Fronto-septal rostrum: prevalence, classification and clinical implications.

OBJECTIVE: To describe a newly observed frontal sinus anatomical variant, the fronto-septal rostrum. METHODS: Consecutive sinus computed tomography scans performed during 2013 were reviewed. The fronto-septal rostrum was defined as a mucosa-lined air space formed in the attachment of the most upper bony nasal septum and the central floor of the frontal sinuses. RESULTS: The study included 400 computed tomography scans from 189 women (47.3 per cent) and 211 men (52.8 per cent), with a mean age of 46.8 years. A fronto-septal rostrum was observed in 122 patients (30.5 per cent), with a mean length of 10.63 mm, width of 4.52 mm, height of 2.18 mm and volume of 63.52 mm3. There was no statistically significant difference related to gender (p = 0.343), and no association between the side of the fronto-septal rostrum and age (p = 0.811) or volume (p = 0.203). CONCLUSION: The newly described fronto-septal rostrum has possible clinical and surgical implications. It is suggested that this aerated space is used in specific surgical indications and its presence evaluated in cases of septal infection.

Temporomandibular joint involvement as a positive clinical prognostic factor in necrotising external otitis.

OBJECTIVE: Necrotising otitis externa is associated with high morbidity and mortality rates. This study investigated whether temporomandibular joint involvement had any prognostic effect on the course of necrotising otitis externa in patients who had undergone hyperbaric oxygen therapy after failed medical and sometimes surgical therapy. METHODS: A retrospective case series was conducted of patients in whom antibiotic treatment and surgery had failed, who had been hospitalised for further treatment and hyperbaric oxygen therapy. RESULTS: Twenty-three patients with necrotising otitis externa were identified. The temporomandibular joint was involved in four patients (17 per cent); these patients showed a constant gradual improvement in C-reactive protein and were eventually discharged free of disease, except one patient who was lost to follow up. Four patients (16 per cent) without temporomandibular joint involvement died within 90 days of discharge, while all patients with temporomandibular joint involvement were alive. Three patients (13 per cent) without temporomandibular joint involvement needed recurrent hospitalisation including further hyperbaric oxygen therapy; no patients with temporomandibular joint involvement required such treatment. CONCLUSION: Patients with temporomandibular joint involvement had lower rates of recurrent disease and no mortality. Therefore, we suggest considering temporomandibular joint involvement as a positive prognostic factor in necrotising otitis externa management.

Bidirectional orbital approach enhances orbital abscess drainage.

OBJECTIVES: Transnasal endoscopic management of subperiosteal orbital abscess (SPOA) secondary to acute rhinosinusitis has become very popular over the past two decades. We describe our transnasal endoscopic approach for orbital complications secondary to acute rhinosinusitis (SPOA and orbital abscess) and the efficacy criteria that can be used to ensure complete drainage. METHODS: The charts of all patients who underwent surgery at Assaf Harofeh Medical Center between January 1993 and June 2007 were reviewed. Age, sex, clinical findings, antibiotic treatment, surgical procedure and outcome were recorded. RESULTS: Nineteen patients with SPOA and three with orbital abscess underwent surgery during which wide exposure of the periorbita was performed. If the abscess was not identified, bidirectional orbital manipulation, while simultaneously keeping a seeker in the abscess space under endoscopic view, enhanced its identification and successful drainage. An immediate reduction in palpable orbital pressure was used as an efficacy criterion for adequate drainage. CONCLUSION: The transnasal endoscopic approach for SPOA and orbital abscess can be enhanced by wide exposure of the periorbita and bidirectional orbital manipulation. Keeping track of orbital pressure during surgery by palpating the eye can be used as an efficacy criterion for assessing adequate drainage.

Variations in the microbiology of peritonsillar abscess.

Microbiologic studies are routinely performed in the assessment of peritonsillar abscess (PTA). Though the bacterial growth rates of PTA are expected to be uniform due to high accessibility and reasonable sterility, they demonstrate a vast range of results, which is partially explained by the differing culturing methods and incubation times. Our aim was to retrospectively examine the changing features identified in the occurrence of PTA bacterial growth rates over a period of seven years. A retrospective study was undertaken on all cases of PTA admitted from January 1996 to December 2002. Details regarding sex, age and country of birth were obtained. Population data and the maximum residue level (MRL) of antibiotics in food were collected. Bacteriologic studies were analysed for gram stain, aerobic and anaerobic culture results, and also antibiotic sensitivities, if obtained. Four hundred and fifty-seven consecutive hospitalisations due to PTA were identified; 281 patients who had 310 hospitalisations with known results of the microbiologic studies were included. The most common pathogens were Streptococcus pyogenes and Prevotella. A statistically significant escalation was seen in the anaerobic growth rate from 6.8% of cases in 1996 to 37% in 1999. A similar change, though not significant, was noticed with the polymicrobial growth rate. None of the parameters investigated showed any statistically significant influence on this tendency. These results may clarify the immense range of bacterial study results reported, suggest a change in the biologic behaviour of the studied bacteria and direct further research.

