Risk factors for recurrent acute mastoiditis in pediatric patients: a registry-based cohort study.

OBJECTIVE: To describe characteristics of pediatric patients with recurrent acute mastoiditis, and to identify risk factors for this condition. STUDY DESIGN: A retrospective cohort study. SETTING: Data based on electronic medical records of the largest Health Maintenance Organization in Israel. METHODS: Children hospitalized due to acute mastoiditis during the years 2008-2018 were identified, and their diagnosis was verified. Patients with recurrent acute mastoiditis were identified and grouped, and their characteristics were outlined and compared to those of the original group to identify risk factors for recurrence. RESULTS: During the 11-year period, a total of 1115 cases of children hospitalized due to acute mastoiditis were identified with a weighted incidence rate of 7.8/100,000. Of this group, 57 patients were diagnosed with recurrence following a full clinical recovery. The incidence proportion of recurrent acute mastoiditis was 5.1% (57/1115), male-to-female ratio was 27:30, 73.4% were younger than 24 months, the median period from the first episode was 3.4 months (IQR 2.0;10.0), and 82.5% of the patients (n = 47) had a single recurrence, whereas 18.5% (n = 10) had two recurrences or more. Mastoidectomy and swelling over the mastoid area during the first episode were identified as the main risk factors for recurrent mastoiditis HR = 4.7 [(2.7-8.2), p < 0.001] and HR = 2.55 [(1.4-4.8), p = 0.003], respectively. Mastoidectomy was the only independent significant risk factor for recurrence in a multivariate analysis. CONCLUSIONS: Mastoidectomy and swelling over the mastoid area during the first episode of acute mastoiditis were found strongly related independent risk factor for future recurrent episodes of acute mastoiditis.

Epidemiology of pediatric acute mastoiditis in Israel: A National Registry 10-year perspective.

Background and Objectives: Previous small studies have proposed a higher incidence of acute mastoiditis in Israeli pediatric patients than in other Western countries. The aim of this study was to describe the incidence of acute mastoiditis and its epidemiological features over a decade, in order to identify variables that could possibly affect the incidence. Methods: All admitted patients aged <18 years diagnosed with acute mastoiditis between 2008 and 2018 at Clalit Healthcare Services were identified and a database was generated. Results: A total of 1189 and 1115 patients met the inclusion criteria, respectively. Acute mastoiditis diagnosis was confirmed in 95.2% of the patients. The incidence was 7.78 cases per 100,000 children-years but was significantly higher in children under 2 years of age (average of 38.31 per 100,000 children-years). No specific pattern was observed in the annualized incidence rate during the study period. Acute mastoiditis was significantly more common in children of Jewish descent than non-Jewish (10.4 vs. 3.03 per 100,000 children-years, P < 0.001) and of high socioeconomic status and is more common in the winter. The prevalence of household parental smoking (52%) was more than double that previously reported in the Israeli population. Conclusions: A higher incidence of acute mastoiditis was observed in the Israeli population than in other reports. The age-dependent rate was identified along with unique epidemiological features such as seasonality, higher incidence in patients of Jewish descent, or high socioeconomic status. Related parental smoking habits lend further support against the exposure of young children to household smoking.Level of evidence: Individual retrospective cohort study.

Laboratory and imaging findings of necrotizing otitis externa are associated with pathogen type and disease outcome: A retrospective analysis.

