Bilateral Myringotomy Research Articles

Impact of upper airway obstruction management in Robin Sequence on need for myringotomy tubes

ObjectiveInvestigate an association between upper airway obstruction (UAO) management in Robin Sequence (RS) and need for bilateral myringotomy and tubes (BMT). MethodsRetrospective chart review of RS patients treated at a tertiary free-standing pediatric hospital from 1995 to 2020 was performed. Patients were grouped based on airway management: conservative, tracheostomy, tongue-lip adhesion (TLA), and mandibular distraction osteogenesis (MDO). Demographic data, cleft palate (CP) association, numbers of BMT and ear infections, and audiogram data including tympanograms were collected. One-way ANOVA and Chi-square/Fisher's exact tests were used to compare continuous and categorical data, respectively. Multivariable regression analysis was used to compare BMT rates between treatment groups. ResultsOne hundred forty-eight patients were included, 70.3 % of which had CP. Most patients (67.6 %) had at least one BMT; 29.1 % required two or more BMT. The rate of BMT was higher in patients with CP compared to those with intact palates (p = 0.003; 95 % CI 1.30–3.57) and those treated with tracheostomy (p = 0.043; 95 % CI 1.01, 2.27). Surgically managed patients were more likely to have hearing loss (67.5 % vs. 35.3 %, p = 0.017) and ear infections (42.1 % vs. 20.0 %, p = 0.014) pre-compared to post-procedure for airway management. ConclusionMost RS patients require at least 1 set of BMT. Those with CP and/or treated with tracheostomy had a higher likelihood of needing BMT. Rate of hearing loss and ear infection was higher in surgically managed RS patients. Patients with RS and overt CP require a statistically higher number of BMTs compared to those with either submucous cleft palate or intact palate.

Myringotomy tube placement: understanding the impact of the coronavirus disease 2019 pandemic.

Otolaryngologists perform bilateral myringotomy and tube placement for surgical management for otitis media with effusion. This retrospective study aimed to address the extent to which the coronavirus disease 2019 pandemic and season impact the number of bilateral myringotomy and tube placement procedures performed at a tertiary care centre. A total of 1248 charts of children who underwent bilateral myringotomy and tube placement from January 2018 through February 2021 were reviewed. The cohort included 41.6 per cent females and 58.4 per cent males, with 63.7 per cent having private insurance. The median age at surgery was 2.6 years. The spring season had the most bilateral myringotomy and tube placement procedures per week. The number of bilateral myringotomy and tube placement procedures performed per week after the onset of the coronavirus disease 2019 pandemic was significantly lower compared to the years prior. There was no difference in number of intra-operative effusions pre-pandemic versus after the pandemic onset. This study sheds light on the impact of the coronavirus disease 2019 pandemic and seasonality on the rates of tympanostomy tube procedures, vital for understanding the temporality of ear infections.

Development and implementation of new clinical research program in a rural hospital for children undergoing myringotomies or tonsillectomies and adenoidectomies

Background & Objective: Pediatric sub-specialty procedures are usually performed in large hospitals by specialists. We aimed to develop a protocol in pediatric patients undergoing bilateral myringotomies (BMT) or tonsillectomies and/or adenoidectomies (T&A) in a rural community hospital. Methodology: An IRB-approved, prospective study was performed at Lexington Medical Center to examine the safety (S), emergence (E), and efficacy (E) (SEE) of an anesthetic protocol in patients under 7 y of age undergoing BMT or T&A. A non-specialist anesthesiology-based team performed the protocol related to SEE. Results: Out of 60 patients enrolled in the study, 4 (6.6%) desaturated (lowest SpO2 87%), and 6 (10%) had poor quality of emergence from anesthesia. The mean times for induction, emergence, and surgery for BMT were 4.8 ± 1.3, 4.2 ± 2.2, and 3.9 ± 1.0 min respectively. The mean times for induction-intubation, emergence-extubation, and surgery for T&A were 9.0 ± 2.9, 12.1 ± 6.8, and 14.6 ± 5.8 min respectively. Conclusion: The development of a clinical research program and study protocol was achieved for pediatric ENT procedures at a rural hospital. We found that Lexington Medical Center had a low incidence of desaturation, good quality of emergence from anesthesia, and efficacy. Key words: BMT: bilateral myringotomies; Desaturation; Emergence; Protocol; Pediatric; Citation: Bryan YF, Wong K, Johnson KN, Choi JA, Harris H, Galla J, Chapman B. Development and implementation of the new clinical research program in a rural hospital for children undergoing myringotomies or tonsillectomies and adenoidectomies. Anaesth. pain intensive care 2023;27(3):315−324. DOI: 10.35975/apic.v27i3.1501 Received: May 17, 2021; Reviewed: August 30, 2021; Accepted: May 10, 2023

