OBJECTIVES:The aim was to investigate the development of perception and self-awareness of two vocal dimensions, vocal loudness and voice quality, in 3- to 6-year-old children with and without voice disorders. STUDY DESIGN:Between-subjects experimental design. METHODS:Sixty 3- to 6-year-old children participated in the study and provided analyzable data (50 phonotypical children and 10 children with voice disorders). Children were split into two age groups for data analysis: 3- to 4- vs 5- to 6-year-olds. All study procedures were conducted remotely via Zoom. Participants completed tasks assessing their (a) perceptions of others' voices and (b) self-awareness of their own voice, each along dimensions of vocal loudness and voice quality. RESULTS:For perception of voice, older phonotypical children identified differences in vocal loudness and voice quality more accurately than younger peers. Children with voice disorders performed similarly to same-age phonotypical children on loudness perception but performed more poorly on perception of voice quality. For self-awareness, vocal loudness was found to develop early in all children, and did not differ statistically across age groups, although children with voice disorders were numerically slightly less accurate than phonotypical children on that test. All children performed at chance level on the voice quality self-awareness test. CONCLUSIONS:The results indicate that perception of both vocal loudness and voice quality show developmental trajectories. Self-awareness of vocal loudness and voice quality exhibit a different trajectory: self-awareness of vocal loudness is already well-developed in 3- to 4-year-old children, while self-awareness of voice quality is yet to mature at age 5-6 years. The study also demonstrates for the first time that children with voice disorders may differ from phonotypical children on some features of voice perception and self-awareness of voice. Data from children with voice disorders were analyzed descriptively, providing initial insights into these differences.

Importance Tonsillectomy is among the most painful otolaryngologic procedures. It is unclear whether a postoperative course of oral steroids reduces pediatric tonsillectomy pain and morbidity. Objective To determine whether a postoperative course of oral dexamethasone reduces postadenotonsillectomy pain in children. Design, Setting, and Participants This was a parallel-design quadruple-blinded randomized clinical trial conducted at a single tertiary academic center that enrolled pediatric patients (3-17 years of age) undergoing adenotonsillectomy from August 2021 to May 2023, with 14 days of follow-up for pain and 5 to 9 weeks for adverse events. Data were analyzed from October 2023 to May 2026. Intervention Oral dexamethasone (0.5 mg/kg; maximum dose, 20 mg) or placebo on postoperative days 2, 4, and 6. Main Outcome and Measure Mean (SD) pain score before medication administered during days 2 to 8 postoperatively. Results Of 763 children screened, 209 participants (median [IQR] age, 7.1 [5.8] years; 99 females [47.4%] and 110 males [52.6%]) were included (104 to the steroid arm and 105 to placebo) in analyses of adverse events and health care utilization. Of these, 131 (61 steroid arm and 70 placebo) completed pain diaries and were included in primary outcome (pain) analysis. Mean (SD) pain before acetaminophen or ibuprofen on days 2 to 8 was 0.72 (95% CI, 0-1.44) points lower in the dexamethasone group (4.12 [2.00]) than placebo (4.84 [2.15]), but wide 95% CIs and differences in pain prior to taking the study medication prevented making definitive conclusions. The dexamethasone group had less pre- and postanalgesic pain on postoperative days 12 and 13 (mean difference, 0.96-2.37 points) and a considerable decrease in odds of receiving an opioid prescription (odds ratio [OR], 0.23; 95% CI, 0.06-0.84) or having an emergency department visit for pain (OR, 0.12; 95% CI, 0.003-0.91). However, the precision of these estimates limits interpretability. Differences in readmissions, nursing telephone calls, posttonsillectomy hemorrhage, and return to normal diet between groups were small and clinically meaningless. Conclusions and Relevance In this randomized clinical trial, postoperative oral dexamethasone was associated with a modest reduction in pain after pediatric adenotonsillectomy, a considerable reduction in opioid prescriptions, and no increase in complications, supporting its use as an analgesic adjunct. Trial Registration ClinicalTrials.gov Identifier: NCT04879823