OBJECTIVE: To examine associations of laboratory and imaging data with diagnostic parameters of necrotizing otitis externa (NOE) and its severity, and to compare between bacterial and fungal infections. METHODS: Records of patients diagnosed with NOE during 2010-2018 at the Department of Otolaryngology, Head and Neck Surgery were reviewed retrospectively for demographics; disease characteristics; and laboratory, scintigraphy, and imaging results. RESULTS: Of 48 patients with NOE, the mean age is 73±11.6 years; 32 (67%) were males; 83% had diabetes mellitus. Common pathogens were pseudomonas (49%) and fungi (33%). Sensitivities of the technetium-scan (SPECT ratio ≥1.5), temporal bone computed tomography (CT), and gallium-scan (SPECT ratio ≥1.3) were: 78.7%, 48.8%, and 31.4%, respectively. Gallium-scan results correlated positively with CT bone involvement (p=0.002) and hospital length of stay (p=0.0014). C-reactive protein (CRP) level correlated with hospital length of stay (p=0.028) and positive technetium-scan results (p=0.012). Fungal infection had a higher technetium SPECT ratio (2.16 vs. 1.77, p=0.04), gallium SPECT ratio (1.4 vs. 1.2, p=0.02), longer duration of systemic treatment (87.4 vs. 37.9 days, p=0.014), and longer hospital length of stay (31.6 vs. 15.2 days, p=0.004) compared to non-fungal infection. Eight (17%) patients had responded poorly to treatment. Fungal pathogens, facial nerve paresis, extra-auricular, and bilateral disease were more prevalent among the non-responders. CONCLUSION: The technetium scan has higher sensitivity than temporal bone CT for diagnosing NOE. The gallium scan and CRP correlated well with hospital length of stay. A high rate of fungal infection was found, with significantly higher technetium and gallium SPECT ratios and worse outcome compared to bacterial infection. Fungal NOE remains therapeutically challenging.

Is Nasal Endoscopy of Diagnostic Value in Chronic Rhinosinusitis Without Nasal Polyps?

Endoscopic examination of the nasal cavity is an integral part of the assessment of patients with chronic rhinosinusitis. However, the benefit gained by performing endoscopy with respect to the patient's medical condition has not been completely assessed. We conducted a prospective cohort in an academic medical center. Thirty-nine patients diagnosed with chronic rhinosinusitis, without polyps, whose ailment was managed conservatively with no surgical intervention. All patients underwent nasal endoscopy, a computed tomography (CT) scan rated for Lund-MacKay score, and completed a sino nasal outcome test (SNOT)-20 questionnaire. This same evaluation was repeated 6 weeks following medical treatment. The CT scan and SNOT-20 questionnaire were independent parameters to evaluate the endoscopy score in each nasal passage. Thirty-nine (28 females) patients completed the follow-up period. A total of 156 endoscopic evaluations were performed, in which 74 nasal cavities were found to have significant pathology and 82 were either normal or displayed mild pathology. The correlation with the Lund-MacKay score was poor with a positive predictive value of 68.9% (31.1% false positive and 28% false negative). However, while looking at the SNOT-20 score, corrected for repeated measures, a higher endoscopy score was associated with a higher SNOT-20 score (odds ratio = 3.53, 95% confidence interval = 1.54-8.09, P = .003). Patients with higher endoscopy scores had a greater probability for exhibiting severe symptoms. However, we could not demonstrate a strong correlation between nasal endoscopy findings and CT scan scores. Therefore, with respect to patients with chronic rhinosinusitis without polyps, nasal endoscopy could be utilized as a beneficial objective tool.

[OTOLARYNGOLOGY, HEAD AND NECK SURGERY - VARIETY OF PATHOLOGIES AND MANAGEMENT OPTIONS].

INTRODUCTION: The field of otolaryngology, head and neck surgery faces a wide range of medical conditions, starting with upper airway morbidity, head and neck tumors, hearing loss and deafness, ear diseases, nose, sinuses, and anterior skull base conditions, pediatric otolaryngology, laryngology and facial and reconstructive plastic surgery. The current issue of this journal presents a variety of manuscripts that are in the forefront of our specialty in Israel and around the world. The management of laryngeal tumors is undergoing thorough modification aiming to preserve the organ while early tumors are treated endoscopically using laser technology. The human papilloma virus is one of the major changes that recently emerged as an important etiologic factor for oropharyngeal carcinoma in young nonsmokers. Hearing loss and deafness are negative contributors to the quality of life. Congenital hearing loss has a major effect on brain development, and speech and language development, therefore, early cochlear implantation is beneficial for well child development. Different aspects associated with cochlear implantation are discussed in this issue. Many fields that are associated with our specialty are gradually utilized by otolaryngologists, for example the utilization of ultrasound by surgeons. The field of otolaryngology head and neck surgery is dynamic and abundant with innovative technologies that are presented in this article, starting with cochlear implants, robotic surgery, and the utilization of 3D printers for complicated facial reconstructions. We are in the midst of a journey and we may assume that the future holds great promise both for our patients and for us as health care providers.

