Epistaxis first-aid: a multi-center knowledge assessment study among medical workers.

PURPOSE: To assess the knowledge and confidence level regarding the basic first-aid for treating epistaxis among medical staff, including nurses and physicians across various medical disciplines. The study focused three aspects of first aid management: location of digital pressure, head position and duration of pressure. METHODS: The study involved 597 participants, categorized into five groups according to their specialties: emergency medicine, internal medicine, surgery, pediatrics, and community-based healthcare. A paper-based multiple-choice questionnaire assessed knowledge of managing epistaxis. Correct answers were determined from literature review and expert consensus. RESULTS: Most medical staff showed poor knowledge regarding the preferred site for applying digital pressure in epistaxis management. For head position, pediatricians and internal medicine physicians were most accurate (79.4% and 64.8%, respectively, p < 0.01), and nurses from the emergency department outperformed nurses from other disciplines; internal medicine, surgery, pediatrics, and community-based healthcare (61.1%, 41.5%, 43.5%, 60%, 45.6%, respectively, p < 0.05). While most medical staff were unfamiliar with the recommended duration for applying pressure on the nose, pediatricians and community clinic physicians were most accurate (47.1% and 46.0%, respectively, p < 0.01), while ER physicians were least accurate (14.9%, p < 0.01). Interestingly, a negative correlation was found between years of work experience and reported confidence level in managing epistaxis. CONCLUSIONS: Our findings indicate a significant lack of knowledge concerning epistaxis first-aid among medical staff, particularly physicians in emergency departments. This finding highlights the pressing need for education and training to enhance healthcare workers' knowledge in managing epistaxis.

Postoperative Upper Airway Volume Measurements Among Children With Craniofacial Abnormalities.

OBJECTIVE: To measure postoperative airway volumes among patients with craniofacial abnormalities and compare them to normative values. STUDY DESIGN: Retrospective, comparative study. SETTING: Academic Medical Center. METHODS: Retrospective analysis of imaging of children with craniofacial abnormalities treated at NYU Langone Health from January 2013 to February 2021. Upper airway volumes postcraniofacial surgery were measured using 3D processing software (Dolphin 3D, version 11.95). These values were compared with published normative values. RESULTS: Twenty-one subjects were identified and compared to normative values. The postoperative oropharyngeal volumes were on average 43.7% smaller than the normative values (P < .001), and the total upper airway volumes were 31.6% smaller (P = .003). No significant differences were observed in the nasopharyngeal or hypopharyngeal volumes of the study cohort compared to the normative data. Among children ages 12 to 17 years (n = 13), the mean oropharyngeal volumes were 47.6% smaller than normal (P < .001), and the mean total upper airway volumes were 34.6% smaller than normal (P < .001). Among children ages 7 to 11 years (n = 8), the mean oropharyngeal volumes were 35.1% smaller than normal (P = .049), but no difference in mean total upper airway volume was observed. CONCLUSION: In children with craniofacial anomalies, postoperative airway volumes remain lower than normative values. However, even a slight increase in airway volume can yield a substantial increase in flow rate. 3D airway evaluations are a valuable tool for surgical planning and analysis and can help with optimizing airway dynamics.

Reconsidering routine admission for children under age 3 undergoing partial tonsillectomy: a prospective study.

BACKGROUND: Partial Tonsillectomy (PT) is an alternative method to treat sleep disordered breathing (SDB) and/or obstructive sleep apnea (OSA). The current guidelines do not differentiate it from traditional tonsillectomy. Thus, children younger than 3 years old undergoing PT are admitted for surveillance similar to traditional tonsillectomy due to possible postoperative complications. The aim of this study is to assess the risks of PT in children 3 years old and younger, compared to older children. METHODS: Children underwent inpatient partial tonsillectomy and/or adenoidectomy, due to SDB/OSA, from 2018 to 2020. A special protocol was designed, including follow-up at 2-, 4-, 6-, 8- and 24-h after surgery. Variables analyzed included visual analogue pain score, oral intake, oxygen saturation, pulse rate, postoperative hemorrhage, urine output, temperature, analgesics and fluid administration. Furthermore, major interventions were recorded. Comparison of all variables between children younger than 3 years old with older children was performed. RESULTS: Ninety-two children were included; mean age of the whole cohort was 44.5 ± 21.9 months. Thirty-five (38%) children were 3-years old or younger and n = 57 (62%) were older than 3 years old, with no significant statistical difference in sex (p = 0.22). Mean age in the younger group was 25.7 ± 6.9 months, and 56.1 ± 20.1 months in the older group. In total we had 7 children with post-operative complications; 4 with fever, 3 with low intake. There were no major interventions recorded in either group. The complications were more common in the older group (n = 5) than the younger group (n = 2) without a statistical significance (p = 0.59). There were no differences in VAS, use of painkillers, oral intake, urine output, oxygen saturation and tachycardia among the two groups. CONCLUSION: This study supports that children undergoing ambulatory PT may be at low risk of complications, regardless of age.

