Factors Associated With Loss to Follow Up After Temporal Bone Fracture.

INTRODUCTION: Inpatient and outpatient evaluation is important for management of temporal bone trauma due to the possible otologic complications that can result. However, there is limited literature on follow up rates following temporal bone fracture. This study aimed to determine the proportion of patients lost to follow up after sustaining temporal bone fractures and identify factors associated with loss to follow up. METHODS: Retrospective review of adult patients who sustained temporal bone fractures at a level I trauma center from January 1, 2019 to January 1, 2024 was completed (IRB H-44161). The primary outcome included prevalence of patient loss to follow up. Secondary variables included initial radiographic and exam findings, otologic complications, and demographic characteristics. Patients who were seen in follow up and lost to follow up were compared, and odds of loss to follow up was calculated. RESULTS: Sixty-nine patients met inclusion criteria for this study, of which 30 patients (43.5%) were lost to follow up. Patients who were White had a significantly lower odds of loss to follow up than those who were not White (OR = 0.2506 (95% CI: 0.0706, 0.8067, P = .0024). While need for acute management was not significantly different between the groups, a significantly lower proportion of patients who were intubated on presentation (P = .0091), had abnormal otoscopic exam (P = .0211), and had otologic complications (P = .0056) were lost to follow up. CONCLUSION: Almost half of patients who sustained temporal bone fractures, including a significantly higher odds of minority race/ethnicity patients, were lost to follow up.

The effect of tympanostomy tubes on otoacoustic emissions.

PURPOSE: Otoacoustic emissions (OAE) are a common screening tool to evaluate cochlear function. Middle ear dysfunction has been shown to impact results of otoacoustic emission testing, but there are limited data on the effect of tympanostomy tubes on OAE. The purpose of this study was to determine whether tympanostomy tube placement significantly improved OAE. METHODS: A retrospective review of charts was completed for patients younger than 18 years old who underwent tympanostomy tube placement from January 1, 2018 to September 1, 2023 and had preoperative and postoperative OAE testing within 6 months of surgery. The primary variable was presence of OAE preoperatively and postoperatively. Chi-square analysis and t test were used for statistical analysis. RESULTS: A total of 212 ears were examined from 111 pediatric patients who underwent tympanostomy tube placement during the study period. Presence of OAE at 3000, 4000, and 5000 Hz were all noted to significantly increase following tympanostomy tube placement, with OAE presence increasing from approximately 27.8% of the sample preoperatively to 95.3% postoperatively at 3000 and 4000 Hz. Patients who noted improvement had a significantly higher proportion of type B tympanogram preoperatively, compared to a higher proportion of type A tympanogram noted in patients who did not note improvement. CONCLUSION: Tympanostomy tubes can significantly improve otoacoustic emissions in patients with middle ear dysfunction.

Hypertrophic pachymeningitis of the internal auditory canal and cerebellopontine angle from a large recurrent attic cholesteatoma.

OBJECTIVES: To describe a rare complication of cholesteatoma. METHODS: Case report with literature review. RESULTS: We report a case of a 37-year-old male who presented for evaluation of otorrhea, headache, and progressive left sensorineural hearing loss. Clinical and radiologic evaluation demonstrated a large recurrent attic cholesteatoma with erosion into the lateral and superior semicircular canals, and diffuse enhancement of the internal auditory canal and cerebellopontine angle suggestive of hypertrophic pachymeningitis secondary to cholesteatoma. After treatment with a course of antibiotics and canal wall down mastoidectomy surgery for cholesteatoma exteriorization, he experienced improvement of his symptoms and resolution of hypertrophic pachymeningitis. CONCLUSION: Hypertrophic pachymeningitis is a rarely described complication of cholesteatoma. In the context of cholesteatoma, treatment with antibiotics and surgical removal or exteriorization of cholesteatoma are effective treatments for HP.

Incidence of audiologic or otolaryngologic evaluation in patients with external ear anomalies.