Adenoid Obstruction Assessment in Children: Clinical Evaluation Versus Endoscopy and Radiography.

BACKGROUND: Hypertrophy of the adenoids is common in children. However, the anatomical site makes the adenoids difficult to assess, and studies evaluating the subject are ambiguous, especially with regard to the use of X-ray as an evaluation tool. OBJECTIVES: To compare medical history with clinical, radiological, and endoscopic evaluations of the adenoids and compare obstructed and non-obstructed children relative to the assessment methods. METHODS: A prospective comparative study was conducted with children who were suspected of having enlarged adenoids. All parents completed a medical history questionnaire and patients underwent clinical evaluation based on Nasal Obstruction Index (NOI) scores, radiological assessment based on the lateral neck X-ray adenoid-nasopharynx (A/N( ratio, and endoscopic evaluation based on anatomical relations. Spearman correlations were used for comparison between methods. RESULTS: We evaluated 36 patients, median age 5.33 years. Correlation measurements for clinical assessment and questionnaire (r = 0.582, P < 0.0001), questionnaire and endoscopy (r = 0.462, P = 0.005), and clinical assessment and nasal endoscopy (r = 0.621, P < 0.0001) were statistically significant. None of the parameters correlated with the radiological findings. A statistically significant difference was found between the obstructed and non-obstructed groups in both questionnaire (P = 0.004) and clinical assessment (P < 0.0001). However, no difference was found in X-ray measurements. CONCLUSIONS: Lateral neck X-ray measurements were not correlated to symptoms, signs, or endoscopic findings. Therefore, medical professionals should use lateral neck radiography when considering adenoidectomy only on a highly selective basis.

The role of surgery in necrotizing otitis externa.

This retrospective case review describes a subset of 5 patients with necrotizing otitis externa (NOE) with a refractory disease course who underwent surgery as part of their management plan between 2008 and 2013. Surgery promoted the cure of 4 of the 5 patients, and a fungal pathogen was recovered in 4 of 5 surgical samples. We conclude that surgery may be a necessary diagnostic and treatment adjunct in selective cases of NOE, especially in patients with a refractory disease course or with a suspected fungal etiology.

Angiomyomatous hamartoma in a submandibular lymph node: a case report.

Angiomyomatous hamartomas have been found almost exclusively in the inguinal and femoral lymph nodes; few reports of these lesions in the head and neck region have been published. We present a case of angiomyomatous hamartoma in the submandibular area, a site that has not been previously reported in the literature. The mass was initially diagnosed as an enlarged lymph node. When it did not regress following broad-spectrum antibiotic treatment, the patient, a 51-year-old woman, underwent an excisional biopsy. Histopathology identified the mass as an angiomyomatous hamartoma. At follow-up 3 years and 9 months postoperatively, the patient exhibited no evidence of recurrence on physical examination and computed tomography. Even though angiomyomatous hamartoma of the head and neck is rare, we suggest that otolaryngologists include it in the differential diagnosis of head and neck masses.

Aneurysmal bone cysts of the head and neck in pediatric patients: a case series.

OBJECTIVES: To characterize aneurysmal bone cysts (ABCs) of the head and neck as seen at a tertiary care center. DESIGN: A case series. METHODS: A retrospective chart review of pediatric patients with aneurysmal bone cyst of the head and neck treated at the Hospital for Sick Children during the years 1994-2006 was carried out. RESULTS: Nine patients with ABC were treated. The average age at diagnosis was 9.3 years (range: 5 months-15 years), six males and three females. Four cysts originated in the paranasal sinuses, two in the mandible, one in the zygoma, one in the mastoid and one in the parietal bone. Two cases were associated with a previous localized trauma (mandible, zygoma). 5/9 presented with pain, 4/9 presented as an asymptomatic mass, 2/9 were associated with proptosis and nasal obstruction, 2/9 with nasal obstruction and 1/9 presented with an aural polyp. Seven cysts were successfully excised while one (in the pterygomaxillary fossa) is being followed conservatively. In one case the ABC was found to be secondary to an extensive osteoblastoma and this child continuous to be problematic. Follow-up time ranged from 2 years and 6 months to 10 years. CONCLUSIONS: ABC of the head and neck may vary in presentation and severity. Surgical removal is the treatment of choice at our institution and may provide a satisfying outcome. ABC may be secondary to an underlying bone pathology (e.g., osteoblastoma) which may make it refractory to treatment.