Impact of Otorrhea and Positive Cultures on Tympanoplasty Outcomes.

BACKGROUND: Chronic suppurative otitis media is a long-standing middle ear infection with a perforated tympanic membrane. Tympanoplasty is the mainstay of treatment. Most surgeons prefer to operate on dry ears; however, this may be difficult to achieve. OBJECTIVES: To investigate the effect of otorrhea and positive cultures on the outcome of tympanoplasty. METHODS: This retrospective analysis reviewed patients with chronic suppurative otitis media who underwent tympanoplasty 2008-2015. Patients were divided into three groups: active discharge and bacterial growth, active discharge without bacterial growth, and no ear discharge. Surgical outcomes were compared among the groups. RESULTS: Among 101 patients included, 43 ears (42.6%) had discharge preoperatively, 58 (57.4%) were dry. Overall closure rate was 81.2% (82/101). Preoperative active discharge closure rate was 88.3% (38/43) and without discharge 75.9% (44/58). There were 38 positive cultures preoperatively and five negative cultures. Cultures were not obtained in 58 cases. Success rates were 89.5%, 80%, and 75.9%, respectively. No significant difference was found between patients who had positive or negative cultures before the procedure (P > 0.48) or among the three groups (P = 0.25). The most common bacteria were Pseudomonas aeruginosa (n=17), followed by Staphylococcus species (n=10). None was significantly associated with operative failure (P = 0.557). The postoperative air threshold difference was not affected by culture results (P = 0.3). CONCLUSIONS: Tympanoplasty success rates and postoperative air threshold differences were not affected by the presence of preoperative otorrhea or positive ear cultures. Surgery can be performed even when the ear is not dry.

Nivolumab-induced diffuse type 2 rhinosinusitis: A case report.

BACKGROUND: Nivolumab, an immune checkpoint inhibitor is used to treat advanced metastatic malignancies. Data showed that nivolumab can cause exacerbated response of T-Helper 2 cells and lead to airway inflammation. OBJECTIVE: To present the upper airway findings of a 69-year-old woman after treatment with nivolumab. METHODS: Case report. RESULTS: A 69-year old woman with no history of chronic rhinosinusitis developed complaints of nasal congestion, rhinorrhea, sneezing, and anosmia. These symptoms started after one year of treatment with nivolumab. Pale polyps were observed on fiberoptic endoscopy examination. A gradual increase in eosinophil blood counts was noted. On histopathology, heavy infiltrates of eosinophils were seen in the tissue. CONCLUSIONS: Nivolumab is used to treat various advanced metastatic malignancies, with a good safety profile. Nevertheless, physicians must be alert to the possibility of evolving type II inflammation in patients, as appropriate therapy can be provided to improve their quality of life.

Is there a correlation between skull base flexure and palatal anomalies in patients with 22q11 deletion syndrome and velopharyngeal dysfunction?

The study aimed at assessing the relationship between skull base morphology, represented by skull base and nasopharyngeal angles, and palatal anatomy among patients with 22q11DS and velopharyngeal dysfunction. Retrospective analysis of patients with 22q11DS and velopharyngeal dysfunction. Age, sex, severity of velopharyngeal dysfunction, type of cleft (overt cleft palate, submucous cleft palate, occult submucous cleft palate, or no-CP, and cephalometric skull base angles were reviewed. Correlations between type of palatal anomaly and the angles were assessed. Among 132 patients, 71 were male (53.8%) and 61 were female (46.2%), ages 3.3-40.0 years (mean 8.3 ± 6.10). No difference in the mean cranial-base angle (P = 0.353) or in the distribution of the three types of cranial base angle sizes was found among the palatal anomaly groups (P = 0.137). More men had normal cranial base angles and more women had acute angulation (P = 0.008). A positive correlation was found between the skull base and nasopharyngeal angles (P = 0.001, r = -0.590). No direct correlation was found between cranial base morphology and palatal anomalies in patients with 22q11DS, and velopharyngeal dysfunction. This is probably because skull base and palate morphology contribute independently to velopharyngeal dysfunction.