PURPOSE: The relationship between specific external ear anomalies (EEA) and hearing loss has been previously described. However, there is no literature regarding the appropriate evaluation of patients with EEA by audiology or otolaryngology. The objective of this study was to determine the incidence of audiologic or otolaryngologic evaluation of patients with EEA. MATERIALS AND METHODS: A retrospective review of charts was conducted following approval from the institutional review board at Boston Medical Center. Charts of patients younger than 18 years old with EEA, identified using International Classification of Diseases (ICD)-9 codes 380-380.99, 744, and 744.4 and ICD-10 codes H61.90-92, Q16.0-16.9, Q17.0-17.9, Q18.0-18.2, from January 2012 to January 2019 were reviewed. Primary variables included incidence of audiologic and otolaryngologic evaluation, newborn hearing screen and audiometry results, and completion of surgical intervention. Binary logistic regressions were conducted for each group for diagnostic, procedural, and demographic characteristics. RESULTS: A total of 723 patients were diagnosed with EEA from January 2012 to January 2019. Of these patients, 327 (45.2 %) were evaluated by audiology and 327 (45.2 %) were evaluated by otolaryngology. Of the 364 patients who obtained audiograms, 63 (17.3 %) demonstrated hearing loss. Surgical procedures were performed on 119 (16.5 %) patients, with the most common procedure being excision of the EEA (n = 79, 66.4 %). A total of 468 patients had a documented newborn hearing screen. Failure of newborn hearing screen and presence of microtia were associated with increased otolaryngologic and audiologic evaluation. CONCLUSIONS: A majority of patients with EEAs do not obtain audiologic or otolaryngologic evaluation.

Factors Associated with Refractory Nasal Congestion Following Adenoidectomy.

OBJECTIVE: The objective of this study was to better characterize factors associated with refractory rhinitis in pediatric patients who underwent adenoidectomy compared to those who had symptom resolution. METHODS: The authors conducted a case series of patients younger than 18 years old who underwent adenoidectomy at Boston Medical Center from October 2012 to December 2018. Patients who underwent tonsillectomy and adenoidectomy or who underwent adenoidectomy for indications other than rhinitis were excluded. Patients who had refractory rhinitis symptoms postoperatively were compared to those who had resolution of their symptoms using Chi-square analysis and t-tests. RESULTS: One hundred three patients who had refractory symptoms following adenoidectomy were compared to 139 patients who had resolution of symptoms. Patients who had refractory symptoms had significantly higher proportion of use (89.3%, P = .0011) and higher mean number of preoperative (1.50, P = .0226) and postoperative (1.10, P < .0001) medications, including nasal saline, intranasal steroids, antihistamines, and/or antibiotics. They were more likely to receive postoperative allergy evaluations (50%, P = .0068) and repeat surgery (30.1%, P < .0001), and had a higher proportion of reported history of allergies (24.3%, P = .0089). CONCLUSION: Use and number of preoperative medications, reported history of allergies, and postoperative allergy evaluation were significantly higher in patients with refractory chronic rhinitis following adenoidectomy. This study identified differences in patients who developed refractory symptoms that may help clinical decision making for surgical management.

Comparison of adenoid assessment by flexible endoscopy and mirror exam.

OBJECTIVE: Assessment of adenoid hypertrophy can be completed through various methods including flexible endoscopy and intraoperative mirror exam. The objective of this study was to compare the effect of adenoid size on the accuracy of these techniques. METHODS: Patients younger than 18 years old who underwent adenoidectomy at Boston Medical Center from October 2012 to December 2018 and had documented preoperative and intraoperative adenoid sizes were included. Cases were identified through Current Procedural Terminology (CPT) codes 42,830 and 42,831 with exclusion of CPT 42820 for tonsillectomy and adenoidectomy. Patients who had less obstruction (75% or less obstruction) and more obstruction (>75%) were compared using Chi-square analysis and t-tests. RESULTS: Of 276 patients who underwent adenoidectomy from October 2012 to December 2018, 84 patients had adenoid size determined both preoperatively by flexible endoscopy and intraoperatively. Thirty-eight (45.2%) patients had intraoperative adenoids that were characterized as less obstructive hypertrophy and 46 (54.8%) had intraoperative adenoids that were characterized as more obstructive hypertrophy. In patients with less obstruction, the mean preoperative adenoid obstruction size of 72% was significantly higher than the mean intraoperative adenoid obstruction size of 63% (p = 0.0212). However, in patients with more obstruction, the mean preoperative adenoid size of 86% was not significantly different from the mean intraoperative adenoid size of 90% (p = 0.1237). CONCLUSION: Adenoid assessment by flexible endoscopy and intraoperative mirror exam may not correlate as closely in patients who have less obstructive hypertrophy.