OBJECTIVE:To investigate the association between community socioeconomic distress and timing of speaking valve (SV) assessment among children who underwent tracheostomy placement. STUDY DESIGN:Retrospective cohort study. SETTING:Tertiary care children's hospital. METHODS:Children who underwent tracheostomy between 2016 and 2022 were included. Associations between the Distress Community Index (DCI) and time to SV assessment were evaluated using regression models adjusted for covariates and stratified by intensive care unit (ICU) type. RESULTS:A total of 147 patients with a mean age at tracheostomy of 4.5 years were included. The cohort was 83.0% white, 11.6% black, and 5.4% Other. DCI breakdown was 19.7% Distressed, 25.2% At Risk, 23.8% Mid-Tier, 18.4% Comfortable, and 12.9% Prosperous. Overall, 71.4% of patients completed the SV assessment. Community distress was not associated with completion of the SV assessment. Higher community distress and younger age at tracheostomy were associated with longer time to SV assessment (P < .001 and P = .003, respectively), with trends in community distress consistent across all ICU types. Patients in the pediatric intensive care unit (PICU) received SV assessments sooner than patients in the neonatal intensive care unit (NICU) (median 18 vs 121 days, P < .001). Stratifying by DCI quintiles, patients from Prosperous communities were 2.41 times more likely to receive a timely SV assessment compared to patients from Distressed communities (hazard ratio [HR] = 2.41, P < .001). CONCLUSION:Higher community distress, younger age at tracheostomy, and stay in the NICU were associated with longer delays in SV assessment. Standardized protocols and support systems are needed to ensure timely SV assessments and thus optimal physiologic, cognitive, and social development for all children with tracheostomy. LEVEL OF EVIDENCE: 3:

Importance:Tonsillectomy is among the most painful otolaryngologic procedures. It is unclear whether a postoperative course of oral steroids reduces pediatric tonsillectomy pain and morbidity. Objective:To determine whether a postoperative course of oral dexamethasone reduces postadenotonsillectomy pain in children. Design, Setting, and Participants:This was a parallel-design quadruple-blinded randomized clinical trial conducted at a single tertiary academic center that enrolled pediatric patients (3-17 years of age) undergoing adenotonsillectomy from August 2021 to May 2023, with 14 days of follow-up for pain and 5 to 9 weeks for adverse events. Data were analyzed from October 2023 to May 2026. Intervention:Oral dexamethasone (0.5 mg/kg; maximum dose, 20 mg) or placebo on postoperative days 2, 4, and 6. Main Outcome and Measure:Mean (SD) pain score before medication administered during days 2 to 8 postoperatively. Results:Of 763 children screened, 209 participants (median [IQR] age, 7.1 [5.8] years; 99 females [47.4%] and 110 males [52.6%]) were included (104 to the steroid arm and 105 to placebo) in analyses of adverse events and health care utilization. Of these, 131 (61 steroid arm and 70 placebo) completed pain diaries and were included in primary outcome (pain) analysis. Mean (SD) pain before acetaminophen or ibuprofen on days 2 to 8 was 0.72 (95% CI, 0-1.44) points lower in the dexamethasone group (4.12 [2.00]) than placebo (4.84 [2.15]), but wide 95% CIs and differences in pain prior to taking the study medication prevented making definitive conclusions. The dexamethasone group had less pre- and postanalgesic pain on postoperative days 12 and 13 (mean difference, 0.96-2.37 points) and a considerable decrease in odds of receiving an opioid prescription (odds ratio [OR], 0.23; 95% CI, 0.06-0.84) or having an emergency department visit for pain (OR, 0.12; 95% CI, 0.003-0.91). However, the precision of these estimates limits interpretability. Differences in readmissions, nursing telephone calls, posttonsillectomy hemorrhage, and return to normal diet between groups were small and clinically meaningless. Conclusions and Relevance:In this randomized clinical trial, postoperative oral dexamethasone was associated with a modest reduction in pain after pediatric adenotonsillectomy, a considerable reduction in opioid prescriptions, and no increase in complications, supporting its use as an analgesic adjunct. Trial Registration:ClinicalTrials.gov Identifier: NCT04879823.