Effect of the coronavirus disease 2019 pandemic on paediatric bilateral myringotomy and tube insertion rates in New Brunswick, Canada.

To assess the effect of the coronavirus disease 2019 pandemic on paediatric bilateral myringotomy and tube insertion rates in New Brunswick, Canada. All paediatric bilateral myringotomy and tube insertion cases from 1 July 2015 through 30 June 2021 were provided by New Brunswick Medicare. The numbers of otolaryngologists, cataract surgical procedures, total hip arthroplasties and thyroidectomies were collected to assess the availability of operating theatres and otolaryngologists. Negative binomial logarithmic regressions were used for analyses. Of the 5175 paediatric bilateral myringotomy and tube insertion cases that were included, the bilateral myringotomy and tube insertion rate significantly decreased by 2.9 times (p < 0.001) during the pandemic. Thyroidectomies, cataract surgical procedures and total hip arthroplasties did not significantly decrease. The number of otolaryngologists increased (20 vs 16-17). Paediatric bilateral myringotomy and tube insertion rates significantly decreased during the pandemic. This cannot be accounted for by reduced otolaryngologists or operating theatre availability. The paediatric bilateral myringotomy and tube insertion rate decrease is likely due to public health measures reducing the transmission of upper respiratory tract infections, resulting in fewer indications for paediatric bilateral myringotomy and tube insertion.

Common Pediatric Otolaryngology Procedures: Ergonomic Considerations.

Background Otolaryngologists in high-volume children's hospitals developed their operating room workflow practices based on the factors of safety, efficiency, and surgeon preference. Recent data show important benefits and potential reduced risks of proper ergonomic positioning for surgeons to prevent injury. These data suggest that the current operating room workflow practices, in addition to prior training, should be monitored and hopefully improved for surgeons' health. Surprisingly, recent studies have suggested the benefits of standing versus sitting on cognitive function. Objective This study reports the workflow norms for seven operating procedures in pediatric otolaryngology. We seek to identify 1) surgeon preferences, 2) when practices become norms, and 3) whether procedure positions are associated with surgeon discomfort or injury. Methods The Otolaryngology Section of the American Academy of Pediatrics was queried employing a 23-question survey. We included demographic information, reasons for preferences, and surgeon-reported pain. We focused on three workflow issues: 1) length of procedures, 2) site selection (operating room bed vs. transport stretcher), and 3) position of the surgeon (sitting vs. standing). Results Sixty-nine American Academy of Pediatrics members completed the survey. The length of the procedure had minimal effect, with 90% sitting for short procedures such as bilateral myringotomy with tubes, myringoplasty, tonsillectomy, and adenoidectomy. All sit for direct laryngoscopy and bronchoscopy. Most stand for the removal of nasal foreign bodies, drainage of neck abscess procedures, and thyroglossal duct cyst excision. Residency training (75%) and personal comfort (81%) were the more frequently cited reasons for preference. Fewer than one in five (16%) reported preexisting neck or back pain, but this doubled (35%) throughouttheir otolaryngology practice. Conditional distributions of pain showed reports of pain were greater for individuals in practice for over 20 years. Conclusions Pediatric otolaryngologists develop their operating room preferences early during residency training. High rates of neck and back pain (35%) may develop during a surgeon's career. We suggest improved understanding of ergonomics in concert with operating room workflow should be considered during otolaryngology residency training since recent data suggest potential benefits of standing on cognitive function.

Effusion Prevalence at Tympanostomy During COVID-19: Follow-Up.

