United States


Abstract Title:
Comparing primary versus secondary trancheoesophageal puncture prosthesis for speech rehabilitation post total laryngectomy
Background
Total laryngectomy (TL) is a catastrophic operation with sequalae of loss of natural voice, dysphagia, and permanent tracheotomy, performed as standard of care for advanced laryngeal/hypopharyngeal cancer. Early rehabilitation efforts have traditionally been focused on esophageal speech, electronic larynx, and tracheoesophageal puncture prosthetic (TEP). TEP is the most used method due to a more natural speech and high success rates, although the choice between primary (immediate) TEP and secondary (delayed) is controversial. While primary TEP allows the avoidance of additional surgery for voice restoration, and enables earlier rehabilitation, there has been concern for higher risk of stoma stenosis, fistula formation, and local infection. Thus, support for delayed TEP proposes possible avoidance of such complications with stomal maturation. This study reports a literature review of studies comparing the efficacy of primary and secondary TEP in terms of complication rates, voice quality, and long term efficacy. 

Methods
A literature review was conducted via PubMed with search phrase “tracheoesophageal voice prosthesis primary vs secondary” with six search results. Based on the inclusion criteria of direct comparison between study groups of primary and secondary TEP, 5 studies were selected for review and one study was eliminated 

Results
Barauna et al. reported a 10% statistically significant reduction in risk of leakage around the prosthesis in the secondary TEP group, and no difference in voice quality between the two groups. Emerick et al. reported an increased risk of pharyngocutaneous fistula with primary TEF, a 2 month sooner achievement of fluent speech in primary TEF group, and no difference in speech fluency. Massaro et al. reported no difference in long term outcome between the two groups. Kao et al. reported a higher success rate of speech restoration for primary TEF group with no difference in complication rates. Sinclair et al. reported no difference in early post-operative complication rate between the two techniques. 
Conclusion
The choice between primary versus secondary TEF should be personalized to the patient of interest to better control associated risks as both are equally effective techniques for speech rehabilitation in the long term.


AMA Research Challenge 2022

Comparing primary versus secondary tracheoesophageal puncture prosthesis for speech rehabilitation post total laryngectomy

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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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poster

Background
Cochlear implantation (CI) surgery is the standard of care treatment for pediatric patients diagnosed with severe to profound sensorineural hearing loss. While considered a relatively safe operation, any invasive procedure involving the skull has risks. There are few recent studies in the United States that have analyzed complication rates among children who have received CI. Furthermore, existing studies fail to discuss specific risk factors that led to post-operative complications, nor offer solutions to reduce their incidence. This study aims to 1) determine the incidence of complications in pediatric CI patients and 2) identify evidence-based risk factors so pediatric otolaryngologists can better identify high-risk patients.

Methods
This is a single institution retrospective study analyzing the pre-, intra-, and post-operative data from 72 pediatric patients who underwent CI surgery between 2016 and 202. SPSS statistical software was used for statistical analysis. Data analysis included the prevalence of preoperative comorbidities, the incidence of postoperative complications, and the assessment of comorbidities versus complications using Chi-Squared tests.

Results
Patients were aged 8.9 months old to 25.8 years old with a mean age of 7.1 years old. Of the 72 patients, there were a total of 101 ears operated on. There were 24 total complications among the 101 ears, yielding an overall complication rate of 23.8%. The most common complication was an infection which occurred in 12.9% of ears. The second most common complication was dysgeusia (3.96%). Of the 72 patients, 72.2% had >1 preoperative comorbidity and 56.9% had an inner ear abnormality on imaging. The most common comorbidities were obesity (26.4%) and eustachian tube dysfunction (22.2%).

Conclusion
Cochlear implantation is a relatively safe procedure that can greatly improve hearing and overall quality of life in patients. Based on our data, there was an overall complication rate of 23.8% with the most common complications being infection and dysgeusia. Further statistical analysis is required before conclusions can be made regarding any correlation between preoperative risk factors and complication rates.