Epinephrine/Lidocaine injection vs. saline during endoscopic sinus surgery.

OBJECTIVES: To assess the safety and effectiveness of an epinephrine/lidocaine mixture administered by injection versus epinephrine administered topically and to learn its pharmacokinetics following administration to the nasal mucosa. DESIGN: A double-blind randomized controlled trial. METHODS: Patients were assigned into two groups and were injected with either epinephrine 1:100,000 and lidocaine 1% or saline alone during endoscopic nasal surgery under general anesthesia. Pledgets soaked in epinephrine 1:1,000 were used throughout the procedure in both groups. Hemodynamic measurements and catecholamine blood levels were obtained. RESULTS: Ten patients were randomized to the epinephrine group and 12 to the saline group. We were able to measure epinephrine and norepinephrine levels following injection in all patients. Epinephrine levels were similar in both groups immediately after injection; however, 15 minutes following injection, epinephrine was significantly higher in saline-injected patients. Mean arterial pressure and heart rate were affected by epinephrine and norepinephrine levels immediately after injection but were never elevated over the normal range. Heart rate was higher (P < .05) in the saline injected group than in the epinephrine group throughout the measurement period. The surgeons believed that the surgical field was bloodier in saline-injected patients (P < .05) however objective estimation of blood loss showed no difference. CONCLUSIONS: Injection of epinephrine/lidocaine mixture does not produce higher blood levels of epinephrine when compared to saline injection and did not induce any harmful side effects. We postulate that the combination with lidocaine 1% may reduce the patients' stress and thus prevent higher catecholamine levels.

Preoperative characteristics and postoperative outcomes following adenoidectomy in children.

OBJECTIVES: (1) To describe various preoperative and diagnostic findings of children undergoing adenoidectomy and (2) to evaluate quality of life outcomes following adenoidectomy in children. METHODS: This was a prospective observational study. Patients who were candidates for adenoidectomy at The Hospital for Sick Children were evaluated with respect to preoperative symptoms, flexible nasal endoscopy (FNE) findings, and nasal airflow (NAF) studies. Following surgery, a quality of life questionnaire was administered to all available patients and an attempt was made to repeat the NAF study. RESULTS: Fifty-seven patients were included in the study (31 females and 26 males). The average age of the patient at surgery was 10.1 years. Thirty patients (52.6%) had a significant NAF study, whereas FNE revealed an average nasopharyngeal obstruction of 73.2%. We did not find any correlation between preoperative symptoms, FNE findings, or NAF study results. The degree of symptom reduction was the only predictor of how satisfied a patient would be in the postoperative period (p<.05). CONCLUSION: In our study of adenoidectomy patients, clinical signs and symptoms appear to be more predictable than the objective tests of NAF and FNE. As such, following these symptoms in the postoperative period is important in determining a patient's satisfaction following surgery.

Partial neurolysis of the hypoglossal nerve for selective lingual atrophy in a porcine model.

OBJECTIVES: Obstructive sleep apnea in children is most commonly treated with adenotonsillectomy; however, in cases of significant tongue base prolapse, this may prove inadequate. Surgical procedures used to increase the retroglossal airway have significant morbidities and low patient acceptability. We theorized that effective reduction of the tongue base can be achieved through partial denervation of the hypoglossal nerve, which is easily accessed in the submandibular space with minimal morbidity. METHODS: We performed a prospective, experimental study in which topographic innervation maps of porcine tongue were generated by stimulating the hypoglossal main trunk and peripheral branches. The effects of complete unilateral nerve sectioning on tongue base volume and linear dimensions were measured and compared to the contralateral control side. In the final stage, only the peripheral nerve that was determined as the main supply to the tongue base was sectioned, and the results were compared to those in the matched controls. RESULTS: A medial branch of the hypoglossal nerve was consistently identified as the main motor supply to the tongue base. Complete denervation resulted in a measurable decrease in the volume of the tongue base as compared to that of controls. Partial neurolysis produced inconsistent changes in 2 subjects, with decreases in linear dimensions that were not proportional to the decrease in volume. Histologically, complete denervation was followed by a significantly greater replacement of muscle with fat and connective tissue as compared with partial neurolysis. CONCLUSIONS: There were inconsistent changes in volume and linear dimensions of the tongue base following partial neurolysis of the hypoglossal nerve over the 3-month experimental period.

