Local Alpha1-Antitrypsin Accelerates the Healing of Tympanic Membrane Perforation in Mice.

BACKGROUND: Most tympanic membrane (TM) perforations heal spontaneously, but 10%-20% remain chronic and might lead to impaired hearing and recurrent middle ear infections. Alpha1-antitrypsin (AAT) is a circulating tissue-protective protein that is elevated under inflammatory conditions and is currently indicated for genetic AAT deficiency. Recently, AAT has been shown to promote tissue remodeling and inflammatory resolution. OBJECTIVE: This study aimed to examine the effects of local clinical-grade AAT treatment on tissue repair in a mouse model of acute traumatic TM perforation. METHODS: Wild-type mice underwent unilateral TM perforation and were either left untreated or treated locally with human AAT (9 × 10-3 mL at 20 mg/mL on days 0, 1, and 2; n = 15/group). The perforations were evaluated macroscopically on a serial basis. Mice were sacrificed on various days post-injury, and TMs were excised for gene analysis by RT-PCR. RESULTS: There were no adverse reactions in hAAT-treated ears throughout the study period. Compared with untreated animals, TM closure occurred earlier in the treated group (days until full closure, median: 4 and 9, respectively). According to gene expression analysis, VEGF, TGFß, and collagen-5A1 were induced earlier in AAT-treated mice (day 4-5 compared with day 9). Additionally, IL-10 expression levels were higher and IL-6 levels were lower in treated versus untreated mice. CONCLUSION: A local tissue environment rich in AAT promotes early tissue repair in a perforated TM model both macroscopically and molecularly. Studies are underway to examine TM functionality and recombinant AAT formulations for micro-dosing in the format of a single local application. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Diagnostic accuracy of eosinophil-to-lymphocyte ratio and eosinophil-to-neutrophil ratio as biomarkers for differentiating between fungal and bacterial infection in necrotising otitis externa.

INTRODUCTION: Necrotizing otitis externa (NOE) is a serious, progressive, and potentially life-threatening infection of the external auditory canal, affecting soft tissue and bone. The most common organism causing NOE is Pseudomonas Aeruginosa and less common are Fungal infections. When managing a patient with NOE, a culture is taken from the EAC in order to tailor the appropriate antimicrobial treatment, however commonly, the culture is sterile. Inflammation biomarkers may be used as adjuncts to inform on the differential diagnosis and as prognostic markers. AIM: To characterize and compare values and ratios of components of the complete blood count (CBC) at admission, at patients with positive swab culture. METHODS: A retrospective study of NOE patients was conducted. We included all patients admitted between the years 2001-2023, for whom a culture swab tested positive. We compared CBC findings at hospitalization between bacteria and fungi-positive culture patients. RESULTS: Eosinophils-to-Neutrophils Ratio (ENR) was significantly lower in the fungal group compared to the bacterial group 0.023 ± 0.02 and 0.04 ± 0.03, respectively (p-value = 0.025). Eosinophils-to-Leukocyte Ratio (ELR) was significantly lower in the fungal group compared to the bacterial group 0.058 ± 0.04 and 0.12 ± 0.1 respectively (p-value = 0.009). For definition of ELR ≤ 0.1 we found that, sensitivity was 88% (95%CI = 0.679-0.979) and NPV 90% (95%CI = 0.709-0.982). For definition of ENR ≤ 0.03 sensitivity was 88% (95%CI = 0.679-0.979) and NPV 88% (95%CI = 0.679-0.979). CONCLUSION: Lower values of ELR and ENR in patients with NOE are associated with fungal infection and can serve as a tool in adjusting an appropriate antimicrobial therapy in cases of sterile or when no culture is available.

Impact of the COVID-19 era on clinical presentation, management and microbiology in paediatric peritonsillar abscess: A case-control study.