ObjectiveTo delineate the impact of breast milk feeding (BMF) on the middle ear (ME) and nasopharyngeal (NP) microbiota of children with and without cleft palate with or without cleft lip (CP ± L); to define differences in ME and NP bacterial composition.DesignProspective cohort.SettingTertiary children's hospital.ParticipantsChildren aged <24 months undergoing first bilateral myringotomy and tubes (BMTs). Groups included CP ± L with BMF ≥3 months (n = 6), CP ± L with no BMF (n = 5), controls with BMF ≥3 months (n = 14), and controls with no BMF (n = 14). Exclusions were immunodeficiency, genetic disorders, and antibiotic treatment ≤14 days prior.Main Outcome MeasuresME effusions (MEEs) and NP swabs were collected. Bacterial 16S rRNA gene sequencing was performed. Main outcome measures were abundance (additive-log ratio transformed), β-diversity (permutational multivariate analysis of variance), and α-diversity.ResultsBMF was associated with increased Acinetobacter (β = 1.46) in MEE. In the NP, BMF was associated with increased Haemophilus (β = 2.40), Neisseria (β = 2.39), Granulicatella (β = 1.53), Gemella (β = 1.86), and Prevotella (β = 1.83), and decreased Staphylococcus (β = -1.88). CP ± L was associated with greater α-diversity (Tail β = 1.58; Shannon β = 1.30) and increased Gemella (β = 2.13), Acinetobacter (β = 1.81), and Pseudomonas (β = 2.90) in MEE. In the NP, CP ± L was associated with an increased abundance of Veillonella (β = 3.48), Streptococcus (β = 2.15), and Staphylococcus (β = 1.74) and a decreased abundance of Afipia (β = -1.58). Paired differences revealed more Staphylococcus in MEE relative to the NP (β = -5.98) and a significant difference in β-diversity between the NP and MEE (β = 1.27). All p < .05.ConclusionsBMF and CP ± L may alter ME and NP microbiota. This represents a first step in the identification of factors that could improve ME health in this population.

Objectives: To determine what patient characteristics are associated with completing asymptomatic pre-operative testing for SARS-CoV-2. Methods: Charts from consecutive patients undergoing ambulatory surgery in otolaryngology at a tertiary care children's hospital from May 4 until May 26, 2020, were reviewed. If two or more siblings were scheduled, only the first sibling was included. Demographics, surgical details, and results of asymptomatic pre-operative testing for SARS-CoV-2 were collected. Patients who completed pre-operative testing were compared with those who did not using logistic regression or Wilcoxon rank-sum tests, alpha = 0.05. Results: 216 patients were included. 56.5 % were male, and median age at surgery was 2 years (range 4 months-20 years). 88 patients (40.7 %) had pre-operative SARS-CoV-2 RT-PCR testing. 97.7 % of sampling occurred 2-3 days prior to the procedure, and 98.9 % of results were available within 2 days. The virus was not detected in any cases. In multiple logistic regression, undergoing surgery at the main hospital location rather than a satellite location (OR: 3.13, p = 0.003) and greater median household income for zip (OR: 1.18/$10,000, p = 0.042) were associated with completing pre-operative testing. However, race, insurance type, surgeon, patient age, previous no-show appointments, and household composition did not alter the odds of completing pre-operative testing. Conclusions: Families were less likely to complete testing if surgery was being performed at a satellite location or if they lived in an area with lesser median household income. This work draws attention to the impact of socioeconomic factors on access to and compliance with pandemic mitigation measures, with important implications for future public health crises.

INTRODUCTION:Tympanostomy tubes (TTs) are a common otolaryngologic procedure. Historically, tubes placed in the anterior inferior (AI) quadrant were thought to last longer, reduce ossicular damage, and minimize hearing loss. However, perforation risk remains at 2-16 %. AI perforations may require more complicated repair compared to PI perforations. This study aims at comparing early hearing outcomes between AI and PI TT placement after 3 months. METHODS:Randomized controlled trial was conducted at a tertiary pediatric hospital. Children (6 months-14 years) undergoing initial TT placement were randomized to receive a tube in AI in one ear and a tube in the PI quadrant in the opposite ear. Exclusion criteria included non-RAOM indications, tube type other than Armstrong, anatomical abnormalities, or genetic conditions. Audiometry and caregiver questionnaires at 3-month follow-up were analyzed using McNemar's Chi-squared test. RESULTS:Of 386 enrolled, 118 completed audiometry (73 with ear-specific data). Only one patient had mild hearing loss (30 dB PTA at 500 Hz) in the PI ear. Tympanometry in 41 participants showed similar rates of flattened admittance: 9.8 % in PI vs. 7.3 % in AI (OR: 1.00). Caregivers of 303 participants reported tube blockage in 5.6 % (PI) vs. 5.9 % (AI) and otorrhea in 25.7 % (PI) vs. 24.4 % (AI). Provider forms for 86 patients showed similar occlusion rates. Tube patency could not be assessed in 41.9 % of PI vs. 3.5 % of AI tubes due to visualization limitations. CONCLUSION:No significant differences in hearing, tube extrusion, or function were observed between AI and PI TT placement at first follow-up.