Diagnostic radiation in pregnancy: perception versus true risks.

Significant numbers of therapeutic abortions are performed for radiation-exposed pregnant women because of concerns about the teratogenic risk. However, available data suggest that current diagnostic radiation procedures are not teratogenic.

Pregnancy outcome following non-obstetric surgical intervention.

OBJECTIVE: To evaluate the effects of non-obstetric surgical procedures on maternal and fetal outcome. METHODS: A systematic review of all English language literature. RESULTS: Fifty-four papers met the inclusion criteria. The overall number of patients reported was 12,452. Reported maternal death was rare at .006%. The miscarriage rate was 5.8%; however, this number is difficult to interpret since matched controls were not available. The rate of elective termination of pregnancy following non-obstetric surgery was 1.3%. The rate of premature labor induced by non-obstetric surgical intervention was 3.5% and this was noted specifically following appendectomy versus other types of interventions (P<.001). A total of 2.5% of pregnancies resulted in fetal loss. The prematurity rate was 8.2%. The rate of major birth defects among women who underwent non-obstetric surgical intervention in the first trimester was 3.9%. Sub-analysis of papers reporting on appendectomy during pregnancy revealed a high rate (4.6%) of surgery-induced labor. Fetal loss associated with appendectomy was 2.6%; however, this rate was increased when peritonitis was present (10.9%). CONCLUSIONS: Modern surgical and anesthesia techniques appear to diminish the rate of maternal death. Surgery in the first trimester does not appear to increase major birth defects and should not be delayed when indicated. Acute appendicitis with peritonitis is associated with higher risk to the mother and fetus.

Pattern of regional metastases from cutaneous squamous cell carcinoma of the head and neck.

OBJECTIVE: To assess the pattern of regional metastases from SCC of the skin of the head and neck as a prognostic factor. STUDY DESIGN AND SETTING: A retrospective chart review of 22 patients treated in a tertiary academic center. RESULTS: Metastases could be assessed clinically in the parotid gland and the neck in 50% and 59% of the patients, respectively. Histologic examination showed metastases in the parotid gland and the neck in 68% and 45.5%, respectively. Occult disease was 36% and 20% in the parotid gland and neck, respectively. The 1st echelon for metastasis was the parotid gland lymph nodes, whereas level II lymph nodes were the 1st echelon in the neck. Metastases to both the parotid gland and neck decreased the overall survival to 0, compared with 60% for metastases to the parotid gland and 100% for the neck. CONCLUSIONS: SCC of the skin of the head and neck with regional metastases has a high incidence of occult metastases in the parotid gland and the neck. Patients with metastases in both sites have a poor prognosis.

Cytokeratin-17 as a potential marker for squamous cell carcinoma of the larynx.

To assess cytokeratin-17 (CK17) as an immunohistochemical marker for squamous cell carcinoma of the larynx, we stained 63 tissue samples from 63 consecutive patients who were believed or suspected to have squamous cell carcinoma of the larynx for CK17 and analyzed them by computerized histomorphometry. The mean staining intensity for CK17 was significantly stronger (p < .01) in cancerous cells, dysplasia, and normal epithelium proximal to the tumor than in distal normal epithelium and polyps. The percentage of stained area, within samples taken from a single patient, was significantly higher in malignancy and dysplasia as compared to distal normal epithelium and in malignancy as compared to dysplasia and proximal normal epithelium (p < .001). The integrated optical density was significantly higher in the malignant epithelium, dysplasia, polyps, and proximal normal epithelium than in distal normal epithelium (p < .0001). We conclude that CK17 is a highly sensitive and specific immunohistochemical marker for premalignant and malignant transformation in the larynx. Further investigation is warranted in order to assess the role of CK17 in determining safe resection borders.