Complications of Pediatric Cochlear Implant Surgery

Background: Cystic fibrosis (CF) is a progressive, genetic disease caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene that disables the body's ability to move chloride to the cell surface. This subsequently causes patients to have chronic sinusitis and a plethora of symptoms. With the advent of modulator therapies for many CF patients, pulmonary function and nutritional status have improved. Their effects on sinus disease as well as the changing role of the otolaryngologist (ENT) is not yet clearly defined. 

Methods: Adult cystic fibrosis patients from Augusta University Adult Cystic Fibrosis Center were included in this study, with stratification of patients based on their demographics, specific gene mutation, modulator therapy, ENT clinic visits, history of polyps, history of nasal surgery, headaches, olfactory dysfunction, and sleep problems. Data was abstracted from the Port CF database and the electronic medical record after obtaining local IRB approval. 

Results: Out of the 98 adult CF patients, 54 were seen by an ENT after 2012. Sixty-one of them had a history of nasal or sinus surgery (62.24%) and 45 had a history of polyps (45.92%). 52% of the total patients were seen between the age ranges 20-29 years, with an equal distribution of male and female patients (27 of each). The most common race was white (83.33%). 42.6% had the commonest mutation F508del/F508del. The most common modulator treatment was elexacaftor/tezacaftor/ivacaftor (72.22%). 24% of patients saw ENT after having started elexacaftor/tezacaftor/ivacaftor therapy. 

Discussion: Sinus disease can contribute to substantial morbidity in CF patients even on modulator therapy with the majority of patients requiring surgical intervention at some point in their lifetime. Almost half of the patients have polyp history, which are known to recur and are difficult to treat adequately. Additionally, many patients have sinonasal symptoms that are untreated. An otolaryngologist, therefore, remains an integral part of the CF team. 

Significance to the audience: This data will help us understand the role of ENT in the standard care of CF patients for the purpose of planning evaluations, referrals, and interventions in the near future.

Sinus Symptoms in Cystic Fibrosis Patients on Modulator Therapy

Late onset sepsis in the NICU: differentiating CoNS from other bacteria and negative work-ups

Biking is a popular childhood activity that has an intrinsic risk of injury. While multiple advocacy groups have pushed for protective equipment to help mitigate these risks, to date, trends in the national health burden of fractures associated with biking in the pediatric population have not been explored in depth. The National Electronic Injury Surveillance System database was queried between 2001 and 2020 to identify fractures presenting to U.S. Emergency Departments associated with riding bicycles in patients aged ≤ 18 years. Analysis of the annual incidence over time was performed with linear regression to determine the significance of trends observed in the number of bicycle-related fractures. A total of 34,722 fractures were identified in the database, representing an estimated 1,019,509 fractures from 2001-2020, or 50,975 fractures annually. The average age was 10.15 years, and most patients were male (70.7%). Linear regression noted that the overall trend was significant for decreasing fractures over the time period (R2=0.9011; P<0.001). Patients struck by a motor vehicle were more likely to be hospitalized (27.1% vs. 5.3%; P<0.001) and more likely to sustain injuries to the axial skeleton (19.0% vs. 5.0%; P<0.001). The majority of patients who sustained a skull fracture were not wearing helmets at the time of injury (85.7%). Fractures in males were more likely to be at the shoulder (M: 12.5%, F: 5.4%; P<0.001) or hand (M: 5.0%, F: 2.6%; P<0.001), and fractures in females were more likely to be at the elbow (M: 7.6%, F: 9.5%; P<0.001) or wrist (M: 20.5%, F: 22.9%; P<0.001). The national burden of fractures associated with riding bicycles in pediatric populations has shown a steady decrease for many years. However, our research demonstrates alarming results regarding motor vehicle involvement and helmet use in pediatric bicycle fractures, as well as several differences across sex in injury patterns.

Pediatric Fractures Associated with Riding Bicycles: A National Twenty-Year Analysis

Background: Childhood obesity affects 1 in 3 children in the U.S. and is associated with a myriad of comorbidities. Executive functions (EF), including goal-directed behavior and self-management, are hypothesized to be impaired in obesity. Additionally, parental mental health issues such as depression, anxiety, and ADHD have seen a significant increase during the COVID-19 pandemic. The EF of children living with parents suffering from mental illnesses such as depression is likely to be impaired. To what degree parental mental health issues are associated with executive dysfunction (ED) in treatment seeking children with obesity is yet to be explored. The primary objective of this study was to compare the presence of ED in children with parents who have mental health diagnoses to those with parents who do not.

