Objective. Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type.Purpose. The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes.Action Statements. The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3-to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for sp...
To compare the cost and margin adequacy of Mohs micrographic surgery (Mohs) and traditional surgical excision (TSE) for the treatment of facial and auricular nonmelanoma skin cancer (NMSC).Design: Prospective cost analysis with each patient serving as his or her own control.Setting: Study was performed from 1999 to 2001 at the University of Connecticut dermatology clinic, a tertiary care referral center.Patients: A total of 98 consecutive patients with a primary diagnosis of NMSC on the face and ears. Main Outcome Measures:The average cost of Mohs and TSE per patient for the treatment and repair of NMSC; adequacy of TSE margins after the initial procedure (because this outcome affects overall cost).Results: Mohs was cost comparable to TSE when the subsequent procedure for inadequate TSE margins after permanent section was Mohs
Idiopathic BPPV subjects have a high prevalence of osteopenia/osteoporosis. Levels of biochemical markers of bone turnover correlate with presence of BPPV. Our results, based on a sample of U.S. subjects, support an association between idiopathic BPPV and disorders of bone turnover.
Full-term and preterm infants were evaluated with click+voked and distortionproduct otoacoustic emissions [CEOEs and DPOEs]. The CEOEs and D W E s recorded from each individual ear were analyzed by calculating the rootimean-square levels within halfa%ave bands. The fail criterion of the OE tests was that the halfoctave RMS DPOE or CEOE levels of an ear under test were below the 1 0 t h percentile of full-term newborns in t w o o r more bands. The DPOE data were collected from 118 ears of 61 premature babies; 80 (68%] ears passed the DPOE test, 30 [25%] ears without middle ear effusions failed the test, and 8 (7%] ears with effusions also failed. The CEOE data were collected from 128 ears of 65 premature babies; 102 (80%) ears passed the CEOE test, 18 (14%) ears without middle ear effusions failed the test, and 8 (6%] ears with effusions also failed. In 23 of 80 ears (29%) that passed the D W E test and in 23 of 102 ears (23%] that passed the CEOE test, RMS OE levels of preterm infants were above the 9 0 t h percentile of fulLterm newborns. The analyses of the combined DPOE and CEOE data obtained from a group of 25 ears of full-term newborns and from a group of 72 ears of preterm babies showed statistically significant correlations between the DPOE and CEOE rootmean-square levels in each of the half-octave bands in the 1.4 to 4 kHz region. For 42 preterm infants tested with auditory brain stem response [ABR), specificity was 86% for CEOE and 74% for DPOE. All infants who failed the ABR also failed OE tests. To the best of our knowledge, this study is the first using combined D W E s , CEOEs, and ABRs for preterm babies. It showed the feasibility of D W E s and CEOEs for this population.
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