Endoscopic treatment of ectopic teeth in the maxillary sinus.

BACKGROUND: Ectopic teeth in maxillary sinus is rare and are usually removed via sub-labial trans-canine fossa approach (SLCFA). The aim of our study was to present our experience with extraction of ectopic teeth in the maxillary sinus via transnasal endoscopic approach (TEA). MATERIAL AND METHODS: Rhinologists were asked to share their experience in the management of ectopic teeth in the maxillary sinus. Data were reviewed retrospectively. RESULTS: Eleven cases were reported in 10 patients from 2010 to 2019, six males and four females with a mean age of 33.5 +/-17 years (range 16 to 61). Seven patients complained of sinonasal symptoms, two were diagnosed incidentally during routine dental work-up, and one had oro-antral fistula. In eight patients, a cyst coexisted within the maxillary sinus. Teeth were located arbitrarily within the sinus. All cases were operated by TEA. One patient had self-limited periorbital emphysema, one had transient cheek numbness, and one had early post-operative bleeding that stopped after endoscopic cauterization. Long-term follow-up revealed good clinical outcomes. CONCLUSIONS: Transnasal endoscopic removal of ectopic teeth from the maxillary sinus is a feasible and rational approach when SLCFA is contraindicated. Key words:Ectopic teeth, dentigerous cyst, endoscopic sinus surgery, Caldwell-Luc.

Is Postextracapsular Tonsillectomy Bleeding More Common on the Side of the Surgeon's Nondominant Hand?

OBJECTIVES: To determine the difference in bleeding when extracapsular tonsillectomy with electrocautery is performed on the dominant and nondominant side of the surgeon's hands. STUDY DESIGN: Retrospective cohort study. SETTING: Academic university hospital. METHODS: Medical record data of patients who were admitted with posttonsillectomy bleeding from January 1, 2000, to July 31, 2017, were reviewed. Included were age, sex, surgical indication, side of posttonsillectomy bleeding, and time of bleeding. Information on the surgeon's dominant hand was also collected. All patients underwent total extracapsular resection with electrocautery. RESULTS: Of 280 patients, 186 met the inclusion criteria, 116 (62.3%) males and 70 (37.7%) females. Ages ranged from 2 to 74 years (mean ± SD, 17 ± 13 years; median, 13 years). In 136 cases (73.1%), bleeding was on the side of the surgeon's nondominant hand (P < .0001). In 50 (26.9%) cases, bleeding was on the side of the surgeon's dominant hand. The odds ratio of bleeding on the side of the surgeon's nondominant hand compared to the dominant hand was 8.99. CONCLUSION: The risk of bleeding following extracapsular tonsillectomy with electrocautery on the side of the surgeon's nondominant hand is significantly higher than on the side of the dominant hand. Thus, additional caution is required when operating on the nondominant side of the oral cavity in extracapsular tonsillectomy using electrocautery. These findings raise questions regarding dexterity as a risk factor for posttonsillectomy bleeding.

A Comparison between Mygind and Kaiteki positions in administration of drops to the olfactory cleft.

OBJECTIVES: Topical nasal steroids are a common treatment intervention for olfactory dysfunction. Penetration of topical treatment to the olfactory cleft (OC), such as nasal drops, is greatly dependent on the position of the head when the treatment is administered. We aimed to examine the penetrance of nasal drops to the OC in two different head positions: the Mygind (lying head back) position and the Kaiteki position. DESIGN AND SETTING: The specimens were firstly positioned in Mygind, and thereafter in Kaiteki positions. Nasal drops mixed with blue food dye were administered into the nostrils in each of the head position. Endoscopic videos were recorded, and two blinded observers scored the extent of olfactory cleft penetration (OCP) using a 4-point scale (0 = none, 3 = heavy). PARTICIPANTS: Twelve fresh-frozen cadaver specimens. MAIN OUTCOME MEASURES: Penetration of the dye into the OC. RESULTS: The mean score of nasal drops penetrance to the OC in the Mygind position was 1.34 (standard deviation, SD = 0.92), as compared to 1.76 (SD = 0.65) in the Kaiteki position. The difference in the OCP score between the two groups was not statistically significant (P > .05). CONCLUSION: Both Mygind and Kaiteki head positions are reasonable options for patients considering topical nasal drops for olfaction impairment. The preference of one position over the other should be determined by patient's preference and comfort.

Endoscopic marsupialization of nasolacrimal duct cysts under topical anaesthesia: 5 years of a single institute experience.

