Objective To perform a systematic review to evaluate the risk of malignancy associated with computed tomography (CT) of the head and/or neck in infants, children, and adolescents. Data Sources Pubmed, EMBASE, and the Cochrane Library were assessed from the date of their inception to January 2014. Additionally, manual searches of bibliographies were performed and topic experts were contacted. Review Methods Data were obtained from studies measuring or estimating the risks of malignancy associated with radiation from head and/or neck CT in pediatric populations according to an a priori protocol. Two independent evaluators corroborated the extracted data. Results There were 16 criterion-meeting studies that included data from n = 858,815 patients. The radiation-related risk of malignancy was estimated using primary patient data for both the exposure and outcome in a minority of studies, with most analyses utilizing mathematical modeling techniques. The data regarding otolaryngology-specific studies were limited and suggested a borderline significant increase in the risk of all combined cancers after facial CT (incidence rate ratio [IRR] = 1.14; 95% CI, 1.01–1.28) and neck/spine CT (IRR = 1.13; 95% CI, 1.00–1.28). Cohort data suggest that 1 excess brain malignancy occurred after 4000 brain CTs (40 mSv per scan) and that the estimated risk in the 10 years following CT exposure was 1 brain tumor per 10,000 patients exposed to a 10 mGy scan at less than 10 years of age. Conclusion Detailed understanding of any potential malignancy risk associated with pediatric imaging of the head and neck furthers our ability to engage in rational, shared, informed decision making with families considering CT scan.

Therapeutic, II.

Objective To perform a systematic review to analyze the diagnostic yield of magnetic resonance imaging (MRI) for pediatric hearing loss, including comparison to computed tomography (CT) and subgroup evaluation according to impairment severity and specific diagnostic findings (cochlear anomalies, enlarged vestibular aqueduct, cochlear nerve abnormalities, and brain findings). Data Sources Pubmed, EMBASE, and the Cochrane library were assessed from their inception through December 2013. Manual searches were also performed, and topic experts were contacted. Review Methods Data from studies describing the use of MRI with or without comparison to CT in the diagnostic evaluation of pediatric patients with hearing loss were evaluated, according to a priori inclusion/exclusion criteria. Two independent evaluators corroborated the extracted data. Heterogeneity was evaluated according to the I2 statistic. Results There were 29 studies that evaluated 2434 patients with MRIs and 1451 patients with CTs that met inclusion/exclusion criteria. There was a wide range of diagnostic yield from MRI. Heterogeneity among studies was substantial but improved with subgroup analysis. Meta-analysis of yield differences demonstrated that CT had a greater yield than MRI for enlarged vestibular aqueduct (yield difference 16.7% [95% CI, 9.1%–24.4%]) and a borderline advantage for cochlear anomalies (4.7% [95% CI, 0.1%–9.5%]). Studies were more likely to report brain findings with MRI. Conclusions These data may be utilized in concert with that from studies of risks of MRI and risk/yield of CT to inform the choice of diagnostic testing.

Background Computed tomography (CT) has been used in the assessment of pediatric hearing loss, but concern regarding radiation risk and increased utilization of magnetic resonance imaging (MRI) have prompted us toward a more quantitative and sophisticated understanding of CT’s potential diagnostic yield. Objective To perform a systematic review to analyze the diagnostic yield of CT for pediatric hearing loss, including subgroup evaluation according to impairment severity and laterality, as well as the specific findings of enlarged vestibular aqueduct and narrow cochlear nerve canal. Data Sources PubMed, EMBASE, and the Cochrane Library were assessed from the date of their inception to December 2013. In addition, manual searches of bibliographies were performed and topic experts were contacted. Review Methods Data from studies describing the use of CT in the diagnostic evaluation of pediatric patients with hearing loss of unknown etiology were evaluated, according to a priori inclusion/exclusion criteria. Two independent evaluators corroborated the extracted data. Heterogeneity was evaluated according to the I2 statistic. Results In 50 criteria-meeting studies, the overall diagnostic yield of CT ranged from 7% to 74%, with the strongest and aggregate data demonstrating a point estimate of 30%. This estimate corresponded to a number needed to image of 4 (range, 2–15). The most commonly identified findings were enlarged vestibular aqueduct and cochlear anomalies. The largest studies showed a 4% to 7% yield for narrow cochlear nerve canal. Conclusion These data, along with similar analyses of radiation risk and risks/benefits of sedated MRI, may be used to help guide the choice of diagnostic imaging.

Seasonal variation exists in family perception of physician competence in the ICU, but opposite to the "July effect." The reasons for this variation are not well understood. Further research is necessary to explore the role of senior provider involvement, trainee factors, system factors such as handoffs, or other possible contributors.

Background: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures. Methods: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay. Results: A total of 174 patients with frontal bone fractures met the authors’ inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11). Conclusions: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.