OBJECTIVE:To examine the relationship between lesion size, auditory-perceptual ratings, patient-related quality of life measure, and acoustic voice measures in children with vocal nodules. METHODS:Thirteen children (5-10 years) with vocal nodules were recruited in this cross-sectional cohort study. Auditory-perceptual ratings of overall voice severity were performed using a Visual Analog Scale. Acoustic measures of cepstral peak prominence (CPP), low/high ratio, and the Cepstral Spectral Index of Dysphonia (CSID) were computed on vowels /a:/, /i:/, and an all-voiced sentence. The Nuss scale was used to rate lesion size from high-speed videoendoscopy (HSV). Patient Voice-Related Quality of Life (PVRQOL) was obtained from both the child and the parent. Correlations were computed for HSV ratings vs. auditory ratings, PVRQOL ratings, and acoustic measures as well as for interrelationships among all variables. RESULTS:Lesion size on HSV correlated moderately with overall severity of auditory-perceptual voice rating and with acoustic measures CPP and CSID, but not with PVRQOL. Significant, strong correlations were observed between auditory ratings and CPP, L/H ratio, and CSID in vowels and sentences. Several moderate strength correlations were observed between PVRQOL subscales (parental and child physical function; child social emotional well-being) and acoustic measures. CONCLUSIONS:Since nodules influence both vocal fold structure and vocal function, multiple parameters (lesion size, auditory-perceptual ratings, measures of physical function and social-emotional impact, and acoustic measurements) are needed to fully characterize the potential effect(s) on the voice. These findings could be used to improve clinical assessment and outcome measurements in children with vocal fold nodules. LEVEL OF EVIDENCE: 3:

OBJECTIVE:To determine the efficacy of acid suppression therapy (AST) for the treatment of gastroesophageal reflux (GER) and airway symptoms in infants with mild to moderate laryngomalacia. METHODS:From 2020 to 2023, infants ≤ 6 months old with laryngomalacia at a tertiary children's hospital were randomized to famotidine and feeding modifications (AST) or feeding modifications alone (no-AST). Laryngomalacia Airway Symptom Score (LASS) and Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R) were completed by guardians. Of 343 patients approached, 257 were excluded due to severe laryngomalacia on LASS, severe GER (I-GERQ-R ≥ 16), prior AST, no laryngomalacia on laryngoscopy, recommendation for supraglottoplasty, and/or other airway anomalies. Twenty-one declined participation. LASS and I-GERQ-R were again completed 1-6 months following enrollment. RESULTS:Sixty-five patients enrolled; 40/65 (62%) followed up at a mean of 3.1 months (SD 1.4 months). Of these 40, 10 (25%) had mild and 30 (75%) had moderate laryngomalacia. Median I-GERQ-R was 11 (range 5-15) at the initial appointment and 7.5 (range 0-26) at follow-up (p = 0.002). Laryngomalacia resolved in 13/40 (33%) at follow-up based on LASS (p < 0.001). Patients randomized to AST (n = 20) and no-AST (n = 20) had comparable improvement on LASS (p = 0.3) and I-GERQ-R (p = 0.8). Additionally, the severity of laryngomalacia at initial consult did not have a significant impact on LASS (p = 0.3) or I-GERQ-R (p = 0.8) improvement. LASS (ρ = 0.423, p = 0.007) but not I-GERQ-R (ρ = 0.122, p = 0.5) improved more with longer time from consult to follow-up. CONCLUSION:This small randomized controlled trial was unable to demonstrate additional benefit from AST compared to feeding modifications alone based on airway and reflux symptoms. LEVEL OF EVIDENCE: 2: TRIAL REGISTRATION:https://clinicaltrials.gov/study/NCT04614974.