OBJECTIVE: To present the outcomes of neonatal nasolacrimal duct cysts treated through endoscopic intranasal marsupialization under topical anaesthesia. METHODS: A retrospective study of 19 infants diagnosed with congenital nasolacrimal duct cyst, with or without dacryocystocele, diagnosed and treated between March 2015 through March 2020. Data were extracted for descriptive purposes and included: birth weight, main presenting symptom, stertor or dyspnoea, unilateral or bilateral occurrence. Follow-up one month after intervention included recurrence of symptoms, physical examination and fibreoptic naso-endoscopy. RESULTS: Nineteen infants with intranasal cyst were presented to our department at the age of 1 day. Four-teen infants had unilateral and 5 infants had bilateral intranasal cysts. There were 8 boys and 11 girls. Mean gestational age at birth was 39 weeks, mean birth weight was 3351 g. 42.1% of infants presented with dacryocystocele, 31.5% with stertor, and 26.3% with dyspnoea. 80% of infants with bilateral cysts presented with dyspnoea. Follow up ranged from 6 to 48 months, no recurrence of symptoms was reported. CONCLUSION: Intranasal endoscopic marsupialization under topical anaesthesia is a successful, safe, low cost procedure for treating neonatal nasolacrimal duct cysts while avoiding general anaesthesia for infants.

Olfactory and Oral Manifestations of COVID-19: Sex-Related Symptoms-A Potential Pathway to Early Diagnosis.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic poses a threat to global health. Early diagnosis is an essential key to limit the outbreak of the virus. STUDY DESIGN: Case series, study conducted between March 25, 2020, and April 15, 2020. SETTING: Ambulatory, nonhospitalized patients who were quarantined in a designated hotel for COVID-19 patients and were recruited by an advertisement at the hotel. SUBJECTS AND METHODS: In total, 140 patients participated in a web-based questionnaire assessing initial symptoms of common viral diseases, olfactory and taste functions, xerostomia, and orofacial pain. RESULTS: A total of 58 men and 70 women participated. Initial symptoms were cough (59.4%), weakness (47.7%), myalgia (46.9%), fever (42.2%), headache (40.6%), impaired sense of smell (38.3%), impaired sense of taste (32.8%), sore throat (26.6%), runny nose (26.6%), and nasal congestion (22.7%). All symptoms were more frequent among women; however, only runny nose was statistically significant (P = .018). The most common combination of symptoms was cough and weakness (37.5%). A total of 25.8% reported olfactory and taste dysfunctions in the absence of other symptoms. In a comparison between the sexes, cough and runny nose were the most common combination in women (P = .018). A total of 38.3% of patients reported olfactory dysfunction as an initial symptom. Anosmia and facial pain were more common among women (P < .001 and P = .01, respectively), and 56% of patients reported xerostomia. CONCLUSION: A considerable number of patients presented with olfactory and oral disorders. Interestingly, women presented with a different cluster of symptoms than men, which may suggest a new clinical approach to diagnosing COVID-19 disease.

[UNCONTROLLED PENETRATION OF THE DENTAL IMPLANT TO THE MAXILLARY SINUS - A COLLABORATION BETWEEN ENT AND ORAL AND MAXILLOFACIAL SURGERY].

INTRODUCTION: The popularity of dental implants is continuously increasing. Displacement of implants into the maxillary sinus is a well-documented complication following this treatment. AIMS: To characterize patients treated in our institution for uncontrolled penetration of dental implants into the maxillary sinus, and highlight the importance of the multidisciplinary approach in treating these cases. METHODS: The charts of all patients treated in 2018 within the Sinuses and Dental Clinic at the Meir Medical Center were reviewed. Data concerning age, gender, timing and the type of treatment performed was retrospectively analyzed. RESULTS: Fifteen patients were included in the study. Ten implants were found in the left sinus and five in the right side. Eight implants were seen in the lower medial alveolar recess. None of the patients presented with an oro-antral fistulae. Ten patients were treated endoscopically - eight through a nasal approach, and two through the mouth. All patients healed uneventfully. CONCLUSIONS: Different approaches can be used to remove implants from the maxillary sinus. DISCUSSION: Most patients in this study were referred adjacent to the displacement of the dental implant. The medial alveolar recess is the most common area of implant displacement. While either a nasal or oral approach can be used to retrieve the implant in the absence of sinus disease, a nasal approach should be preferred in the presence of such pathology. The collaboration between the otorhinologist and the maxillofacial surgeon, enables both the dental and rhinosinus considerations to be considered. This cooperation allows practitioners to design better treatment plans for patients with dental implants involving the sinuses.