OBJECTIVES: Peritonsillar abscess (PTA) is the most common soft-tissue infection of the head and neck. This potential complication of tonsillitis has demonstrated unique microbial trends during the COVID-19 pandemic. This era has resulted in a major shift in the hygiene and social habits of the general population, which has resulted in changes in the presentation, management and microbiology of several infectious diseases. To date, the impact of COVID 19 on PTA microbiology and clinical presentation in the paediatric population has yet to be investigated. DESIGN: Retrospective chart review comparing all cases of paediatric (age 0-18) PTA in an academic tertiary centre during the COVID-19 pandemic (03/2020-02/2022) and compared them to two control groups: pre-COVID (03/2018-02/2020) and post-COVID (03/2022-03/2023). All patients were treated with either needle aspiration, incision and drainage or both means in addition to intravenous antibiotics. SETTING: A large Ear Nose and Throat department in a tertiary referral center. PARTICIPANTS: Consecutive children aged 18 years or under, admitted with a diagnosis of Peritonsillar abscess. MAIN OUTCOME MEASURES: We analyzed the clinical and microbiologcal features of all cases of pediatric peritonsillar abscess during the COVID-19 era (03/2020-02/2022) and compared them to a pre and post control cases. RESULTS: A total of 96 PTA cases were included (35 pre-COVID, 35 COVID and 26 post-COVID). The means of procedural treatment shifted in favour of incision and drainage versus needle aspiration during the COVID era. The length of hospitalisation increased during the COVID era (3.6 days vs. 2.1 and 3.1 pre and post-COVID respectively, p < .001). No other notable differences in the clinical and demographic features were found between the three eras. The COVID-19 era saw an increase in Fusobacterium (37.1% vs. 8.6% and 24% pre and post-COVID, respectively; p = .008) and Streptococcus Anginosus (31.4% vs. 5.7% and 7.7% pre and post-COVID, respectively; p = .007) species isolation. CONCLUSIONS: The COVID-19 pandemic did not seem to impact the clinical presentation of paediatric PTA yet resulted in a change in microbiological pathogens. The choice of I&D as a means to shorten hospital stay during the pandemic may have led to an actual increase in hospital stay, suggesting that NA may be the preferred management approach.

Cochlear implantation compliance among minorities at high risk for hearing impairment following universal newborn hearing screening.

INTRODUCTION: The universal newborn hearing screening (UNHS) allows for early detection of hearing impairment (HI). The goal of this current study was to evaluate the impact of cultural background involving consanguineous marriage on newborn HI diagnosed using UNHS, and compliance with hearing rehabilitation. MATERIALS AND METHODS: This is a retrospective cohort study that included all children born at a single tertiary medical center between 2011 and 2017 who did not pass the UNHS (oto-acoustic emission and auditory brainstem response), and were diagnosed with HI. The study group included children from consanguineous marriage cultural background which were compared to a control group-all other children. Data were retrieved from the computerized medical charts and included epidemiological, audiological, and pregnancy/delivery-related data, and known risk factors for congenital HI. RESULTS: A total of 238 (196 study and 42 control) neonates were diagnosed with HI. Family history of HI was significantly more prevalent in the study group in mild-severe and profound HI subgroups (p = 0.03 and 0.01, respectively). Study group demonstrated lower rates of cochlear implantation (CI) compliance (p = 0.079), performed at a significantly older age (23 months (IQR 17-36.5) vs. 16 (IQR 12-26) months, p = 0.021). When recommended, bilateral CI compliance was significantly lower in the study group (94.1 vs.48.9%, p < 0.001). CONCLUSION: UNHS allows for early HI detection among minority populations at higher risk for CI, yet compliance rates remain lower compared with control. Familiarity of families with the importance of early detection and HI risk may result in higher compliance rates for cochlear implantation. Health providers should aim to improve education and communication with this unique group of patients and consider health promotion programs.

Rates of Delayed Postcochlear Implant Pain in the Pediatric Population-Role of Proactive Approach.