OBJECTIVE:To compare the safety and efficacy of nonopioid versus opioid pain management following adenotonsillectomy (AT) among pediatric patients. STUDY DESIGN:An open-label randomized controlled trial. SETTING:Tertiary care children's hospital. METHODS:Patients aged 3 to 17 years undergoing AT were eligible. Participants were randomly assigned to receive either acetaminophen and ibuprofen (nonopioid group) or acetaminophen, ibuprofen, and oxycodone (opioid group). Pain scores and prevalence of emergency department (ED) visits, hospital readmission, and posttonsillectomy hemorrhage (PTH) were compared between groups. RESULTS:From January 2019 to March 2020, 267 patients were enrolled and randomly assigned; 144 completed a postoperative pain diary. Of the 144, 69 (48%) patients received an opioid prescription, and 75 (52%) did not. Mean pain scores before (opioid: 5.78, 95% CI: 5.29-6.27 vs nonopioid: 5.66, 95% CI: 5.20-6.12) and after (opioid: 2.33, 95% CI: 1.89-2.78 vs nonopioid: 2.24, 95% CI: 1.82-2.66) analgesics were not significantly different between opioid and nonopioid groups. Although 7/75 (9%) from the nonopioid group crossed over and requested opioids, only 43/69 (62%) randomly assigned to receive opioid prescription consumed opioids. The rate of opioid consumption increased with increasing age: 18/71 (25%) patients aged 3 to 7 years, 22/57 (39%) 8 to 12 years, and 10/16 (63%) 13 to 17 years, P = .015. Differences in ED visits, hospital readmissions, and PTH between opioid and nonopioid groups were not significant. CONCLUSION:Many children do not require opioid analgesics following AT, particularly children less than 8 years of age. Postoperative pain scores and outcomes were similar in opioid versus nonopioid groups. Opioid prescriptions should be limited or avoided altogether after pediatric AT. TRIAL REGISTRATION:Title: Nonopioids for analgesia after adenotonsillectomy in children; ID: NCT03618823, Clinicaltrials.gov.

Introduction: Subperiosteal orbital abscesses (SPOA) are the most common suppurative complications of acute bacterial sinusitis. Medial SPOAs arise from infection of the ipsilateral ethmoid sinus and favor initial conservative management reserving surgical drainage for patients who do not demonstrate clinical improvement. No standard algorithm defining medical versus surgical treatment of medial SPOAs exist in the pediatric population. Objectives: To identify a size cutoff for medial SPOAs to predict the likelihood for surgical drainage. Methods: This is a retrospective review of patients with medial SPOAs at a tertiary care center from 2003 to 2017. Diagnosis of SPOA was based on radiographic findings. Variables included are patient demographics, antibiotic therapy, surgical intervention, and length of stay. Results: 82 patients with a medial SPOA were included with an average age at presentation of 6.27 (range 0-15) years were included in this study. 62 patients were male (75.6 %), and 20 were female (24.4 %). The average abscess length was 16.1 mm, range 4.5-30.7 mm. The average abscess width was 4.17 mm, range 1.5-14.6 mm. The odds ratio for surgical treatment with every 1 mm increase in abscess width was 1.89 (95CI:1.33-2.69, p < 0.001). Abscesses over 3.6 mm width were 6.65 times more likely to undergo surgical drainage than those less than 3.6 mm (OR:6.65, 95CI:2.52-17.54, p < 0.001). The average(SD) length of stay was 5.4(3.0) days for patients who underwent surgery and 4.0(0.9) days for patients treated with conservative measures, p < 0.001. Conclusion: Medial SPOAs greater than 3.6 mm were more likely to undergo surgical drainage; however there was no difference in the likelihood of drainage between anteriorly and posteriorly based medial abscesses. These findings help further characterize the landscape of pediatric subperiosteal abscesses that are managed with surgical drainage.