Gentamicin-induced ototoxicity in hemodialysis patients is ameliorated by N-acetylcysteine.

Aminoglycoside (AG) antibiotics are associated with several side effects, including a reversible nephrotoxicity and a permanent ototoxicity. Oxidative stress is thought to contribute to the pathophysiology of both conditions. We studied the possible protective effect of the antioxidant N-acetylcysteine (NAC) in gentamicin-induced hearing loss in hemodialysis patients. This study includes 53 hemodialysis patients scheduled to receive gentamicin for dialysis catheter-related bacteremia that were randomized to receive the antibiotic with or without NAC. Hearing function was assessed by the standard technique of pure-tone audiograms over a range of frequencies. Audiometric evaluations were performed at baseline, 1 week and at 6 weeks after the completion of gentamicin therapy. A total of 40 patients completed the study protocol with a mean duration of therapy of almost 15 days. At both 1 and 6 weeks after the completion of antibiotic therapy, there were significantly more patients exhibiting ototoxicity in the control group compared with the group receiving NAC. Additionally, significantly more patients in the control group had bilateral ototoxicity. The greatest otoprotective effect of NAC was noticed in the high audiometric tone frequencies. Taken together, our study suggests that NAC treatment may ameliorate gentamicin-induced ototoxicity in hemodialysis patients.

The endoscopic Draf II frontal sinusotomy: non-navigated approach.

OBJECTIVE: Endoscopic endonasal Draf II frontal sinusotomy is indicated for a variety of pathologies such as mucocele and non-responsive chronic frontal sinusitis. However, this approach is challenged and controversial. The objectives were to evaluate the advantages, disadvantages, indications, and rate of complications of this approach, without the use of a navigation system. METHODS: The files and computed tomography (CT) scans of 25 patients who underwent endoscopic endonasal Draf II sinusotomy at Assaf Harofeh Medical Center between 1999 and 2002 were reviewed. RESULTS: Thirty-one frontal sinuses were operated on and follow-up was between 18 and 62 months (average 30.3). Twenty-two sinuses (71%) had previous surgery. The Draf II procedure was used in 3.7% of all cases during the survey period. The most frequent indication for surgery was inflammation (48%) followed by mucocele (28%). In all but 2 sinuses (93%), the frontal floor between the lamina papyracea and the middle concha was drilled out. Twenty-four patients (96%) were successfully ventilated. No major complications were noted. CONCLUSIONS: The Draf II approach can be used safely and successfully without a navigation system, including cases of revision endoscopic sinus surgery. Correct interpretation of the surgical field and a CT scan are crucial for success. Careful patient selection is essential for this procedure.

Inner ear damage in children due to noise exposure from toy cap pistols and firecrackers: a retrospective review of 53 cases.

This retrospective study presents the findings of inner ear damage documented in 53 children exposed to impulsive sound emitted by toy weapons and firecrackers. There were 49 boys and four girls aged between four and fourteen years. Thirty-nine children were affected unilaterally while fourteen had bilateral hearing loss (total of 67 ears). Most of the hearing loss (>70%) was sensorineural high frequency hearing loss, while only nine out of the 67 injured ears had sensorineural mid frequency hearing loss. Seven children sustained a traumatic ear drum perforation. Dizziness or tinnitus was reported by twenty children, with pathological ENG findings in four of them. This paper re-emphasizes the possibility of inner ear damage in children from exposure to noisy toys.

Thyroglossal duct cyst: is thyroid scanning necessary in the preoperative evaluation?

BACKGROUND: Evaluation of thyroglossal duct cysts before surgical excision traditionally includes hormonal evaluation, ultrasound of the neck, and thyroid scanning. OBJECTIVE: To evaluate the need for thyroid scanning in cases of thyroglossal duct cysts scheduled for operation. METHODS: A retrospective chart review of 100 cases of thyroglossal duct cyst between 1988 and 1995 was carried out. RESULTS: No cases of ectopic thyroid were detected. CONCLUSION: Our goal was to document the presence of normal thyroid tissue by non-invasive tools such as ultrasound, rather than to rule out the existence of ectopic thyroid tissue by radionuclide scanning. Radionuclide scanning is justified in cases of lingual thyroid and where a normally located thyroid gland cannot be detected.