Methods: This was a double-blinded, cross-sectional study of 11-17 year old patients who were recruited from a multidisciplinary pediatric weight management (PWM) clinic. At initial appointments, all parents were asked about a family history of mental health diagnoses. Parents also completed the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) parent form, to assess for ED in their presenting children. The scores that were analyzed from the BRIEF-2 assessments included the patients’ global executive composite (GEC), inhibit, and shift scores, which provide a global summary of all BRIEF-2 clinical scales, insight into impulsive behavior, and shifting attention between tasks, respectively. These scores were compared utilizing t-tests between the children of parents with and without mental health diagnoses.

Results: Of the 39 participants analyzed, 21 (53.8%) had one parent with a mental health diagnosis and 7 (17.9%) had both parents with a mental health diagnosis. Furthermore, 17 (43.5%) of the children had ED, 14 (35.9%) had problematic inhibit scores, and 19 (48.7%) had problematic shift scores. There were no significant differences in GEC, inhibit, and shift scores between children whose parents did and did not have mental health diagnoses, p = 0.07, 0.09, 0.08, respectively.

Conclusion: This study was underpowered to associate child ED with parental mental health diagnoses. Given that this is an interim analysis of an ongoing study, this association may be proven with a larger cohort. Of interest is that over half of our treatment seeking population had at least one parent with a mental health diagnosis, much higher than a global estimate of 15-23%. This suggests that parental mental health illnesses may be concentrated among children seeking PWM, over 70% of whom have severe obesity. Thus, further investigation is needed on how parental mental health illnesses impact patient PWM outcomes.


Relationship between Executive Dysfunction and Parental Mental Health in a Pediatric Weight Management Clinic

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Our understanding of underlying risk factors for this disease in very low birth weight (VLBW) infants is still evolving. ROP has also been frequently observed in VLBW infants with patent ductus arteriosus (PDA), however little is known about the factors influencing their co-occurrence. We sought to explore the association of PDA and ROP in VLBW infants and analyze the role of co-morbidities in altering their association. We posit that VLBW infants with severe PDA may be at a higher risk of developing clinically significant ROP.

Severe Patent Ductus Arteriosus as an Independent Risk Factor for Clinically Significant Retinopathy of Prematurity in Very Low Birth Weight Infants

Background: Studies have shown that children with ADHD have higher problematic use of video games, though none have investigated the types of games played. Some of the most popular video games are online multiplayer games, meaning that there is no option to pause the game. This can be especially frustrating for kids with ADHD, who have poor time management skills. The lack of research into types of games played means that there is a gap in information used to tailor anticipatory guidance. Children with ADHD are also at higher risk of addiction. DSM-5 defined criteria for gaming addiction, but there have been no studies on gamers with ADHD using this criteria.

Methods: The study was conducted at an outpatient pediatric subspecialty office using a cross-sectional survey method. The survey was completed by 119 participants and assessed aspects of video game usage and screened for video game addiction using DSM-5 criteria. The most frequently played game was determined to be primarily single player or multiplayer.

Results: Among children with ADHD, there was no significant difference in positive screening for gaming addiction between those who primarily played video games with versus without a pause button. However, in children with no ADHD diagnosis, there was a significant difference in positive addiction screening between those who primarily played games with a pause button versus without. A chi-square test of independence was performed to examine the relationship between the criteria for video game addiction being met and whether the most frequently played game has a pause button. The relation between these variables was significant, p = .019. 
When comparing positive addiction screening for children with versus without ADHD, regardless of primary game type played, there was a 9% increase in positive screening for addiction in children with ADHD, though this number was not significant.

Conclusion: Children with ADHD whose most frequently played video game does not have a pause button did not have an increased risk of video game addiction. However, children without ADHD were more at risk for video game addiction when their primary game was multiplayer. This warrants further research into the types of video games children are playing.