Purpose: A novel "Modified TCA Alloderm (TM) Myringoplasty" (TCA myringoplasty) technique for reconstruction of uncomplicated chronic tympanic membrane (TM) perforations is described. Materials and methods: Descriptive surgical technique for TCA myringoplasty on 12 total patients from 1/1/2020 to 12/31/2020. 3 patients were excluded for incomplete records. Statistical analysis employed Wilcoxon signedrank tests. Both structural (pre/post visual inspection and tympanogram) and functional (pre/post pure tone average, PTA) outcome measures are reported. Results: 12 total ears were analyzed from 9 patients. Average age at surgery was 6 (range 3-22). Perforation size ranged from 10 to 60 %. Rate of structural success was 100 %. Functionally, postoperative PTA were significantly decreased from preoperative (mdn(range) = 18.44(13.13-24.38) vs mdn(range) = 11.25(6.25-22.50), p =.008). Only one TM required >1 procedure to achieve closure. Conclusions: Chronic TM perforations are typically reconstructed via Type I tympanoplasties with temporalis fascia, reserving myringoplasty for favorable perforations (<25 % in size and posterior). Our novel TCA myringoplasty technique has excellent outcomes independent of size and location. We apply a chemical peel concept to a modified myringoplasty technique, obviating incisions and graft harvest. Advantages of Alloderm (TM) include: 1) a more rigid graft, facilitating manipulation and precise placement; 2) various size and thickness options, especially useful for dimeric tympanic membranes, tympanolysis of adhesions, and bilateral perforations; 3) no donor morbidity and harvest time; 4) autologous tissue preservation. The sole disadvantage of cost is mitigated by reduced operative time and complication management. This study revealed encouraging proof-of-concept preliminary data warranting prospective and sufficiently powered analysis, supporting the technique as a viable alternative to the gold standard.

OBJECTIVE:Evidence supporting the use of acid suppression therapy (AST) for laryngomalacia (LM) is limited. The objective of this study was to determine if outpatient-initiated AST for LM was associated with symptom improvement, weight gain, and/or avoidance of surgery. METHODS:A retrospective cohort was reviewed at a tertiary-care children's hospital. Patients were included if they were diagnosed with LM at ≤6 months of age, seen in an outpatient otolaryngology clinic between 2012 and 2018, and started on AST. Primary outcomes were improvement of airway and dysphagia symptoms, weight gain, and need for surgery. Severity was assessed by symptom severity. RESULTS:Of 2693 patients reviewed, 199 met inclusion criteria. Median age of diagnosis was 4 weeks (range: 0-29 weeks). LM was classified as mild/moderate (71.4%) and severe (28.6%) based on symptom severity. Severity on flexible fiberoptic laryngoscopy (FFL) was not associated with clinical severity. Weight percentile, airway symptoms, and dysphagia symptoms improved within the cohort. In total, 26.1% underwent supraglottoplasty (SGP). In multivariate analysis, only severe LM on FFL was predictive of SGP (OR: 7.28, 95%CI: 1.91-27.67, p = .004). CONCLUSION:Clinical symptom severity did not predict response to AST raising the question of utility of AST in LM. Severity of LM based on FFL, not clinical severity, was associated with decision to pursue SGP. Prospective randomized trials are needed to better understand the role of AST in LM. LEVEL OF EVIDENCE:Level 3.

Introduction: The coronavirus disease of 2019 (COVID-19) pandemic catalyzed an unprecedented redesign and innovative overhaul of health care delivery thrusting from fringe to mainstream virtual care. With a return to conventional practice, we now must create a research and policy agenda using the changes wrought by COVID-19 to help create a better health care system in its aftermath. The purpose of this study was to assess satisfaction of otolaryngology outpatient visits during the pandemic. Methods: A prospective survey study was performed on caregivers of all patients ages 0-26 years old seen in the Division of Pediatric Otolaryngology at our large tertiary care children's hospital from February-April 2020. The three study groups were those seen in-person 6 weeks before telemedicine was implemented (IBTM), those seen in telemedicine during the first 6 weeks (TM) it was implemented at our hospital, and those seen in-person during the telemedicine period (IDTM) in the same timeframe. The survey consisted of satisfaction questions related to their visit, if their child was recommended surgery at the time of the visit, and if the caregiver agreed with the recommendation. A medical record review was also performed. Results: A total of 176 caregivers completed the survey with 113(64.2%) completing the survey for an IBTM appointment, 59(33.5%) for a TM appointment, and 4(2.3%) for an IDTM appointment. There were 100(56.8%) male patients and 167(94.9%) were white. Families gave a higher response for the statement "The ability to communicate with the physician" (p=.012) and "The overall outpatient experience" (p=.004) in the IBTM cohort compared to the TM group. There were no significant differences for the other statements regarding the ability to understand recommendations, courtesy, and knowledge of the physician. Regardless of group, 98.6% of caregivers agreed with surgical recommendation when surgery was recommended. However, when surgery was not recommended at the appointment, caregivers were 11x more likely to disagree with the surgical recommendations, OR:11.49,95%CI:1.44-91.38,p=.005. Conclusion: We conclude that telemedicine was equally well received by patients as compared to traditional live assessments suggesting that virtual care is a viable post-pandemic paradigm change. Satisfaction was rated as "Good" or "Excellent", however, messaging when surgery is not recommended was less acceptable and must be improved to obtain increased caregivers' agreement in an era of shared decision making.