OBJECTIVE: To investigate the rates of delayed postoperative cochlear implantation pain (DPCIP) in the pediatric population, using a "reach-out" proactive approach. Secondary aims included the possible impact of surgery extent or the patient ethnicity on DPCIP rates. MATERIALS AND METHODS: A cross-sectional study was conducted at Soroka University Medical Center in Israel. Demographics and data regarding the surgery and surgical complications were collected from the medical records of the patients. A telephone questionnaire was conducted for parents of all children who underwent cochlear implantation (CI) between 2007 and 2020. The questions addressed pain at four time periods: during hospitalization after surgery, 3 months, 2 years, and 5 years after surgery. RESULTS: Out of 213 patients, 129 (60%) were included in this study. The mean age was 41 months (±40). Unilateral CI was performed in 72 (56%) patients. At 3 months and 2 years after surgery, 8.5% of patients reported pain (visual analog scale [VAS] ≥ 1). Five years after surgery, a slight increase in the number of patients who reported pain (12%) was observed. Of those experiencing pain 2 years and 5 years after surgery, 10/12 (83%) and 11/16 (69%), respectively, reported a new onset of the pain. Surgery extent and cultural background were not significantly associated with DPCIP rates. No correlations were found between patients complaining of pain and any surgical complications. CONCLUSIONS: DPCIP rates may be underrecognized and higher than previously reported, reaching up to 12%. This long-term effect should be acknowledged and discussed with parents upon informed consent.

Acute otitis media in the first two months of life and the impact of pneumococcal conjugate vaccines: A retrospective cohort study.

BACKGROUND: Information on pneumococcal vaccination's impact on the prevention of acute otitis media (AOM) at very young ages is limited. OBJECTIVES: To define the trends in tympanocentesis-proven AOM incidence, clinical characteristics, microbiology, and antibiotic resistance in infants <2 months of age in southern Israel, before and after the sequential introduction of 7- and 13-valent PCVs. METHODS: A retrospective population-based cohort study including children <2 months of age diagnosed with AOM at the pediatric emergency room between January 2005-Decmber 2009 (pre-vaccination group, group 1) and January 2013-July 2021 (post-PCV13 introduction, group 2). RESULTS: 160 patients were enrolled, 89 (55.6%) in group 1 and 71 (44.4%) in group 2. The mean incidence of AOM decreased from 1.2 cases/1000 live births for group 1 to 0.45 cases/1000 live births for group 2, P < 0.001.130 (81.25%) patients were hospitalized, with higher hospitalization rates in group 1 vs. group 2 (84/89, 94% vs. 46/71, 65%, P < 0.001). Hospitalization length was longer in group 1 vs. group 2 (4.07 ± 4.09 days vs. 2.70 ± 1.82 days, P = 0.021). Positive MEF cultures were reported in 94/160 (58.75%) patients, with a decrease in positivity rates between the 2 groups (71/89, 80% vs. 23/71, 32%, P < 0.001). S. pneumoniae was the most common pathogen (55/94, 58.5%); it was the most frequent pathogen isolated in group 1 (46/71, 65%), and the second most common pathogen in group 2 (9/23, 39%), P = 0.03. A significant increase was recorded in the percentages of patients with negative MEF cultures (from 21% to 68%, P < 0.001). CONCLUSIONS: The introduction and implementation of PCV13 in southern Israel was associated with a decrease in AOM in children <2 months of age and of S. pneumoniae recovery in these patients and was accompanied by less admissions and shorter hospitalizations. An increase in the proportions of negative bacterial cultures from MEF was recorded during the study period.

Safety and long-term efficacy of tonsillectomy versus subtotal tonsillectomy in children with sleep disordered breathing.

OBJECTIVES: to compare safety and long-term symptoms after TE compared to Subtotal Tonsillectomy (STT). METHODS: A retrospective review data of 412 patients, one to twelve years old that underwent either TE or STT, as treatment for sleep disorder breathing, at two different medical centers. Symptoms were assessed by a questionnaire 3-5 years post-surgery. Additionally, data regarding immediate post-operative symptoms and complications were also collected. RESULTS: Long-term symptoms score was significantly lower in the TE group: 1.585 (±1.719) compared to 1.967 (±1.815) in the STT group (p = 0.033); 51.3% of patients in the ST group presented long-term SDB symptoms, compared to 40.6% in the TE group (p = 0.035); The main difference between the groups was snoring as 49% of the STT group suffered from snoring, versus 28.9% in the TE group (p < 0.001). CONCLUSIONS: TE showed an advantage over STT in resolving snoring in the long term.