We previously reported pandemic year (2020) intraoperative middle ear effusion (MEE) rate at time of bilateral myringotomy tube (BMT) placement was 18% lower compared to pre-pandemic year (2019). After mandatory stay at home orders (MSHO) and pandemic social distancing precautions were relaxed, we aimed to assess the impact of a persistent pandemic with new COVID-19 variants on MEE presence during BMT. This study is a retrospective chart summary exempted by Nemours institutional review board at a single tertiary children's hospital. Children < 18years who underwent BMT during March 1, 2019-June 31, 2019 (pre-COVID), March 1, 2020-June 31, 2020 (PY1), and March 1, 2021-June 31, 2021 (PY2) were included. Statistical analysis included chi-squared and KruskalWallis. A total of 1069 BMTs were reviewed: 551 (52%) during pre-COVID, 227 (21%) during PY1, and 291 (27%) during PY2. There were no significant differences in age, sex, or BMI across comparison groups. Intraoperative MEE was significantly higher pre-COVID (83%) compared to PY1 (65%) and PY2 (69%) (P < .001) despite a small rebound in PY2. Intraoperative MEE remains lower in subsequent pandemic years despite relaxed public health measures and may be impacted by persistent public health measures like masking, lower return to daycare, variable social distancing, and/or change to access to health care.

Adherence to Tympanostomy Tube Clinical Practice Guidelines in an Advanced Practice Provider Clinic.

We compared adherence rates by attending otolaryngologists (OTOs) and advanced practice providers (APPs) to the 2013 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline (CPG) for children with recurrent acute otitis media (RAOM) undergoing bilateral myringotomy and tympanostomy tube placement (BMT). Patients aged 6 months to 12 years old undergoing BMT for RAOM who had a pre-operative visit with an independent APP or OTO were reviewed. Patients satisfied CPG criteria if middle ear effusion was identified at the pre-operative visit (pre-op) or if they did not have effusion but met exception criteria based on their risk for developmental difficulties and contraindications to medical therapy. Adherence rates between APPs and OTOs were compared. Agreement between pre-op and time-of-surgery middle ear effusion identification was assessed. Nine hundred twenty-three patients were included. Six hundred one patients were seen by OTOs and 322 by APPs. Middle ear effusion was identified at pre-op in 84% of APP patients and in 76% of OTO patients (P = .005). Eight percent of APP patients and 11% of OTO patients met exception criteria (P = .138). Overall, 87% of OTO patients and 92% of APP patients met either CPG or exception criteria for BMT (P = .037). A logistic regression model demonstrated that pre-op provider type did not significantly impact rates of agreement between pre-op visit and time-of-surgery middle ear effusion identification. Independent APP-led clinics can reliably and effectively deliver evidence-based care for prevalent conditions such as RAOM at similar rates of adherence to CPGs as OTOs.

Middle Ear Condition at the Time of Pediatric Myringotomy Tube Placement: Pain Associations Following Intraoperative Fentanyl/Ketorolac and Seasonal Variation.

Ketorolac-refractory pain behavior following bilateral myringotomy and pressure equalization tube placement (BMT) is associated with the absence of middle ear fluid. Intraoperative fentanyl/ketorolac affords more reliable pain control than ketorolac alone. We hypothesized that middle ear condition would correlate with postoperative pain despite such combination therapy. We further sought to demonstrate seasonal variation in ear condition and its influence on pain. We conducted a single-institution retrospective cohort study of healthy children (9 months-7 years), who underwent BMT by a single surgeon from 2015 to 2020. Anesthetic care included sevoflurane/nitrous oxide/oxygen/air by mask and intramuscular fentanyl/ketorolac. Left/right middle ear fluid status was recorded at the time of BMT, and ear condition (primary exposure) was dichotomized as bilateral infected (mucoid or purulent) or normal/unilateral infected. The primary outcome was maximum postanesthesia care unit Face, Legs, Activity, Cry, and Consolability (FLACC) score: 4-10 (moderate-to-severe pain) versus 0-3 (no-to-low pain). Rescue oxycodone, acetaminophen administration, and emergence agitation were secondary outcomes. Statistical analysis incorporated generalized linear mixed-effect models (GLMMs) with random intercepts to account for clustering by anesthesia provider. A year-over-year monthly time-series analysis was conducted using an autoregressive integrated moving average (ARIMA) regression model. Excluding recurrent cases, 1149 unique evaluable subjects remained. Bilateral infection prevalence was 39.8% (457/1149; 95% confidence interval [CI], 37.0-42.6). Probability of moderate-to-severe pain behavior was 23.5% (270/1149; 95% CI, 21.1-26.0) overall. Compared to patients with bilateral infected middle ears, those with normal/unilateral infected ears were more likely to have a FLACC score ≥4 (26.7% [185/692] versus 18.6% [85/457]; odds ratio [95% CI], 1.7 [1.2-2.3]; P = .002). Variability in pain outcome explained by the multivariable GLMM was 4.7%. Fentanyl dose response was evidenced by oxycodone administration differences ( P ≤ 0.002). Moderate-to-severe pain and emergence agitation were more likely with reduced fentanyl dosing. Bilateral infection prevalence exhibited seasonality, peaking in March and nadiring in July. However, pain outcomes did not vary by season. Normal/unilateral infected ears at time of pediatric BMT are associated with higher incidence of moderate-to-severe postoperative pain following intraoperative fentanyl/ketorolac administration, but the predictive value of ear condition on pain is limited. Infections were less common in the summer.