Craniofacial structure variations in patients with palatal anomalies and velopharyngeal dysfunction.

PURPOSE: Cephalometric evaluation of craniofacial and craniopharyngeal morphology is important for understanding the factors affecting velopharyngeal dysfunction (VPD) in patients with palatal anomalies. MATERIALS AND METHODS: In this study, 366 patients with VPD were retrospectively stratified into cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP groups. Lateral cephalometrics were used to assess craniofacial, craniopharyngeal, and velopharyngeal anatomy. RESULTS: The average craniofacial morphology in patients with VPD differed significantly according to the type of palatal anomaly. The non-CP and OSMCP groups differed from the CLP, CP, and SMCP groups in nasopharyngeal size and shape as depicted by a larger ANS-Ptm-Ve angle, a smaller S-N-Ba and NBa-PP angles, and a shorter linear value of S-Ar in the non-CP group. The CLP and CP groups had shorter ANS-Ptm, shorter Ptm-P, and smaller SNA and SNB angles. CONCLUSION: VPD patients with overt clefts have different skeletal and nasopharyngeal shapes compared to non-CP and OSMCP. Velopharyngeal function assessment should include the size and shape of the nasopharyngeal space in addition to the size and the activity of the velum and posterior and lateral walls of the nasopharynx. This should enable a more precise understanding of VPD pathology, and lead to improvements in the posterior pharyngeal flap technique in order to obtain better postoperative speech outcomes after surgical management of velopharyngeal dysfunction.

Orbital complications associated with paranasal sinus infections - A 10-year experience in Israel.

OBJECTIVE: Orbital involvement is the most common complication of sinus infections. The epidemiology of the disease is continuously changing in the antibiotic era. MATERIALS AND METHODS: Data on patients who were hospitalized due to acute sinusitis and orbital complications were retrospectively collected and analyzed from four medical centers in Israel during the years 2002-2012. RESULTS: 288 patients were included in the study, the average age was 14.4 years, 180 were males, and 220 were children. No significant annual increase in the number of patients was noted. The lowest number of patients was found during the summer 19.4%. A linear direct correlation was found between older age and prolonged hospital stay. Children were presented with a significantly higher Chandler score than adults. No patient had cavernous sinus thrombosis. 101 (35%) patients received antibiotics before hospital admission. Their average hospital stay was similar to those who were not treated prior to admission. 106 patients (39.8%) had fever. A direct correlation was found between older age and the presence of fever. 102 (35.4%) patients had leukocytosis. The difference in white blood cell count between patients younger than two years of age to the other groups was statistically significant. Forty four (15.3%) patients underwent surgical intervention. A direct correlation was found between leukocytosis and older age to surgery. CONCLUSIONS: Periorbital cellulitis occurs mainly in children and males and is less frequent in the summer. Children tend to have worse orbital involvement with lower temperatures than adults. Older age and leukocytosis are associated with surgical intervention.

Morphology of the human tympanic membrane annulus.

OBJECTIVE: To study the full panoramic view with figuring of the morphology and topography of the human tympanic annulus. STUDY DESIGN: Postmortem material analysis. SETTING: University-affiliated hospital. SUBJECTS AND METHODS: Twenty-three single, normal human adult tympanic membranes were completely extracted from formalin-fixed temporal bones. They were faced medially and placed at the same level of a graph paper mounted on a board. High-quality images of the tissue preparations were taken, and computer-aided measurements of the annular caliber were calculated at nine reference points. The 6 o'clock direction served as a midpoint, and another four reference points were set anteriorly and posteriorly in clockwise and counterclockwise directions. RESULTS: The annulus has a horseshoe-like shape with a small part absent above the neck of the malleus. The maximal mean caliber at the manubrial axis (6 o'clock direction) was 748 +/- 201 mum. The annulus gradually thins out almost symmetrically anteriorly and posteriorly, until it reaches about 15 percent of the maximal caliber at its end points (152 +/- 87 and 113 +/- 42 mum, respectively). Significant differences were found between adjacent reference points on both anterior and posterior sides. CONCLUSIONS: The annulus has a horseshoe-like shape and gradually thins out almost symmetrically, reaching anteriorly and posteriorly about 15 percent of the maximal caliber at the manubrial axis. These new data may provide guidance in transcanal middle ear exploration and suggest the possibility of varied functions attributable to the annulus regarding middle ear sound transmission and TM vibratory properties. The data may contribute to understanding the development of marginal perforations and posterior superior retraction pockets.