Post-operative clinical course in children undergoing mastoidectomy due to complicated acute mastoiditis.

PURPOSE: To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) following surgical treatment. METHODS: A retrospective chart review of children diagnosed with CAM who underwent mastoid surgery during 2012-2019 in a tertiary care university hospital. 33 patients, divided into 2 groups: 17 patients with sub-periosteal abscess (SPA) alone-single complication group (SCG) and 16 patients with SPA and additional complications: sigmoid sinus thrombosis (SST), peri-sinus fluid/abscess, epidural/subdural abscess, and acute meningitis-multiple complications group (MCG). RESULTS: 33 patients belong to the SCG 17(51%) and 16(49%) belonged to the MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P = 0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P = 0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings; a total of 18 positive cultures were reported. Fusobacterium necrophorum counted for 8/18(44.5%) of all positive cultures, 7/9(77.8%) in the MCG vs. 1/9(11.1%) in the SCG, P = 0.004. Streptococcus pneumoniae was reported only in SCG (5/9, 55.5%, vs. 0/9, P = 0.008). CONCLUSION: Post-mastoidectomy fever due to CAM is not unusual and seems to be a benign condition for the first 5-6 days, following surgery. MCG patients are more prone to develop POF. F. necrophorum is more likely to be associated with MCG, and S. pneumoniae is common in SCG patients.

Diabetes and glycemic control in necrotizing otitis externa (NOE).

PURPOSE: Although the association between necrotizing otitis externa (NOE) and diabetes mellitus (DM) is well known, there is little knowledge in regards to the effects of DM and glycemic control on the outcome of NOE. The aim of the study was to determine the effects of DM duration and glycemic control, and in-hospital glycemic control on NOE severity. METHODS: A retrospective case series analysis, including all patients hospitalized between 1990 and 2018 due to NOE were included. Data collected included NOE disease characteristics, duration of DM, DM-associated comorbidities, glycated hemoglobin (HbA1c), urine microalbumin and in-hospital blood glucose measurements. Disease severity was defined based on duration of hospitalization (above or below 20 days) and need for surgery. RESULTS: Eighty-nine patients were included in the study. Eighty-three patients (94.3%) had DM. Preadmission HbA1c was 8.13% (5.8-12.6%). Forty-nine patients (65.5%) had mean blood glucose of ≥ 140 mg/dL and 26 (34.5%) had ≤ 140 mg/dL. DM duration was 157.88 months among NOE patients who required surgery, and 127.6 months among patients who were treated conservatively (p value 0.25). HbA1c in patients hospitalized < 20 days was 7.6%, and 8.7% among NOE hospitalized ≥ 20 days (p value 0.027). Seven patients with mean blood glucose of ≤ 140 mg/dL had Pseudomonas Aeruginosa (PA-NOE) (26.7%), in comparison to 25 (51.0%) with mean blood glucose measurement of ≥ 140 mg/dL (p = 0.045). CONCLUSIONS: HbA1c at admission is associated with longer hospitalization duration among NOE patients. Mean blood glucose during hospitalization was associated with a higher likelihood of PA infection, however, it had no effect on disease outcome.

Retroauricular Abscess in Adults.