701 Outcomes for Paediatric Patients Awaiting Bilateral Myringotomy and Ventilation Tube Insertion for Otitis Media with Effusion Listed Prior to the COVID-19 Pandemic

Abstract Aim The decline in the incidence of otitis media with effusion (OME) during the COVID-19 pandemic has become apparent. This review investigates the outcomes for children with OME awaiting bilateral myringotomy and ventilation tube (BMT) who were referred prior to the COVID-19 pandemic. Method All patients were reviewed in otolaryngology clinics between 1st February and 30th April 2021. Patients included were referred due to hearing, vestibular or developmental disorders prior to the first COVID-19 lockdown on 23rd March 2020. Analysis of routine consultation and audiological assessment was completed from records. Results There were a total of 48 patients awaiting BMT. The average age was 6.8 years, with a male to female ratio of 1.38:1. Most initial referrals (54.2%) were due to hearing loss, followed by recurrent ear infections (33.3%). Forty-four patients were diagnosed with OME. Of those, only 9% remained awaiting BMT. All others were removed from the waiting list. One patient remained listed for an adenotonsillectomy, 30 were discharged, and nine required follow-up appointments. Conclusion Our review demonstrates a significant reduction of BMT for OME following COVID-19. Further research on public health measures and changes in clinical practice during the 2020 lockdown would clarify the impact on OME.

Intranasal Midazolam With Lidocaine for Sedation in Pediatric Myringotomy and Tube Surgery: A Randomized Controlled Trial

Background and Aims: Intranasal midazolam (INM) sedation for children has been associated with side effects. This prospective, double-blind, placebo-controlled trial assessed whether the addition of lidocaine to INM (INM+L) affected efficacy or discharge time among pediatric patients undergoing elective bilateral myringotomy and tube placement (BMT).Methods: This trial enrolled children aged between 18 months to seven years undergoing BMT, physical status class 1 or 2, in a single academic medical center. Interventions were placebo (intranasal saline), INM only (0.2mg/kg of INM concentration 5mg/ml), and INM+L (0.2mg/kg INM with addition of lidocaine 4% based on 25% of midazolam volume). Outcomes included post-anesthesia care unit times, observed behavioral distress (OBD) visual analog scale (VAS) (by nurse and parent), and sedation scores by certified registered nurse anesthetist (CRNA) and registered nurse (RN).Results: Forty-two subjects were included, 14 in each group, with 52% female, 41% physical status 2, and an average age of 2.7 years. Post-anesthesia care unit times averaged 36.5 minutes (range 15-132 minutes), with no delay in discharge with INM or INM+L versus placebo (p=0.88). Verbal complaints were highest among INM+L at the time of administration (p=0.01). RN-scored OBD at one minute post administration differed significantly across the three groups (p=0.01). Parental OBD scores did not differ across treatment groups. Agitation was greatest at time of induction of anesthesia in the placebo group (p=0.01).Conclusions: The addition of licodaine to INM does not adversely influence time to discharge and does not reduce side effects, improve efficacy, or change duration of action of INM.