Objectives: To determine if children with cystic fibrosis (CF) who are otitis media prone and treated with tympanostomy tube placement (TTP) follow the natural course of non-CF children regarding the incidence of tympanostomy tube otorrhea (TTO) (21-34%). Methods: All CF patients seen at a large tertiary pediatric hospital were retrospectively reviewed from 2010 to 2019. A total of 483 patients were identified and seventeen met the inclusion criteria and were included in the analysis. Data collected included demographics, CF diagnosis history including date of diagnosis and genotype, TTP notes, and otorrhea found in otolaryngology clinic and pediatrician clinic notes for up to 18 months postTTP. Results: CF was diagnosed at a median age of 13 days (0 days to 6 years). In terms of surgical frequency, 14/17 (82.4%) patients had one TTP, 2/17 (11.8%) had two TTPs, and 1/17 (5.9%) had five TTPs. The median (range) age at first TTP was 2 years (3 months to 13 years). After the first TTP, TTO occurred in 5 (29.4%) patients at 3 months, 6 (35.3%) at 6 and 9 months, and 7 (41.2%) at 12 and 18 months at median (range) = 1 (0-5) otolaryngology appointments and median (range) = 0 (0-8) pediatrician appointments. Conclusion: To our knowledge this is the first study to report that CF children are more likely to be severely affected with recurrent acute otitis media (RAOM), to require TTP, and to exhibit a natural history of TTO commensurate with the non-CF population.

Introduction: Subperiosteal orbital abscess (SPOA) is a serious suppurative complication of pediatric sinusitis. The objective of this study is to stratify patient selection into those best treated medically versus surgically based on clinical outcomes. Methods: This is a retrospective review of patients diagnosed with SPOA complicating sinusitis treated at a tertiary care pediatric hospital from 2002 through 2016. SPOA was diagnosed by CT scan. Characteristics evaluated include demographics, abscess size, location, and measurements, length of hospital stay, medical and surgical interventions, presenting symptoms, and complications. Results: A total of 108 total SPOA secondary to sinusitis patients were included. A majority, 72.2%, were male with an average age at presentation of 6.8 years. The mean +/- standard deviation abscess cubic volume was 0.98 +/- 1.27 cm(3) (median(range) = 0.44(0.01-7.34 cmcm(3))). With an abscess volume of 0.510 cm(3), there was a sensitivity of 71.2% and a specificity of 84.4% for needing surgical drainage. Those with large abscesses at our volume threshold were 13 times more likely to require surgery than those with small abscesses, OR: 13.41, 95% CI: 5.02-35.86, p < .001. Patients that required surgery had an abscess closer to the orbital apex with the majority, 25 (61.0%), being the most proximal to the apex, p = .004. The likelihood of surgery decreased with increased distance from the orbital apex in medial abscesses (OR:.92, 95%CI: 0.86-0.98, p = .009). Conclusion: In the pediatric population, SPOA is a serious consequence of sinusitis. This study provides evidence supporting that larger abscess size is a significant risk factor for requiring surgery. The appeal of our study is that it provides evidence and support that employ clinical parameters already assessed as standard practice in evaluating these patients. In summarizing the clinical translational relevance of our study, when determining whether to treat a patient with surgery and antimicrobial/medical therapy vs. non-surgical medical therapy alone, the clinician should focus on size of 0.510 cm(3) or larger for abscesses in any location as a relative indication for surgery.

