Acute mastoiditis in children: contemporary opportunities and challenges.

BACKGROUND: Mastoiditis is the most common intra-temporal complication of acute otitis media. Despite potentially lethal sequelae, optimal management remains poorly defined. METHOD: A retrospective case review was conducted of children diagnosed with mastoiditis at a tertiary referral centre, in North East England, between 2010 and 2017. RESULTS: Fifty-one cases were identified, 49 without cholesteatoma. Median patient age was 42 months (2 months to 18 years) and median hospital stay was 4 days (range, 0-27 days). There was no incidence trend over time. Imaging was conducted in 15 out of 49 cases. Surgery was performed in 29 out of 49 cases, most commonly mastoidectomy with (9 out of 29) or without (9 out of 29) grommets. Complications included sigmoid sinus thrombosis (3 out of 49) and extradural abscess (2 out of 51), amongst others; no fatalities occurred. CONCLUSION: A detailed contemporary description of paediatric mastoiditis presentation and management is presented. The findings broadly mirror those published by other UK centres, but suggest a higher rate of identified disease complications and surgical interventions.

Radiology of acute mastoiditis and its complications: a pictorial review and interpretation checklist.

BACKGROUND: Mastoiditis is an otological emergency, and cross-sectional imaging has a role in the diagnosis of complications and surgical planning. Advances in imaging technology are becoming increasingly sophisticated and, by the same token, the ability to accurately interpret findings is essential. METHODS: This paper reviews common and rare complications of mastoiditis using case-led examples. A radiologist-derived systematic checklist is proposed, to assist the ENT surgeon with interpreting cross-sectional imaging in emergency mastoiditis cases when the opinion of a head and neck radiologist may be difficult to obtain. RESULTS: A 16-point checklist (the 'mastoid 16') was used on a case-led basis to review the radiological features of both common and rare complications of mastoiditis; this is complemented with imaging examples. CONCLUSION: Acute mastoiditis has a range of serious complications that may be amenable to treatment, once diagnosed using appropriate imaging. The proposed checklist provides a systematic approach to identifying complications of mastoiditis.

Downstream effects of striatal-enriched protein tyrosine phosphatase reduction on RNA expression in vivo and in vitro.

Striatal-enriched protein tyrosine phosphatase (STEP) is a brain-specific tyrosine phosphatase that has been shown to de-phosphorylate several key neuronal signaling proteins, including kinases (extracellular signal-regulated kinase (ERK1/2), FYN, PYK2) and glutamate receptor subunits (N-methyl-d-aspartate receptor subtype 2B (NR2B), glutamate receptor 2 (GLUR2)). Step knock-out mice have increased phosphorylation of these substrates in the brain, with potential functional consequences in synaptic plasticity and cognitive tasks. It is therefore of interest to identify the molecular pathways and downstream transcriptional targets that are impacted by Step knockdown. In the present study, striatal RNA samples from Step wild-type, knock-out and heterozygous mice were hybridized to Affymetrix microarray chips and evaluated for transcriptional changes between genotypes. Pathway analysis highlighted Erk signaling and multiple pathways related to neurotrophin signaling, neuronal development and synaptic transmission. Potential genes of interest identified by microarray were confirmed by quantitative real-time polymerase chain reaction (qRT-PCR) in the cortex and hippocampus, which shared several transcriptional alterations with the striatum. In order to evaluate Step knockdown in an in vitro system, a panel of genes were evaluated using qRT-PCR in rat cortical neurons that were transduced with lentivirus expressing short hairpin RNA against Step or a non-targeting control. Our data suggest that Step has a role in the expression of immediate early genes relevant to synaptic plasticity, in both in vitro and in vivo systems.

Post-surgical tympanostomy tube follow up with audiology: experience at the Freeman Hospital.

BACKGROUND: Tympanostomy tube (grommet) insertion is a common procedure, with little guidance in the current literature regarding post-operative surveillance. Our institution implemented a protocol to follow up post-surgical grommet patients via audiology at six weeks. METHODS: A retrospective audit of all patients less than 16 years old who had undergone grommet insertion during a three-month period. RESULTS: A total of 149 patients had grommets inserted. Exclusion criteria left a cohort of 123 individuals; 82 (67 per cent) were followed up by audiology. Of these, 13 (11 per cent) did not attend follow up, and were discharged; 53 (43 per cent) were discharged from audiology with normal thresholds; and 16 (13 per cent) were referred back to a consultant. Therefore, the overall reduction in patients followed up by an otolaryngologist was 54 per cent. CONCLUSION: We recommend a six-week follow up with audiology following grommet insertion, allowing for referral back to ENT services in the event of related complications.

The effect of GMC guidelines on the length of otolaryngological out-patient clinics in a district general hospital.

The British Association of Otolaryngologists has laid down guidelines on the length of time that should be allocated to an out-patient consultation. The General Medical Council (GMC) has also produced guidelines as to what is to be discussed with a patient during an out-patient consultation. This study was designed to determine what effect adhering to the GMC's guidelines would have on the length of an out-patient consultation. Out-Patient consultations were timed for patients referred with common otolaryngological complaints. The study was then repeated after the researchers had been given specific instructions on what to discuss with the patients to comply with the GMC guidelines. Consultation times more than doubled after application of the GMC guidelines. This study highlights the difficulty of specifically adhering to guidelines from our regulatory body, while attempting to fulfil the demands for consultations, with the existing manpower levels available.

CT scanning of middle ear cholesteatoma: what does the surgeon want to know?

The history of surgery for middle ear cholesteatoma is of an evolution of techniques to meet the challenges of inaccessible disease and of post-operative cavity management. The concept has traditionally been of exploration guided by awareness and anticipation of all, possibly asymptomatic, complications. Modern imaging reliably demonstrates surgical anatomy, dictating the ideal approach, forewarns of complications and may reveal the extent of disease. An apparent resistance amongst otologists to universal CT scanning prior to mastoidectomy contrasts with the enthusiasm of skull base surgeons or rhinologists for appropriate imaging.

Pattern of ambulatory pharyngo-oesophageal motility and pH-metry in healthy volunteers.

Oesophago-pharyngeal reflux is widely accepted as an aetiological factor in many laryngeal and lower respiratory tract diseases. This study aims to establish normal reference ranges for pharyngo-oesophageal pH and pressure. Twenty-five asymptomatic healthy volunteers underwent ambulatory pharyngo-oesophageal pressure and pH-metry. Acid exposure times were very low. Only one subject showed any evidence of oesophago-pharyngeal reflux during recumbency. Two distinct upper oesophageal sphincter pressure patterns were observed during recumbency-one with episodic dry swallows and moderate tonic pressures, the other with almost complete manometric quiescence. Negative results, i.e. the exclusion of abnormal cervical reflux, appear to be more achievable than quantifiable positive results, but this is not absolutely clear from our results. Categorisation of an individual as having abnormal upper pH-metry requires use of a synchronous pharyngeal probe. pH-metry is likely to be of value in establishing the role of reflux in relation to laryngeal or respiratory disease.

Aspergillus mastoiditis in a patient with acquired immunodeficiency syndrome.

We present the case history of a patient who was severely immunocompromised due to infection with the human immunodeficiency virus (HIV), and who subsequently developed acute mastoiditis due to Aspergillus fumigatus. Fungal otomastoiditis is a rarely reported complication of HIV infection. A high index of suspicion is required in these patients to facilitate early diagnosis and appropriate therapy.