Types of Video Games Played and Their Effect on Video Game Addiction in Children With and Without Attention Deficit-Hyperactivity Disorder

Phrenic Nerve Injury: Results of a Northwestern Phrenic Nerve Clinic Registry

Background: Fronto-orbital advancement requires removal of the fronto-orbital bandeau via extra- and intra-cranial osteotomies. During this transitional osteotomy, visualization of the saw blade is lost as it passes through the fronto-orbital-sphenoid junction. This places the dura and parenchyma of the temporal lobe at risk of injury. We aim to provide a three-dimensional analysis of the space surrounding this osteotomy to determine differences amongst different types of craniosynostoses. 

Method: We reconstructed 3D skulls from head CT scans of 30 patients with 6 different types craniosynostosis (4 with Apert sydrome, 3 Crouzon syndrome, 2 Muenke syndrome, 6 metopic, 6 nonsyndromic bicoronal, and 6 unicoronal), and landmarked them with 47 cephalometric points using Mimics 24.0 (Materialise NV, Lueven, Belgium). Statistical analyses were performed to determine differences in the linear and volumetric measurements among the 6 groups.

Results: Multiple significant differences were found amongst groups. The mean distance from the lateral orbital rim to cornea was significantly different among the 6 groups, with Apert syndrome having the largest (16.1± 2.3mm) value. The average distance of the middle cranial fossa from the frontozygomatic suture was significantly different with Apert (10±3.4mm), Muenke (10.4±2.0) and bicoronal (9.5±1.6mm) having the smallest values. The mean cephalocaudal depth of the temporal lobe tip from the edge of the sphenoid was significantly different, with Apert having the largest average depth (38±11.6mm). The thickness of the fronto-orbito-sphenoid junction at the level of the supraorbital rim was significantly different among the groups, with smallest values for the Apert (3.6±3.1mm) and bicoronal (3.7±1.3mm) groups. The mean distance from the cornea to the supraorbital rim, overall orbital depth, and overhang of the lesser sphenoid wing over the middle cranial fossa did not show significant difference among the groups.

Conclusion: Patients with Apert syndrome have the most unfavorable morphology of the anterior and middle cranial fossae. They have the highest corneal overhang beyond the lateral orbit, a large projection of the middle cranial fossa anteriorly, the most vertically deep middle cranial fossa and the thinnest bone at the fronto-orbital-sphenoid junction, all of which make retraction and protection of the temporal lobe more challenging during fronto-orbital advancement.

Alterations in Sphenoid anatomy in Craniosynostosis: Implications for Fronto-orbital Advancement

Background: 
Hourly flap checks are the most common means of assessing the vascular status of flaps during the first 24 hours following autologous breast reconstruction (ABR). This practice often requires ICU admission which is a known driver of healthcare costs and decreased patient satisfaction. This study seeks to address these issues by demonstrating the safety of a longer interval between flap checks during the first 24 hours following ABR. 
Methods:
This is a retrospective review of ABR surgeries performed by multiple surgeons from 2017 to 2020. Two cohorts were present, one which underwent flap checks every hour in the ICU (Q1 cohort) and the other which underwent flap checks every four hours on the hospital floor (Q4 cohort). Our primary outcome measures were length of stay (LOS), flap takebacks, total flap loss, and partial flap loss. 
Results: 
575 total flaps were reviewed. 331 in the Q4 cohort and 244 in the Q1 cohort. There was no significant difference in the rates of flap take back (p=.59), partial flap loss (p=.69) or total flap loss (p=.34) between the two cohorts. The Q4 cohort also had a significantly shorter LOS (p=.01).
Conclusion: 
This study demonstrates the safety of lengthened flap check intervals during the first postoperative day in patients following ABR. Lengthened flap check intervals will decrease the cost of ABR and increase patient satisfaction by avoiding ICU admission. These changes will ultimately make ABR a more accessible means of breast reconstruction for all patients to pursue.

Comparing Flap Monitoring Intervals in the 1st Postoperative Day: A Retrospective Analysis of Major Complications Following Autologous Breast Reconstruction

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Comparing primary versus secondary tracheoesophageal puncture prosthesis for speech rehabilitation post total laryngectomy

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