Should Excess Topical Decongestant Use Raise a Red Flag? Rhinitis Medicamentosa and Opioid Use Disorder.

OBJECTIVE: The objective of this study was to determine whether patients with rhinitis medicamentosa (RM) have an increased odds of having an opioid use disorder (OUD) and which characteristics may predict this association. METHODS: The authors conducted a retrospective case control study of patients 18 years and older who presented to the otolaryngology clinic at an academic medical center from January 2013 through December 2017. Cases, defined as patients who presented with excessive decongestant nasal spray usage based on history, were matched to control patients who presented with chronic rhinitis and did not report regular nasal decongestant usage. The charts were reviewed for patients that carried a problem of opioid abuse, identified using ICD-9 codes 304.XX or ICD-10 codes F11.XX. The primary outcome of this study was the odds of having an OUD. Secondary outcomes were assessed by summary statistics. RESULTS: One hundred and thirty-one cases of RM were matched to 1871 controls of chronic rhinitis. Seven cases (5.3%) and 24 (1.3%) controls had a diagnosis of OUD, consistent with an odds ratio of 3.98 for opioid abuse in patients with RM (95% CI: 1.47-9.71). Oxymetazoline was used by 85.5% (n = 112) of patients with RM. Thirty-six patients (27.1%) with RM underwent nasal surgery following a diagnosis of RM, of which twenty patients (55.6%) were prescribed opioids following the procedure. CONCLUSIONS: RM is associated with increased odds of having an OUD.

Characteristics and Receipt of Medication Treatment Among Young Adults Who Experience a Nonfatal Opioid-Related Overdose.

STUDY OBJECTIVE: Nonfatal opioid overdose represents an opportunity to engage young adults into using medication for opioid use disorder. We seek to describe characteristics of young adults who experience nonfatal overdose and estimate rates of and time to medication for opioid use disorder for young adults relative to those aged 26 to 45 years. METHODS: We conducted a cohort study using retrospective administrative data of 15,281 individuals aged 18 to 45 years who survived an opioid-related overdose in Massachusetts between 2012 and 2014, using deidentified, individual-level, linked data sets from Massachusetts government agencies. We described patient characteristics stratified by age (18 to 21, 22 to 25, and 26 to 45 years) and evaluated multivariable Cox proportional hazards models to compare rates of medication for opioid use disorder receipt, controlling for age, sex, history of mental health disorders, and addiction treatment. RESULTS: Among 4,268 young adults in the year after nonfatal overdose, 28% (n=336/1,209) of those aged 18 to 21, 36% (n=1,097/3,059) of those aged 22 to 25 years, and 36% (n=3,916/11,013) of those aged 26 to 45 years received medication for opioid use disorder. For individuals aged 18 to 21 and 22 to 25 years, median time to buprenorphine treatment was 4 months (interquartile range 1.7 to 1.8 months); to methadone treatment, 4 months (interquartile range 2.8 to 2.9 months); and to naltrexone treatment, 1 month (interquartile range 1 to 1 month). Individuals aged 18 to 21 years were less likely (adjusted hazard ratio 0.60 [95% confidence interval 0.45 to 0.70]) to receive methadone than those aged 22 to 25 and 26 to 45 years. Individuals aged 18 to 21 years and those aged 22 to 25 years were more likely to receive naltrexone (adjusted hazard ratio 1.65 [95% confidence interval 1.36 to 2.00] and 1.41 [95% confidence interval 1.23 to 1.61], respectively) than those aged 26 to 45 years. CONCLUSION: One in 3 young adults received medication for opioid use disorder in the 12 months after surviving an overdose. Type of medication for opioid use disorder received appeared to be age associated. Future research should focus on how medication choice is made and how to optimize the emergency department for medication for opioid use disorder initiation after nonfatal overdose.