Effect of Intranasal versus Intravenous Fentanyl on the Emergence Agitation after Sevoflurane Anesthesia in Children Undergoing Bilateral Myringotomy: A Prospective Randomized Controlled Double-Blinded Study

Effect of Intranasal versus Intravenous Fentanyl on the Emergence Agitation after Sevoflurane Anesthesia in Children Undergoing Bilateral Myringotomy: A Prospective Randomized Controlled Double-Blinded Study

Formula Otorrhea in Pediatric Patients With Cleft Palate.

The case series details 2 unusual cases of male newborns with cleft lip and palate (CLP) that later developed formula otorrhea. Both patients underwent bilateral myringotomies with the insertion of pressure equalizing (PE) tubes for chronic otitis media with effusion (OME). Chronic otorrhea associated with feeding occurred post-PE tube insertion and the otorrhea was later confirmed to be due to reflux of formula. Patients were treated with antibiotic ear drops, routine ear cleaning, anti-reflux medication, and reflux precautions. After definite cleft palate repair, formula otorrhea completely resolved. When patients with CLP develop chronic OME or otorrhea following PE tube placement, reflux of formula into the middle ear should be considered and treated accordingly.

Effect of Insurance Type on Postoperative Tympanostomy Tube Follow-up.

Bilateral myringotomy with tube insertion (BMT) is a common procedure performed in children. Appropriate follow-up is necessary to ensure management of postoperative sequalae. The objectives are to investigate (1) the relationship between insurance type and postoperative follow-up attendance and (2) the effect of follow-up on need for further care after BMT. Retrospective cohort study. The study included patients <3 years of age undergoing BMT for recurrent acute otitis media at a tertiary care children's hospital within a single year and followed for 3 years. Patients were excluded if they had received a prior BMT; underwent a concurrent otolaryngologic procedure; or had a syndromic diagnosis, craniofacial abnormality, or any significant cardiac or respiratory comorbidity. Number of follow-up appointments, demographics, socioeconomic status, and postoperative outcomes were analyzed. A total of 734 patients were included with mean (SD) age of 1.4 years (0.50). The majority of patients had private insurance (520/734, 70.8%). Patients with public insurance attended fewer postoperative appointments (1.5 vs 1.8, P < .001) and had a higher incidence of BMT-related emergency department (ED) visits (10.3% vs 3.8%, P = .001). There was no significance found when different insurance providers were compared. An adjusted multivariate regression analysis showed that patients with private insurance were more likely to attend postoperative appointments (odds ratio, 3.52 [95% CI, 2.12-5.82]; P < .001) and less likely to have a BMT-related ED visit (odds ratio, 0.42 [95% CI, 0.20-0.89]; P = .024). Insurance type is related to outcomes after the treatment of recurrent acute otitis media with BMT. Future studies that survey individuals will help identify barriers that contribute to patient absence at follow-ups and need for subsequent ED visits.

Minimally Invasive Anesthesia in Pediatric Circumcision: A Case Series.

Anesthetic management of pediatric circumcisions typically involves intravenous access and advanced airway management. We explored the use of a minimally invasive anesthetic protocol for pediatric circumcisions akin to the anesthetic management for bilateral myringotomy and tympanostomy. Five pediatric circumcisions were performed under mask ventilation without intravenous access and evaluated for intraoperative anesthesia times, patient outcomes, and complications. The mean (standard deviation) intraoperative anesthesia time was 41.4 (5.7) minutes, and 1 patient experienced a mild intraoperative complication with emesis at induction. Pediatric circumcisions can be efficiently and safely performed with minimally invasive anesthesia.

Middle ear effusion prevalence at time of tympanostomy before and during COVID-19 pandemic

