First name
Lisa
Last name
Elden

Title

Lateral Neck Radiography in Preoperative Evaluation of Adenoid Hypertrophy.

Year of Publication

2019

Number of Pages

3489419895035

Date Published

2019 Dec 21

ISSN Number

1943-572X

Abstract

<p><strong>OBJECTIVE: </strong>To assess the value of lateral neck radiographs in quantifying adenoid hypertrophy to help guide treatment decisions in patients with symptoms of nasal obstruction.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective review.</p>

<p><strong>METHODS: </strong>Quantitative radiologic grading of adenoids was correlated with the intraoperative grading to select cases in agreement between the two methods. The percent airway obstruction was calculated as a ratio of adenoid size to the size of the nasopharyngeal airway near the level of the choanae on the lateral neck radiographs for adenoidectomy cases in which radiographic and intraoperative grading of adenoid size were in agreement.</p>

<p><strong>RESULTS: </strong>A total of 426 adenoidectomy cases with preoperative lateral neck radiographs were reviewed (M:F = 254:172 for age range 9 months to 16 years), and only cases in agreement between radiographic and intraoperative adenoid grading were included in radiographic analysis (N = 234). The percent airway obstruction values were significantly different between "severely obstructive" (N = 137, mean = 94.71, SD = 6.55, range [72.00; 100.00]) and "moderately obstructive" adenoid categories (N = 97, mean = 78.53, SD = 6.91, range [63.67; 98.08]), not only within clinically relevant age groups (1-3 years, 4-7 years, 8-15 years), but also for the entire data set (95% CI [14.41; 17.95],  &lt; .0001). "Mildly obstructive" category was omitted due to small sample size (N = 4).</p>

<p><strong>CONCLUSION: </strong>Lateral neck radiographs can provide useful supplemental information on the degree of nasopharyngeal airway obstruction when other clinical findings do not clearly point toward adenoid hypertrophy as a primary cause of nasal obstruction. In our data set, a 65% nasopharyngeal airway obstruction represents a value two standard deviations below the mean for "moderately" obstructive adenoid category, and can be viewed as a simplified cut-off to indicate that the degree of adenoid enlargement is clinically relevant. This cut-off value can assist in evaluation of patients with symptoms of nasal obstruction.</p>

<p><strong>LEVEL OF EVIDENCE: </strong>4.</p>

DOI

10.1177/0003489419895035

Alternate Title

Ann. Otol. Rhinol. Laryngol.

PMID

31868005

Title

Dexamethasone and risk of bleeding in children undergoing tonsillectomy.

Year of Publication

2014

Number of Pages

872-9

Date Published

2014 May

ISSN Number

1097-6817

Abstract

<p><strong>OBJECTIVE: </strong>To determine whether dexamethasone use in children undergoing tonsillectomy is associated with increased risk of postoperative bleeding.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study using a multihospital administrative database.</p>

<p><strong>SETTING: </strong>Thirty-six US children's hospitals.</p>

<p><strong>SUBJECTS: </strong>Children undergoing same-day tonsillectomy between the years 2004 and 2010.</p>

<p><strong>METHODS: </strong>We used discrete time failure models to estimate the daily hazards of revisits for bleeding (emergency department or hospital admission) up to 30 days after surgery as a function of dexamethasone use. Revisits were standardized for patient characteristics, antibiotic use, year of surgery, and hospital.</p>

<p><strong>RESULTS: </strong>Of 139,715 children who underwent same-day tonsillectomy, 97,242 (69.6%) received dexamethasone and 4182 (3.0%) had a 30-day revisit for bleeding. The 30-day cumulative standardized risk of revisits for bleeding was greater with dexamethasone use (3.11% vs 2.71%; standardized difference 0.40% [95% confidence interval, 0.13%-0.67%]; P = .003), and the increased risk was observed across all age strata. Dexamethasone use was associated with a higher standardized rate of revisits for bleeding in the postdischarge time periods of days 1 through 5 but not during the peak period for secondary bleeding, days 6 and 7.</p>

<p><strong>CONCLUSIONS: </strong>In a real-world practice setting, dexamethasone use was associated with a small absolute increased risk of revisits for bleeding. However, the upper bound of this risk increase does not cross published thresholds for a minimal clinically important difference. Given the benefits of dexamethasone in reducing postoperative nausea and vomiting and the larger body of evidence from trials, these results support guideline recommendations for the routine use of dexamethasone.</p>

DOI

10.1177/0194599814521555

Alternate Title

Otolaryngol Head Neck Surg

PMID

24493786

Title

Variation in quality of tonsillectomy perioperative care and revisit rates in children's hospitals.

Year of Publication

2014

Number of Pages

280-8

Date Published

2014 Feb

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVE: </strong>To describe the quality of care for routine tonsillectomy at US children's hospitals.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children's hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital.</p>

<p><strong>RESULTS: </strong>Of 139,715 children who underwent same-day tonsillectomy, 10,868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%-98.8%) and antibiotics (median 16.3%, range 2.7%-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10-18 vs 1-3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P &lt; .001) across hospitals in total revisits (median 7.8%, range 3.0%-12.6%), revisits for bleeding (median 3.0%, range 1.0%-8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%-4.4%).</p>

<p><strong>CONCLUSIONS: </strong>Substantial variation exists in the quality of care for routine tonsillectomy across US children's hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals' tonsillectomy quality improvement efforts.</p>

DOI

10.1542/peds.2013-1884

Alternate Title

Pediatrics

PMID

24446446

Title

Improving adherence to otitis media guidelines with clinical decision support and physician feedback.

Year of Publication

2013

Number of Pages

e1071-81

Date Published

2013 Apr

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVE: </strong>To assess the effects of electronic health record-based clinical decision support (CDS) and physician performance feedback on adherence to guidelines for acute otitis media (AOM) and otitis media with effusion (OME).</p>

<p><strong>METHODS: </strong>We conducted a factorial-design cluster randomized trial with primary care practices (n = 24) as the unit of randomization and visits as the unit of analysis. Between December 2007 and September 2010, data were collected from 139,305 otitis media visits made by 55,779 children aged 2 months to 12 years. When activated, the CDS system provided guideline-based recommendations individualized to the patient's history and presentation. Monthly physician feedback reported adherence to guideline-based care, changes over time, and comparisons to others in the practice and network.</p>

<p><strong>RESULTS: </strong>Comprehensive care (all recommended guidelines were adhered to) was accomplished for 15% of AOM and 5% of OME visits during the baseline period. The increase from baseline to intervention periods in adherence to guidelines was larger for CDS compared with non-CDS visits for comprehensive care, pain treatment, adequate diagnostic evaluation for OME, and amoxicillin as first-line therapy for AOM. Although performance feedback was associated with improved antibiotic prescribing for AOM and pain treatment, the joint effects of CDS and feedback on guideline adherence were not additive. There was marked variation in use of the CDS system, ranging from 5% to 45% visits across practices.</p>

<p><strong>CONCLUSIONS: </strong>Clinical decision support and performance feedback are both effective strategies for improving adherence to otitis media guidelines. However, combining the 2 interventions is no better than either delivered alone.</p>

DOI

10.1542/peds.2012-1988

Alternate Title

Pediatrics

PMID

23478860

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