Iodine Content of the Best-Selling United States Adult and Prenatal Multivitamin Preparations.

BACKGROUND: Iodine is essential for thyroid hormone production and fetal development. Even mild maternal iodine deficiency in gestation may be associated with impaired child neurodevelopment. Iodine requirements increase during pregnancy and lactation. Supplements containing 150 µg/day are recommended by the American Thyroid Association for all U.S. women who are pregnant, lactating, or planning pregnancy. The contribution of multivitamin supplements as an iodine source for pregnant and nonpregnant US adults has not been well studied. This study aimed to understand better the contribution of the top-selling adult multivitamins (AMV) and prenatal multivitamins (PMV) to iodine nutrition in the United States. METHODS: Product names, dollar sales, unit and volume sales, and recommended daily intakes of the top-selling 99 AMV and 60 PMV from July 2016 to July 2017 were obtained from Information Resources, Inc. Iodine content and source were determined from product labels. After excluding private-label brands and unavailable product labels, a final sample of 89 AMV and 59 PMV was analyzed. RESULTS: Of the 89 AMV, 74.2% contained iodine. The median (range) iodine content of AMV was 150 µg (38-150 µg) per daily serving. Over the study period, 8,924,371,955 AMV doses were sold, of which 84.8% contained iodine. Thirty-four (57.6%) of the 59 PMV contained iodine, with a median (range) iodine content of 150 µg (25-290 µg) per daily serving. Over the study period, 466,927,559 PMV doses were sold, of which 76.8% contained iodine. All iodine-containing AMV used potassium iodine as an iodine source. Of iodine-containing PMV, 73.5% used potassium iodide, 23.5% kelp, and 2.9% inactivated Saccharomyces cerevisiae as an iodine source. CONCLUSIONS: During the one-year study period, a higher proportion of AMV doses than PMV doses contained iodine. Some PMV but no AMV included sources of iodine known to be highly variable. The median iodine content of the top-selling AMV and PMV was at the recommended 150 µg daily intake, but the range remains wide. Twenty-four percent of PMV doses sold did not contain iodine. More effort is needed to ensure adequate iodine content in prenatal vitamins for women who are pregnant, lactating, or planning pregnancy.

Toxic epidermal necrolysis associated with rifaximin.

PURPOSE: The case of a patient who developed toxic epidermal necrolysis (TEN) after treatment with rifaximin for hepatic encephalopathy is reported. SUMMARY: A 62-year-old Caucasian woman with a history of alcohol abuse arrived at the emergency room with complaints of abdominal pain and acute onset of jaundice, likely secondary to alcoholic hepatitis. Laboratory tests and multiple imaging studies conducted in the emergency department revealed signs of chronic liver disease and common bile duct dilation with ascites. At admission, she had low concentrations of serum sodium, serum chloride, serum creatinine, and serum albumin and elevated liver function test values. On hospital day 7, the patient developed an altered mental status, which was diagnosed as toxic metabolic encephalopathy, primarily hepatic in origin. The patient was given lactulose 20 g via nasogastric tube every 12 hours and rifaximin 400 mg orally every 8 hours. The patient received only two doses of the rifaximin before it was discontinued. On hospital day 27, oral rifaximin 550 mg twice daily was initiated. After 12 days of rifaximin therapy, the patient developed a diffuse, erythematous, maculopapular, and desquamating cutaneous reaction on her chest, arms, and legs. The suspected diagnosis was determined to be a severe cutaneous adverse drug reaction, possibly TEN. Use of the Naranjo et al. scale revealed that rifaximin was a possible cause of the reaction. Rifaximin was discontinued, and antihistamines and i.v. corticosteroids were initiated. The reaction completely resolved after one week. CONCLUSION: A 62-year-old woman developed possible TEN after receiving rifaximin to treat hepatic encephalopathy.