OBJECTIVES: To describe the clinical course and outcome of a group of adults who presented with a subperiosteal abscess (SPA) MATERIALS and METHODS: A retrospective chart review of patients with SPA. RESULTS: Between 2001 and 2015, 7 such patients-5 men and 2 women-were identified. Their age ranged from 18 to 62 years. Six of them suffered from chronic otitis media (COM) and presented with signs and symptoms of otalgia, pain, and swelling around the mastoid. Five of the patients underwent a previous mastoidectomy for cholesteatoma (4- canal wall down and 1 had canal wall up). One of the non-operated patients had cholesteatoma and the other one had chronic suppurative otitis media without cholesteatoma. One patient developed peripheral facial nerve palsy that resolved after surgery, otherwise, no other intratemporal or intracranial complications were observed. Management included a canal wall down mastoidectomy, abscess drainage, and parenteral wide-spectrum antibiotics. One patient suffered cardiovascular and respiratory comorbidities, requiring the delay of surgery for 6 days. This patient underwent incision and drainage of the abscess before surgery. Pathogens were recognized in 4 of the patients and included Streptococcus pneumoniae, Candida albicans, Staphylococcus aureus, and Corynebacterium. CONCLUSION: SPA in adults is rare but may be seen in cases of neglected COM, whether previously operated or not. Comorbidities in older population group may require postponing surgery, so immediate incision and drainage may be warranted, as well as post-surgical intensive care.

Computer tomography findings in necrotizing otitis externa based on the offending pathogens.

PURPOSE: High-resolution temporal bone computer tomography (HRTBCT) is the most common initial radiological modality used for the assessment of necrotizing otitis externa (NOE). OBJECTIVES: (1) To compare the extension of disease, as seen on HRTBCT, in patients with NOE caused by different pathogens and (2) assess whether radiological findings may suggest the offending pathogen in cases of sterile-NOE. METHODS: All NOE patients were hospitalized between 1990 and 2018. All patients underwent HRTBCT at admission. Three groups (fungus-NOE, PA-NOE and sterile-NOE) comprising of ten patients each were randomly selected. HRTBCT was reevaluated by a senior radiologist. Thirteen radiological subsites were selected for reevaluation. RESULTS: All patients in the fungal-NOE group complained of otalgia, compared to nine in the sterile-NOE and six in the PA-NOE groups (p value = 0.044). External ear canal edema and granulation tissue were the most common findings in all groups. Surgery was performed in five patients in the fungal-NOE and PA-NOE and three in the sterile-NOE group (p value = > 0.05). Radiological findings indicating severe bone erosion within the EEC was seen in all patients but 3 (p value = > 0.05). Severe TMJ erosion was seen in one patient within the fungal-NOE and PA-NOE group (p value = > 0.05). When mild and severe involvement were combined, TMJ bone erosion was seen in four patients in the fungal-NOE and only in one patient in the PA-NOE (p = 0.04). CONCLUSIONS: TMJ involvement may be more common in fungal disease, suggesting a different spreading pathway, as opposed to PA-NOE. Accordingly, TMJ involvement on HRTBCT may justify antifungal treatment in sterile culture-NOE.

Impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on acute mastoiditis in children in southern Israel: A 12-year retrospective comparative study (2005-2016).

OBJECTIVES: To define the trends in acute mastoiditis (AM) incidence, microbiology, complications and management in children, before and after the 13-valent pneumococcal conjugate vaccine (PVC13) introduction. METHODS: Medical records of all AM patients <15 years of age diagnosed during 2005-2016 were reviewed. The study years were divided into three periods: pre-vaccination (2005-2008), interim (2009-2011) and post-PCV13 vaccination (2012-2016). RESULTS: 238 patients (53.4% males) were enrolled, 81, 56 and 101 in the 3 time periods, respectively. Overall, 177/238 (75.2%) of children were <5 years of age. Mean AM incidence in the whole population was 10.32/100,000, with no changes during the study years. Ninety-three (45.6%) of 204 evaluable patients had positive middle ear fluid/mastoid cultures; S. pneumoniae (SP) was isolated in 47/93 (50.5%) cases. Mean incidence of SP-AM during the study years was 2.49 cases/100,000. A trend for decrease in mean incidence of SP-AM was recorded between the pre and the post-vaccination periods (3.05/100,000 vs. 1.82/100,000, P = 0.069). Among patients <5 years, SP-AM rates decreased from pre to post-vaccination period (19/50, 38% vs. 15/73, 20.6%, P = 0.034). No changes were reported in percentages of culture negative-AM and of AM complications in the post-PCV13 period compared with the pre-vaccine period. A significant decrease in distribution of PCV13 serotypes was recorded (17/19, 89.5% vs. 8/12, 66.6% and vs. 7/16, 43.75% during the 3 study periods, P = 0.015) accompanied by a complementary increase in non-vaccine serotypes. CONCLUSIONS: The introduction of PCV13 was accompanied by a significant decrease in SP-AM cases among children <5 years of age. PCV13 serotypes decreased significantly as etiologic agents of SP-AM while non-vaccine serotypes and culture negative-AM became more common in the postvaccination period.