Vasomotor rhinitis following trauma to the nose.

Complaints of nasal obstruction following nasal trauma without any deformation have been noticed by rhinologists for many years. However, neither an epidemiologic nor a pathophysiologic connection has ever been established. The complaints and physical examination findings of these patients resemble those of vasomotor rhinitis. Only very few articles suggesting nasal trauma as a possible cause for vasomotor rhinitis have ever been published. We present a retrospective study that found 87 of 802 patients to suffer from vasomotor rhinitis following nasal trauma. No other factors known to cause vasomotor rhinitis were present in these patients. None had any previous nasal problems. We therefore suggest that nasal trauma was the causative factor in their vasomotor rhinitis.

Chronic sinusitis: a sequela of inferior turbinectomy.

Inferior turbinectomy has generated a great deal of controversy among rhinologic surgeons. Proponents of partial and total inferior turbinectomy cite numerous studies of large numbers of patients with subjective relief of nasal obstruction after turbinectomy. Clinical studies critical of turbinectomy have focused on complications such as hemorrhage, crusting, adhesions, and atrophic rhinitis. Our study was undertaken to evaluate the incidence of chronic sinusitis post inferior turbinectomy. Postoperative evaluation by history, physical examination, and computerized tomography of the paranasal sinuses revealed that a significant number of patients who underwent inferior turbinectomy developed sinusitis. Patients evaluated in our clinic for nasal obstruction underwent a detailed history, physical examination along with nasal endoscopy and coronal computerized tomography of the paranasal sinuses. Those patients with nasal obstruction not responsive to medical treatment and without evidence of sinusitis underwent submucous resection and inferior turbinectomy. The incidence, cause, and possible prevention of post inferior turbinectomy sinusitis is discussed in this article.

[Epiglottitis in adults].

Acute epiglottitis in the child is an emergency, well known to pediatricians, that requires rapid diagnosis and treatment. Aggressive treatment in recent years has markedly decreased mortality (17). Acute epiglottitis in adults has been thought to be rare, but lately numerous studies have shown an increase in the disease. We present 19 older patients, aged 13-72 (mean 44.7 years), with acute epiglottitis. A most important finding was the relatively long time from onset of symptoms until diagnosis, averaging 2.5 days. All the blood and throat cultures were negative, except for a single throat culture which yielded Pseudomonas aeruginosa. The most common presenting symptoms were severe sore-throat and dysphagia; half presented with some respiratory distress. Diagnosis was usually made on indirect laryngoscopy, but lateral X-ray of the soft tissues of the neck was found to be highly reliable. Treatment was usually conservative, including antibiotics, rehydration and steroids to alleviate edema. All patients were under strict observation for the first 48 hours, but only 1 required intubation. There were no deaths.

Small bowel obstruction: a review of 264 cases and suggestions for management.

Two hundred and sixty-four cases of acute small bowel obstruction were retrospectively reviewed for the purpose of defining factors which could point to the presence of strangulated bowel. History, physical signs and investigations, including body temperature, X-rays, white blood count, and serum amylase, were not significantly different in the simple and strangulated groups. Although an elevated urinary white blood count and a palpable mass were more common in the strangulated group, they were not sufficiently reliable for early diagnosis of strangulation. In reviewing the literature, it is clear that all hernias with obstruction must undergo emergency surgery. Cases with intra-abdominal complete intestinal obstruction should also undergo emergency surgery. A more conservative attitude can only be taken when there is incomplete obstruction.

Diffuse idiopathic skeletal hyperostosis with dysphagia (a review).

Dysphagia due to cervical osteophytes is not common. However, diffuse idiopathic skeletal hyperostosis (DISH) with cervical involvement which causes dysphagia is even rarer. The otolaryngologist is not generally familiar with this entity. The diagnosis can be made by plain cervical X-ray films, a barium swallowing esophagogram and or a CT scan of the neck. When doubt still exists, further extra-axial X-ray films can be helpful. Although most patients have been treated surgically, there may be a role for conservative therapy initially, as surgery in elderly DISH patients is often morbid and even fatal. A 79-year-old patient with DISH (Forestier's disease) is reported. Non-steroidal anti-inflammatory therapy was successfully implemented. DISH is compared with other disorders of the cervical spine which may cause dysphagia.