BackgroundManagement of pediatric otitis media with effusion (OME) and recurrent otitis media typically includes observation up to 3 months. Bilateral myringotomy and tube (BMT) placement is performed due to persistent effusion with associated symptoms such as decreased hearing. With the COVID-19 pandemic and mandatory stay at home orders (MSHO), children were quarantined at home and many remained home after MSHO. We reviewed the prevalence of middle ear effusion (MEE) at the time of BMT during similar time periods in the year before, during and after MSHO in this pandemic year. Study designRetrospective summary of BMT cases at a single tertiary children's hospital. MethodsAll children <18 years who underwent BMT between March 1, 2020 and July 1, 2020 and between March 1, 2019 and July 1, 2019 were included. Statistical analysis included chi-squared and Mann-Whitney U tests. ResultsA total of 778 cases were reviewed; 551 (71%) were performed pre-pandemic and 227 (29%) during onset of pandemic (N = 778). There were no significant differences in gender, age, and BMI between groups, but significantly fewer Caucasians (58% vs. 45%, p < 0.05) and more Hispanics (20% vs. 33%, p < 0.05) during-COVID. The prevalence of intraoperative effusion during-COVID was significantly lower compared to pre-COVID (65% vs. 83%, p < 0.001). ConclusionPandemic and COVID-19 MSHO were associated with significantly lower intraoperative OME prevalence. Further research may elucidate the impact of face covering, social distancing, and virtual schooling on the incidence of pediatric ROM, OME, and ENT symptoms.

It's a rash: Antibiotic allergies in the modern era of antibiotic stewardship

ObjectivesTo determine whether current guidelines emphasizing antibiotic stewardship in pediatrics have been associated with reduced prevalence of antibiotic allergies in children severely affected by otitis media undergoing bilateral myringotomy with tympanostomy tube insertion (BMT) or by recurrent sinusitis or adenotonsillitis undergoing adenoidectomy with or without tonsillectomy. MethodsCase series of consecutive patients undergoing BMT or adenoidectomy with/without tonsillectomy for recurrent acute otitis media, recurrent sinusitis, or recurrent tonsillitis during November 2008 or November 2017 at a tertiary care children's hospital. Children with primarily obstructive indications for surgery, with prior tube placement or adenoidectomy, or with surgery by an outside provider were excluded. Demographics, type of surgery, and allergies or allergic symptoms were collected from the electronic medical record. Factors associated with antibiotic allergies were compared using logistic regression, Wilcoxon rank-sum, or Chi-squared test. ResultsSeventy-five children who underwent surgery during 2008 and 75 children who underwent surgery in 2017 were included. Overall, median age at surgery was 3.24 years (range 0.56–17.49 years). Seventy-nine (52.7%) patients were female and 95 (63.3%) had private insurance. BMT was the most common surgery (82 children, 54.7%) followed by tonsillectomy with adenoidectomy (46 children, 30.7%), and adenoidectomy without tonsillectomy (39 children, 26.0%). Symptoms of allergic rhinitis were reported by 53 (35.3%) patients, and 11 (7.3%) and 5 (3.3%) had positive environmental and food allergy testing, respectively. Surprisingly, there was not a significant difference between the prevalence of antibiotic allergies in patients undergoing surgery during 2017 (17 patients, 22.7%) compared with 2008 (14 patients, 18.7%) (OR: 1.28, 95% CI: 0.578–2.82, p = 0.546). However, antibiotic allergies were less common in females (OR: 0.413, 95% CI: 0.182–0.937, p = 0.034) and more common in patients with a family history of antibiotic allergies (OR: 36.9, 95% CI: 5.12-∞, p < 0.001). ConclusionPediatric otolaryngology surgical patients continue to exhibit a similar and high prevalence of antibiotic allergies in 2017 compared with 2008. Future studies are needed to determine whether this is because of overdiagnosis of antibiotic allergies or a failure of antibiotic guideline adherence to reduce antibiotic allergy prevalence.

MASSIVE AIR PULMONARY EMBOLISM: IS IT REAL?

