Objectives: Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes. Design: Prospective cohort study. Setting: Tertiary referral critical care center. Patients: Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation. Interventions: Laryngoscopy following endotracheal intubation. Measurements and Main Results: One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48–2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0–6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0–0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0–1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury. Conclusions: Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.

Objective In this meta-analysis, we reviewed observational studies investigating differences in intelligence quotient (IQ) scores of children with unilateral hearing loss compared to children with normal hearing. Data sources PubMed Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO Review methods A query identified all English-language studies related to pediatric unilateral hearing loss published between January 1980 and December 2014. Titles, abstracts and articles were reviewed to identify observational studies reporting IQ scores. Results There were 261 unique titles with 29 articles undergoing full review. Four articles were identified, which included 173 children with unilateral hearing loss and 202 children with normal hearing. Ages ranged from 6 to 18 years. Three studies were conducted in the United States, and one in Mexico. All were of high quality. All studies reported full-scale IQ results; 3 reported verbal IQ results, and 2 reported performance IQ results. Children with unilateral hearing loss scored 6.3 points lower on full-scale IQ, 95% CI [−9.1, −3.5], p-value <0.001; and 3.8 points lower on performance IQ, 95% CI [−7.3, −0.2], p-value 0.04. When investigating verbal IQ, we detected substantial heterogeneity among studies; exclusion of the outlying study resulted in significant difference in verbal IQ of 4 points, 95% CI [−7.5, −0.4], p-value 0.028. Conclusions This meta-analysis suggests children with unilateral hearing loss have lower full-scale and performance IQ scores than children with normal hearing. There also may be disparity in verbal IQ scores. Future studies should investigate ways to reduce potential differences in intellectual achievement.

In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life.OBJECTIVE To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes. DESIGN, SETTING, AND PARTICIPANTSThis prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center.INTERVENTION Onabotulinum toxin A treatment of facial synkinesis. MAIN OUTCOMES AND MEASURES Patient-reported outcomes on the Synkinesis AssessmentQuestionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment. RESULTSIn total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was −14.2 (95% CI, −17.0 to −11.5; P < .001). There was a significant association of postinjection questionnaire score with younger patients, female sex, total dose, and synkinesis severity. Oculo-oral synkinesis may respond more to treatment compared with oro-ocular synkinesis.CONCLUSION AND RELEVANCE Patients with facial synkinesis responded significantly to botulinum treatment. Treatment began with 6 core facial muscles that were injected during most treatment sessions, and dosages increased after the first injection until steady state was achieved. Those with a greater degree of morbidity, younger patients, and females showed significant improvement, and the larger the dose administered, the greater the response. Oculo-oral synkinesis may be more responsive than oro-ocular synkinesis.LEVEL OF EVIDENCE 3.

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Objectives: (1) Describe a presentation of first branchial cleft anomalies. (2) Compare outcomes of first branchial cleft to other branchial cleft anomalies with attention to otologic findings. Methods: For this case-controlled study, databases at Seattle Childrens Hospital were queried by International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes for pediatric branchial cleft cases from 2004 to 2013. Inferential analysis was performed using unpaired t test. Measurements of risk were calculated using Fisher’s exact test. Results: The query identified 104 subjects; 24 (23.1%) of whom had first branchial cleft anomalies, the remaining 80 (76.9%) had second or third branchial cleft anomalies. First branchial cleft anomalies were diagnosed at an older age, 2.65 years (SD = 3.3) versus 1.66 years (SD = 4), P value .28 (not significant). They also presented with a range of otologic findings, including otorrhea (25%), otitis media (29.2%), tympanic membrane web (26.1%), and cholesteatoma (16.7%). They had greater risk of requiring primary incision and drainage: 14 (58.3%) versus 3 (3.8%), odds ratio (OR) 15.12, 95% confidence interval (CI) [3.8, 88.9], P value <.0001. They were also more likely to have recurrent disease: 7 (29.1%) versus 3 (3.8%), OR 7.6, 95% CI [1.59, 49.1], P value .008. They were more likely to undergo additional surgery: 6 (26.1%) versus 4 (5%), OR 4.91, 95% CI [1.07, 25.72], P value .04, often related to residual ear disease. Conclusions: Children with first branchial cleft anomalies present with a range of otologic manifestations that increase the risk of persistent disease and that may require specific treatment such as tympanoplasty.

IMPORTANCEPatients with laryngeal injury after endotracheal intubation often present long after initial injury with mature fibrosis compromising cricoarytenoid joint mobility and glottic function.OBJECTIVE To compare functional outcomes between early and late intervention for intubation-related laryngeal injury. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study involved 29 patients with laryngeal injury resulting from endotracheal intubation who were evaluated at a tertiary care center between May 1, 2014, and June 1, 2018. Ten patients with intubation injury to the posterior glottis who received early treatment were compared with 19 patients presenting with posterior glottic stenosis who received late treatment. Statistical analysis was performed from May 1 to July 1, 2019.EXPOSURES Early intervention, defined as a procedure performed 45 days or less after intubation, and late treatment, defined as an intervention performed greater than 45 days after intubation.MAIN OUTCOMES AND MEASURES Patient-specific and intervention-specific covariates were compared between the 2 groups, absolute differences with 95% CIs were calculated, and time to tracheostomy decannulation was compared using log-rank testing. RESULTSThe 2 groups had similar demographic characteristics and a similar burden of comorbid disease. Ten patients who received early intervention (7 women [70%]; median age, 59.7 years [range, 31-72 years]; median, 34.7 days to presentation [IQR, 1.5-44.8 days]) were compared with 19 patients who received late intervention (11 women [58%]; median age, 53.8 years [range, 34-73 years]; median, 341.9 days to presentation [IQR,). Nine of 10 patients (90%) who received early intervention and 11 of 19 patients (58%) who received late interventions were decannulated at last follow-up (absolute difference, 32%; 95% CI, −3% to 68%). Patients who received early treatment required fewer total interventions than patients with mature lesions (mean, 2.2 vs 11.5; absolute difference, 9.3; 95% CI, 6.4-12.1). In addition, none of the patients who received early treatment required an open procedure, whereas 17 patients (90%) with mature lesions required open procedures to pursue decannulation. CONCLUSIONS AND RELEVANCEThis study suggests that early intervention for patients with postintubation laryngeal injury was associated with a decreased duration of tracheostomy dependence, a higher rate of decannulation, and fewer surgical procedures compared with late intervention. Patients who underwent early intervention also avoided open reconstruction. These findings may bear relevance to the management of patients requiring extended durations of endotracheal intubation during recovery for critical illness related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

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