Clarifying the Diagnosis and Management of Acute Uncomplicated Pediatric Mastoiditis.

INTRODUCTION: Acute pediatric mastoiditis is a bacterial infection of the mastoid bone most commonly associated with acute otitis media. Complicated mastoiditis is traditionally characterized by intracranial complications or subperiosteal abscess, but definitions are inconsistent in the literature. Surgical intervention is identified as the main treatment for complicated mastoiditis, but there is some evidence to support medical management of uncomplicated mastoiditis. This study sought to clarify the diagnostic criteria and management of uncomplicated acute mastoiditis. METHODS: All cases of acute pediatric mastoiditis were identified from a single institution over a 16-year period and reviewed for demographic and clinical data. Two different definitions of uncomplicated mastoiditis were compared; the traditional one that excluded patients with intracranial complications or subperiosteal abscess (SPA) and the proposed definition that also excluded patients with any evidence of bony erosion including coalescence, not just SPA. Univariate and multivariate analysis was conducted. RESULTS: Eighty cases were identified. Using the traditional definition of uncomplicated mastoiditis, 46.3% of cases were uncomplicated, compared to 36.2% when using the proposed definition. Truly uncomplicated patients, categorized with the proposed definition, were treated more consistently: no patients underwent mastoidectomy and they were less likely to receive a long term course of antibiotics. On multivariate regression analysis, only categorization with the proposed definition of uncomplicated mastoiditis was independently associated with less long-term antibiotic therapy and non-surgical management. CONCLUSION: Uncomplicated acute mastoiditis should be defined using clinical criteria and exclude any cases with evidence of bony erosion, including coalescence or subperiosteal abscess. These truly uncomplicated patients often do not require mastoidectomy and can be prescribed a shorter course of antibiotics. Further research into treatment pathways is necessary to optimize the management of uncomplicated acute pediatric mastoiditis.

Gross Pathology of Routine Pediatric Tonsillectomy Specimens: Optimizing the Value of Patient Care.

OBJECTIVE: This investigation seeks to evaluate the effect of gross pathologic analysis on our management of patients undergoing routine tonsillectomy and to evaluate charges and reimbursement. STUDY DESIGN: Retrospective chart review from 2005 through 2016. SETTING: Academic medical center. SUBJECTS AND METHODS: Participants were pediatric patients aged 14 years and younger undergoing tonsillectomy for either sleep-disordered breathing or tonsillitis, with tonsillectomy specimens evaluated by pathology, and without any risk factors for pediatric malignancy. Records were reviewed for demographics, surgical indications, and pathology. Abnormal reports prompted an in-depth review of the chart. Charges and reimbursement related to both hospital and professional fees for gross tonsil analysis were evaluated. RESULTS: From 2005 to 2016, 3183 routine pediatric tonsillectomy cases were performed with corresponding specimens that were sent for gross analysis revealing no significant pathologic findings; 1841 were males and 1342 were females. Ten cases underwent microscopy by pathologist order, revealing normal tonsillar tissue. The mean charge per patient for gross analysis was $60.67 if tonsils were together as 1 specimen and $77.67 if tonsils were sent as 2 separate specimens; respective reimbursement amounts were $28.74 and $35.90. CONCLUSIONS: Gross pathologic analysis did not change our management of routine pediatric tonsillectomy patients. Foregoing the practice at our institution would eliminate $19,171.72 to $24,543.72 in charges and $9081.40 to $11,344.40 in reimbursement per year. Eliminating this test would improve the value of patient care by saving health care resources without compromising clinical outcomes.

The presentation and clinical significance of sinonasal respiratory epithelial adenomatoid hamartoma (REAH).

BACKGROUND: Sinonasal respiratory epithelial adenomatoid hamartoma (REAH) is a benign glandular proliferation with ciliated epithelium. Little is known about REAH, with only a few published case reports appearing since its original description in 1995. Classically described as an isolated polypoid lesion arising from the nasal septum, more recent descriptions also suggest that REAH can occur among nasal polyps. We report the largest experience with REAH to date, and aim to better understand and characterize this unique entity. METHODS: In this case series, all cases of REAH diagnosed between 2006 and 2011 were reviewed. Clinical presentation, histologic and radiographic features, and operative findings were examined. RESULTS: There were 45 patients 19 females and 26 males, with a mean age of 55.9 years (range, 23-83). Most cases of REAH (33/45, 73%) were found in association with another pathologic process (sinonasal polyposis, adenoiditis, hereditary hemorrhagic telangiectasia [HHT], inverted papilloma [IP], or malignancy). Of these, REAH occurring among diffuse polyposis (79% of cases) represented the large majority. The average Harvard computed tomography (CT) stage for this cohort was 3.1. The other presentation of REAH (12/45, 27%) was an isolated sinonasal mass. In cases of isolated REAH, the majority of lesions (75%) were noted to be originating in the olfactory clefts. CONCLUSION: Isolated REAH, which may mimic a neoplasm, appears to be a different clinical entity than the more common form encountered in association with nasal polyps and inflammation. Further investigation into the etiology and clinical significance is needed.