Our objective was to assess the utility of using lesion-mapping software to calculate precise orbital volumes to predict patients who would benefit from early surgical intervention. We retrospectively reviewed patients diagnosed with subperiosteal orbital abscess (SPOA) secondary to sinusitis at a tertiary pediatric hospital from 2005 to 2016. Diagnoses were confirmed by CT scans. Lesion-mapping software was used to measure SPOA volume using initial CT images. Data collected included patient demographics, length of hospital stay, and subsequent medical or surgical treatment. Thirty-three (52%) patients ultimately underwent surgical intervention, while 30 (48%) were managed medically. Between the surgical and medical groups, there were no differences in gender, age, or comorbidities. The surgical group had larger abscess volumes than the medically managed group (0.94 mL vs. 0.31 mL, p < 0.01). Overall, increased SPOA volume was associated with increased age (Pearson’s coefficient = 0.374, p ≤ 0.01) and increased total days of intravenous (IV) antibiotic administration (Pearson’s coefficient = 0.260, p = 0.039). Patients who underwent surgery on the day of admission had 25% shorter hospital stay than patients who had delayed surgery (p < 0.01). Our calculated sensitivity-optimized SPOA volume cutoff of 0.231 mL yielded sensitivity of 90.9% and specificity of 70.0%. This is the first study to use lesion-mapping software for precise calculation of SPOA volumes, which can help refine indications for early surgical intervention and help decrease length of hospital stay.

Purpose: Recent data have challenged the historical paradigm that cystic fibrosis (CF) protects against otitis media (OM). These findings raised questions about the pathogenesis of this ostensible change. In this study our aim is to characterize acute OM (AOM) risk based on CF genotype. Methods: A retrospective chart review was completed at a tertiary care pediatric hospital. Charts of 159 CF patients seen at our facility from 2010 to 2019 were reviewed. Data collected included demographics, AOM infections, cystic fibrosis transmembrane conductance regulator (CFTR) allele mutations, pulmonary exacerbations (PE), and pancreatic insufficiency (PI) status. Mutation alleles were divided into five classes based on CF guidelines, which were further classified as severe (classes I-III) or mild (classes IV-V). Results: 54% of patients had at least one episode of AOM with a mean of 1.5 episodes of AOM (standard deviation = 2.3). 86% of patients had severe/severe (S/S) alleles and 14% had severe/mild (S/M). S/S patients had significantly more PE (p = .004) and increased rates of PI (p < .001). Of the 131 patients with S/S mutations, 57% had an episode of AOM while only 46% the 22 S/M patients had an AOM episode (p = .357). Conclusions: To our knowledge this is the first report showing a clinical trend towards increased middle ear disease in patients with severe CFTR mutations. Future prospective studies will be powered to demonstrate whether this trend is statistically significant. Patients with S/S mutations not only have more severe clinical phenotypes but may have additional unexpected complications such as middle ear disease.

INTRODUCTION:Voice disorders are a common communication disorder in children. Behavioral voice therapy is recommended by both Otolaryngologists and Speech-Language Pathologists as a first-line approach for treatment of benign vocal fold lesions that affect children in large numbers. However, the role of cognitive mechanisms critical to voice therapy have not yet been explored.OBJECTIVE:This proof-of-concept study aims to provide preliminary data on the potential relation between cognitive abilities and behavioral results of voice therapy for children with benign phonotraumatic vocal fold lesions.METHODS:Six children (4;05 -9;02 years) diagnosed with vocal fold nodules completed a battery of cognitive tests from the NEuroPSYchological (NEPSY-II) Assessment and a standard course of "Adventures in Voice" therapy. Recordings pre and post intervention were analyzed acoustically using the Cepstral Spectral Index of Dysphonia (CSID) and perceptually using visual analog scales (VAS) for severity and resonance separately. Raw and age-corrected scaled scores from the NEPSY-II were then examined for their possible relation to voice outcomes.RESULTS:Multiple cognitive functions correlated with voice outcomes. Raw score measures for Design Fluency, Inhibition, Fingertip Tapping, and Narrative Memory correlated favorably with all voice outcome measures. Age correlated with all NEPSY-II raw scores and perceptual voice outcome measures. Scaled scores for Auditory Attention, Design Fluency, Fingertip Tapping (Dominant hand), and Narrative Memory correlated with all voice outcome measures.CONCLUSION:Results suggest that there is merit to further investigation of the relation between cognitive skills and their development and voice treatment outcomes in children with benign phonotraumatic lesions. Future studies with larger samples will build on present findings.