children and families.

African-American Ethnicity as a Risk Factor for Respiratory Complications Following Adenotonsillectomy
Speaker: Linda Horwood, PhD
Date: Saturday, April 21, 2012
Time: 3:22 3:29pm

San Diego, CA Children of African-American ethnicity are at risk for major respiratory complications (i.e., requiring physician intervention) following adenotonsillectomy (T&A).

A retrospective cohort study was conducted on children who underwent T&A at our institution from 2002 to 2006. Our database included detailed perioperative data, demographic information and results of testing for suspected obstructive sleep apnea (OSA). At our institution, African-American children undergo a routine preoperative sickle cell test (TestSC). Data on TestSC was included for all children. Parental report of ethnicity was available for 23% of our cohort. We established that having a TestSC was an accurate proxy for African-American ethnicity (sensitivity 96%, specificity 93%, PPV 77%, NPV 99%).

Study results showed seventy-four (12.5%) of 594 children experienced major respiratory complications. Compared to other children, those who had major respiratory complications had a TestSC (p = 0.010), were aged 2 and under (p < 0.001), had lower weight for age z-scores (p = 0.037), had moderate-severe OSA (p = 0.003) and had comorbidities (p < 0.001). When controlling for these variables in a multivariate analysis, children of African-American ethnicity (TestSC used as a proxy) were at higher risk of having major perioperative respiratory complications (adjusted OR, 1.82; 95% CI, 1.05, 3.14; p = 0.003).

In conclusion, children of African-American ethnicity are nearly twice as likely to experience major respiratory complications related to T&A. Future work should determine the genetic or environmental aspects of African-American ethnicity that place these children at risk for serious surgical morbidity.

Do Perioperative Antibiotics Affect Complication Rates After Primary Adenotonsillectomy in Children?
Speaker: Carolyn Nguyen, MD
Date: Saturday, April 21, 2012
Time: 3:59 4:06pm

San Diego, CA The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published clinical guidelines in January 2011 with recommendations against the routine use of perioperative antibiotics for tonsillectomy with or without adenoidectomy.

During two distinct three-month periods, 1,031 the children underwent primary adenotonsillectomy [524 with antibiotics (AB), 507 without antibiotics (NAB)] that met the study criteria. The mean ages were 6.6 years AB [1.0-17.8, standard deviation (SD) 3.8] and 6.3 years NAB (1.0-17.8, SD 3.6) p>0.05. The male: female ratios were 1.18 AB and 1.15 NAB p>0.05. Ambulatory cases accounted for 69% AB and 67% NAB p>0.05.

Outcome measures included length of inpatient stay and postoperative complications including readmission for bleeding, pain and emesis. Study results show of the patients admitted postoperatively, the mean lengths of inpatient stay were 1.24 days AB and 1.37 days NAB p>0.05. There were no significant differences in the rates of readmission for bleeding observation (3.4% vs. 3.7%), bleed requiring cauterization (1.7% vs. 2.8%), pain (3.4% vs. 3.9%), emesis (1.1% vs. 1.8%) and all other complications (1.5% vs. 2.2%) between the AB and NAB groups, respectively p>0.05 for all metrics.

There were no statistically significant differences between the complication rates with and without the use of perioperative antibiotics. Our findings represent the largest single institution sample that primarily analyzes this question and further support the AAO-HNS recommendation.


Contact: Mary Stewart
American Academy of Otolaryngology - Head and Neck Surgery

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