Intratympanic gentamicin for Menière's disease: a meta-analysis.

OBJECTIVES: To systematically review the published experience on intratympanic gentamicin treatment for intractable Menière's disease. STUDY DESIGN: Meta-analysis using a random effect model. METHODS: A comprehensive literature search was performed for articles using intratympanic gentamicin as a sole treatment modality with reporting of results according to the American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) guidelines for Menière's disease. Two reviewers independently assessed trial quality and extracted data. RESULTS: Fifteen trials with 627 patients met the inclusion criteria. All trials reported "before-after" outcome measures, using patients as their own controls. No double-blind or blinded prospective control trials were identified. Complete (class A) vertigo control was achieved in 74.7% (confidence interval [CI]95% 67.8-81.5%) of patients, and complete or substantial (class B) control was achieved in 92.7% (CI95% 89.5-96.0%). The success rate was not affected by gentamicin treatment regimen (fixed vs. titration). Hearing level and word recognition were not adversely affected, regardless of gentamicin treatment regimen. Analysis of functional level was not performed because of lack of data in the selected articles. CONCLUSIONS: Intratympanic gentamicin treatment for intractable Menière's disease appears to be effective in the relief of vertigo. Cochleotoxicity and ototoxicity is unlikely to be a major side effect. However, the level of evidence reflected from the eligible articles is insufficient, especially because of relatively poor study design. Therefore, it is prudent that patients eligible for this type of treatment should be selected carefully and titrated with low-dose gentamicin. Further investigation with this treatment modality with control subjects is warranted.

Central mucoepidermoid carcinoma of the mandible in a child.

Central mucoepidermoid carcinoma is an uncommonly encountered tumor. A rare case of this malignant tumor arising in the mandible of a 14-year-old adolescent is presented. Symptoms, signs, and management approach are discussed. A literature review of similar previously described cases is discussed as well.

Classification of fungal sinusitis in immunocompetent patients.

OBJECTIVE: The objective of this study was to review the subgroup classification of fungal sinusitis in immunocompetent patients. METHODS: The study design included 19 immunocompetent patients with fungal sinusitis who were operated on between 1993 and 1998. RESULTS: Ten of 19 patients showed a fungus ball. They underwent a limited surgical endoscopic procedure, and no further treatment was needed. Four patients had allergic fungal sinusitis and were treated postoperatively with irrigation, topical steroids, and oral steroids in 2 patients as well. Five patients had chronic sinusitis with significant bone erosion. All 5 underwent an extensive endoscopic procedure and were treated postoperatively by repeated irrigation, endoscopic cleaning, and no antifungal preparation. Two patients of this group are reported broadly. CONCLUSIONS: Fungal sinusitis in immunocompetent patients is not a rare condition and can be divided into 3 categories: 1) fungus ball, 2) chronic erosive (noninvasive) fungal sinusitis, and 3) allergic fungal sinusitis. The symptomatology, treatment, and prognosis varied significantly among the 3 different categories.

Acyclovir in the treatment of idiopathic sudden sensorineural hearing loss.

BACKGROUND: Idiopathic sudden sensorineural hearing loss (ISSNHL) is a vexing problem that continues to pose a diagnostic and therapeutic enigma for the otologist. The aim of the study, adopting the viral theory, was to discover whether patients with ISSNHL would benefit from early treatment with acyclovir and hydrocortisone compared with patients treated by hydrocortisone alone. METHODS: Sixty patients with ISSNHL were treated in a prospective controlled randomized manner. Patients were seen within 7 days of onset and were divided randomly into 2 groups. The study group patients were treated with acyclovir and hydrocortisone, whereas those in the control group were treated with hydrocortisone alone. RESULTS: We compared the 2 groups before and after treatment regarding SRT, mean hearing level at each frequency, speech reception threshold improvement, gender, age, tinnitus, and balance complaints. The overall improvement was 78%. CONCLUSION: We conclude that there probably is no benefit from the addition of acyclovir in the treatment of ISSNHL.