SESSION TITLE: Fellows Pulmonary Vascular Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Air embolism is a rare but potentially catastrophic condition that occurs when air enters into the vasculature. Here we present a case of venous- air-embolism causing hemodynamic compromise that was treated with hyperbaric oxygen. CASE PRESENTATION: 63 years old female with COPD on LTOT presented at an outside hospital with worsening shortness of breath, found to be in hypercarbic respiratory failure presumable from acute exacerbation of COPD. Peripheral iv lines were placed, she was given fluids and placed on antibiotics, nebulizers and steroids. Patient rapidly deteriorated into refractory shock requiring pressors and hypoxia needing endotracheal intubation. Patient was also noted to have a seizure while in the ED. On transfer to our hospital, patient continued to remain in refractory shock and refractory hypoxia with PaO2/FiO2 ratio of 150. CXR showed changes consistent with obstructive lung disease. CT scan of chest was performed given unexplained hypoxia and shock which showed evidence of air in the main pulmonary artery extending into the segmental and subsegmental arteries with air also tracking from left subclavian vein into SVC. CT scan of head was unremarkable. Diagnosis of venous air embolism was made, and patient was placed in left lateral decubitus, Trendelenburg position with 100% FiO2 on the ventilator. Decision was made to proceed with hyperbaric oxygen therapy (HBO) due to severe hemodynamic instability. ENT was consulted for bilateral myringotomies prior to the therapy. Patient successfully received hyperbaric oxygen therapy for almost 7 hours, with complete resolution of air embolism on repeat CT scan of chest. Patient came off of vasopressors immediately after completion of treatment. She was extubated on day 4 of mechanical ventilation. DISCUSSION: Air embolism is a rare but potentially catastrophic condition that occurs when the air enters into the vasculature. It can be venous and arterial. Common causes include vascular intervention, surgery, trauma, barotrauma from mechanical ventilation and diving. Diagnosis require high clinical suspicion and imaging evidence. Treatment options are limited including positioning, HBO and direct removal of air. Venous embolisms are self-limiting if volume of air is <50 ml, beyond which patients can have direct and indirect effect of embolism. Based on indications different treatment tables are used for HBO therapy. It was thought that our patient had iatrogenic air embolism from IV access placed on the left arm. She was appropriately started on HBO as she was hemodynamically unstable. There is limited literature about direct removal of air using catheters and it is typically performed when catheters are already in place. CONCLUSIONS: Air embolism, especially pulmonary air embolism, is life threatening and prompt intervention with appropriate positioning and HBO are life saving measures. Reference #1: King, Melissa B., and Keith R. Harmon. “Unusual forms of pulmonary embolism.” Clinics in chest medicine 15.3 (1994): 561-580. Reference #2: Leach, R. M., P. J. Rees, and P. Wilmshurst. “Hyperbaric oxygen therapy.” Bmj 317.7166 (1998): 1140-1143. Reference #3: Bessereau, Jacques, et al. “Long-term outcome of iatrogenic gas embolism.” Intensive care medicine 36.7 (2010): 1180-1187. DISCLOSURES: No relevant relationships by Hassan Yousaf, source=Web Response

The Addition of Intravenous Propofol and Ketorolac to a Sevoflurane Anesthetic Lessens Emergence Agitation in Children Having Bilateral Myringotomy with Tympanostomy Tube Insertion: A Prospective Observational Study.

The aim of this prospective observational study was to determine if children undergoing bilateral myringotomy and tympanostomy tube insertion with a sevoflurane anesthetic plus intravenous propofol and ketorolac experienced a lower incidence of emergence agitation than those receiving a sevoflurane anesthetic alone. Duration of procedure, length of stay in post-anaesthesia care and level of nursing effort required to care for patients were also assessed. In this study, 49 children younger than 13 years of age received a sevoflurane anesthetic. Fifty-one percent of these patients also received a single injection of propofol 1 mg/kg and ketorolac 0.5 mg/kg at the end of the procedure. Patients were assessed for emergence agitation using the Pediatric Anesthesia Emergence Delirium scale in the post-anaesthesia care unit. Four children receiving a sevoflurane anesthetic alone experienced emergence agitation, while no children receiving propofol and ketorolac experienced emergence agitation (p = 0.05). The length of stay until discharge from the hospital was 6.98 min longer for patients receiving propofol and ketorolac but did not reach statistical significance (p = 0.23). Nurses reported greater ease in caring for patients receiving the propofol and ketorolac injection (recovery questionnaire score 4.50 vs. 3.75, p = 0.002). In this study, adding a single injection of intravenous propofol and ketorolac to the end of a brief sevoflurane anesthetic for bilateral myringotomy with tube insertion was associated with a lower incidence of emergence agitation without significantly increasing the time to discharge from the hospital.

Efficacy and Safety in Combining Primary Palatoplasty and Myringotomy in Patients with Cleft Palate.