Trauma-induced vestibular dysfunction: Possible functional repair under α1-antitrypsin-rich conditions.

Transient vestibular organ deafferentation, such that is caused by traumatic tissue injury, is presently addressed by corticosteroid therapy. However, restoration of neurophysiological properties is rarely achieved. Here, it was hypothesized that the tissue-protective attributes of α1-antityrpsin (AAT) may promote restoration of neuronal function. Inner ear injury was inflicted by unilateral labyrinthotomy in wild-type mice and in mice overexpressing human AAT. A 2-week-long assessment of vestibular signs followed. All animals responded with peak vestibular dysfunction scores within 4 h after local trauma. While wild-type animals displayed partial or no recovery across 7 days post-injury, AAT-rich group exhibited early recovery: from behavioral score 9-out-of-9 at peak to 4.8 ±â€¯0.44 (mean ±â€¯SD) within 8 h from injury, a time when wild-type mice scored 8.6 ±â€¯0.54 (p < 0.0001), and from vestibular score 15-out-of-15 to 7.8 ±â€¯2.2 within 24 h, when wild-type mice scored 13.0 ±â€¯2.0 (p < 0.01). Thus, recovery and functional normalisation of an injured vestibular compartment is achievable without corticosteroid therapy; expedited tissue repair processes appear to result from elevated circulating AAT levels. This study lays the foundation for exploring the molecular and cellular mediators of AAT within the repair processes of the delicate microscopic structures of the vestibular end organ.

Endogenous α1-antitrypsin levels in the perilymphatic fluid correlates with severity of hearing loss.

OBJECTIVES: To determine the levels of endogenous α1-antitrypsin in the perilymph of patients undergoing cochlear implant (CI), and its reverse association with the severity of hearing loss. STUDY DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The study includes 38 patients undergoing CI surgery, 11 patients diagnosed with congenital deafness and 27 non-congenital deafness, eight patients diagnosed with moderate hearing loss (N = 8; PTA = 70 dB), severe hearing loss (N = 11; PTA 70-90 dB) and profound hearing loss (N = 19; PTA > 90 dB). MAIN OUTCOME AND MEASURE: 1 to 12 µL perilymphatic fluids were collected by micropipette. α1-antitrypsin levels were determined, and current and historic audiological parameters were obtained. RESULTS: The congenital and non-congenital group exhibited AAT concentrations of 2.5 ± 1.9 × 106 LFQ and 3.2 ± 1.2 × 106 LFQ, respectively (mean ± SD; P = .38). Mean levels of α1-antitrypsin in the perilymph fluid within the moderate group was 3.64 × 106  ± 2.1 × 106 LFQ vs 3.5 × 106  ± 1.2 × 106 in severe hearing loss (P = .81) and 2.4 × 106  ± 1.1 × 106 LFQ in the profound hearings loss group (P = .06). The difference in levels of AAT in samples from the severe hearings loss group vs the profound hearings loss group reached statistical significance (P = .04). CONCLUSION: Insufficiency in α1-antitrypsin levels in the perilymph fluid of the inner ear appears to display a relationship with the severity of hearing loss. The prospect of introducing clinical-grade plasma-purified α1-antitrypsin directly onto the site of cochlear injury deserves thorough investigation.

Surgery for necrotizing otitis externa-indications and surgical findings.