Background:Patients born with a cleft lip and palate undergo multiple surgical procedures, increasing the infants’ exposure to anesthesia and potential risk of neurocognitive delays. In addition, these numerous procedures lead to greater use of hospital resources. This study analyzes the differences in anesthetic exposure and perioperative characteristics between performing combined versus separate primary palatoplasty (PP) and placement of bilateral myringotomy tubes (BMT).Methods:We reviewed patients younger than 2 years who underwent PP and BMT at our institution from June 2014 to January 2019. Patients who underwent PP and BMT during the same admission (combined group = 74) and during separate admissions (separate group = 26) were studied. Due to the small sample size in the separate group, additional data for this group were gathered by propensity score matching by gender, race, and American Society of Anesthesiology class. Statistical analyses were carried out to identify significant differences between the 2 groups. Linear regression was performed to compare perioperative variables.Results:One hundred patients met the inclusion criteria. There were no significant differences in demographic characteristics or American Society of Anesthesiology class, surgery and anesthesia duration, dosage of intraoperative dexmedetomidine, hospital length of stay, and perioperative complications (P > 0.05). Per contra, combined group had significantly lower intraoperative dosages of fentanyl (P = 0.01) and shorter postoperative care unit stay (P = 0.047).Conclusions:This study documents decreased postoperative care unit time and anesthesia drug exposure without increased length of stay or perioperative complications in patients undergoing combined PP and BMT. These results support combining PP and BMT to reduce exposure to potentially neurotoxic medications and to increase efficient utilization of hospital resources.

Principal Factors Associated With Ketorolac-Refractory Pain Behavior After Pediatric Myringotomy and Pressure Equalization Tube Placement: A Retrospective Cohort Study.

Prophylactic analgesic administration reduces pain behavior after pediatric bilateral myringotomy and pressure equalization tube placement (BMT). We hypothesized that postoperative pain in children treated with intraoperative ketorolac would, among several exposures of interest, be strongly associated with ear condition. We conducted a retrospective cohort study of healthy children (9 months to 7 years) who underwent BMT at the Children's Hospital of Philadelphia or its ambulatory surgery centers from 2013 to 2016. Anesthetic care included preoperative oral midazolam, sevoflurane/nitrous oxide (N2O)/air/oxygen (O2) by mask, and intramuscular ketorolac. Demographic and procedural information included left and right tympanic membrane (normal, retracted, or bulging) and middle ear (normal/no, serous, mucoid, or purulent effusion) conditions. Because tympanic membrane and middle ear conditions were highly concordant and mean maximum Face, Legs, Activity, Cry and Consolability (FLACC) scores (0-10) were not different across the array of abnormal findings, we categorized each ear as normal or abnormal based on middle ear effusion alone. We then defined the ear condition of each child (primary exposure) using bilateral findings: normal/normal, normal/abnormal, and abnormal/abnormal. Secondary exposures included age, BMT history, procedure duration, facility location, and attending surgeon/anesthesiologist pair. The primary outcome was maximum postanesthesia care unit FLACC score: 4-10 (moderate-to-severe pain) versus 0-3 (no-to-low pain). Rescue oxycodone, acetaminophen administration, and emergence agitation were secondary outcomes. Statistical analysis incorporated generalized linear mixed models with random intercepts accounting for the clustering effect of provider pairs. Adjusting for multiple comparisons, significance level was set at P = .004. Excluding recurrent cases, 1922 unique evaluable subjects remained. The probability of moderate-to-severe pain behavior (FLACC, 4-10) was 52.4% (95% confidence interval [CI], 50.2-54.6) overall. In a confounder-adjusted model, ear condition was significantly associated with moderate-to-severe pain: compared to bilateral abnormal (effusions), odds ratio (OR) (95% CI) for bilateral normal was 2.2 (1.6-2.9), P < .0001. Younger age (OR, 1.1 [1.1-1.2] per year; P = .001) and longer procedure duration (OR, 1.1 [1.0-1.2] per minute; P = .0008) were likewise related to higher pain. With surgeon added to the model, variance explained by provider pairs decreased from 9.60% to 1.05%. Two secondary outcome associations also emerged: comparing bilateral normal to abnormal ears, ORs were 1.7 (1.3-2.2), P = .0001, for rescue oxycodone and 2.0 (1.2-3.3), P = .008, for emergence agitation. Pain behavior after BMT varies by surgeon and is strongly associated with ear condition. Ketorolac as a single prophylactic analgesic appears less effective in younger children with normal middle ear findings.