PURPOSE: Treatment for necrotizing otitis externa (NOE) includes long term antibiotic and surgery in selected cases. Indications and extent of surgery, however, are still not defined. The aims of this study were: (1) present our experience in surgery for NOE (2) compare high-resolution computer tomography and perioperative findings (3) suggest recommendations for indications and extent of surgery. METHODS: A retrospective case series study was conducted in a tertiary referral center. Patients hospitalized due to NOE between the years 1990-2015 and underwent surgery were included. RESULTS: Twenty patients were included in the study. HRTBCT was performed in 17 patients. Most common radiological findings included mastoid fullness (n = 13, 76.4%) and edema of external ear canal (n = 12, 70.5%). Surgical indications included lack of response to treatment (n = 18) and facial nerve palsy (n = 2). Seven patients underwent local debridement. Most common operative findings included soft tissue necrosis (n = 4, 57.1%) and gross bony destruction of the external ear canal (n = 2, 28.5%). Thirteen patients underwent tympanomastoid surgery. Most common operative findings included granulation tissue in the mastoid (n = 7, 53.8%) and mastoid bony erosion (n = 4, 30.7%). Facial canal involvement was seen in four patients (30.7%). CONCLUSION: This is the first study to describe a large group of surgically treated NOE. Initial surgical approach should be based on clinical and HRTBCT findings. Minimal HRTBCT findings may be addressed with local debridement. Severe HRTBCT findings should be addressed with canal wall up mastoidectomy as the minimal surgical procedure. Further extent should be decided based on perioperative findings.

Manifestations of verbal and physical violence towards doctors: a comparison between hospital and community doctors.

BACKGROUND: Healthcare workers, in the hospital and in community clinics, are frequently exposed to verbal and physical abuse that can lead to frustration and despair. This study's objectives were to evaluate trends in violence towards hospital and community doctors in the Negev region of Israel and to compare them to the results of a previous 2005 study. METHODS: A convenience sample of doctors in the hospital and in the community completed anonymous questionnaires on previous exposure to work place violence and their attitudes to it. The data were collected in 2017. RESULTS: One hundred forty-five doctors participated in the study, of who 63 were hospital doctors and 82 were community doctors. Fifty nine percent of the doctors reported that they experienced at least one incident of verbal abuse over the previous year and 9% were exposed to physical abuse, compared to 56 and 9%, respectively, in the previous study. More hospital doctors (58.7%) were exposed to verbal abuse on the part of family members than community doctors (35.8%) (P = 0.007). The most common reason for a violent outbreak was long waiting times, followed by dissatisfaction with treatment, both consistent with the findings in the previous study. Seventy one percent said that violence was a major problem for doctors. The majority (73.9%) had not participated in a workshop or other training for preventing workplace violence or coping with it, an improvement over the 83% who reported not receiving any training in the previous study. CONCLUSIONS: Workplace violence is a major issue, which affects hospital and community physicians alike. There is a rise in the number of doctors who have undergone training in this area, although the majority have yet to receive formal training.

Acute bacterial meningitis caused by acute otitis media in adults: A series of 12 patients.

We conducted a retrospective chart review to characterize the outcomes of 12 patients-9 men and 3 women, aged 21 to 79 years (mean: 49)-who had been treated at our tertiary care center for acute bacterial meningitis caused by acute otitis media (ABMAO). Fever was the most common presenting sign/symptom, observed in 8 patients, followed by otalgia, neck stiffness, headache, and confusion. An opaque and bulging tympanic membrane was observed in 8 patients. Cultures were positive for Streptococcus pneumoniae in the cerebrospinal fluid, ear, and blood in 7, 5, and 3 patients, respectively. Immediate treatment included tympanocentesis, with aspirates sent for bacteriologic cultures. Seven patients (58.3%) underwent surgery; 5 were operated on early, and 2 underwent surgery at a later stage because of a suspected defect in the mastoid bone. A cortical mastoidectomy was performed in 6 of the 7 surgical patients; the remaining patient underwent a canal-wall-down procedure. Ten patients experienced a full recovery, 1 died, and 1 had a poor neurologic outcome (vegetative state); both of the latter 2 patients were older than 60 years. We conclude that early diagnosis, administration of antibiotics, and myringotomy are crucial for control of ABMAO. A cortical mastoidectomy with ventilation tube insertion can be reserved for patients who do not respond, which is common.