Screening and treatment of methicillin-resistant Staphylococcus aureus in children undergoing open airway surgery.

OBJECTIVES: (1) To determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization in children undergoing open airway surgery using a screening protocol; (2) to examine the rates of postoperative infection in this cohort; and (3) to determine adherence to a MRSA antibiotic protocol. DESIGN: Retrospective cohort study. SETTING: Tertiary pediatric referral center. PATIENTS: The study population comprised 180 children undergoing 197 open airway operations from January 2007 to March 2009 at the Cincinnati Children's Hospital Medical Center. INTERVENTION: Methicillin-resistant Staphylococcus aureus screening and treatment protocol. MAIN OUTCOME MEASURES: Prevalence of MRSA colonization, postoperative infection rates, colonization rates by site, and adherence to antibiotic protocol. RESULTS: A total of 180 patients who underwent 197 operations were included in the study. The overall prevalence of MRSA was 32.5%. There were no significant differences between MRSA-colonized and noncolonized patients regarding age at surgery, sex, gestational age at birth, or comorbidities. Postoperative infection rates were similar between the 2 groups (16% MRSA colonized; 17% MRSA noncolonized). Three patients who developed postoperative MRSA infections were MRSA negative on preoperative screening. Intraoperative adherence was high in both groups. CONCLUSIONS: We describe a MRSA screening and treatment protocol for children undergoing open airway surgery. We found a high prevalence (32.5%) of MRSA colonization in these patients. Treatment of MRSA-colonized patients resulted in postoperative infection rates similar to those in MRSA-noncolonized patients. Treatment of MRSA-colonized patients resulted in no MRSA-associated postoperative infections, graft loss, or dehiscence. MRSA screening and treatment protocols may be helpful in minimizing MRSA-associated postoperative infections in these patients.

Multifocal synchronous ipsilateral Warthin tumors: case report and review of the literature.

We report a case of a 73-year-old woman who presented with an enlarging superficial parotid mass, a concomitant ipsilateral deep-lobe parotid mass, and associated upper jugular lymphadenopathy. The clinical presentation and radiographic imaging were suggestive of malignancy, and the patient was treated with total parotidectomy with upper jugular lymph node sampling. Pathologic examination revealed two distinct masses, one in the superficial lobe and one in the deep lobe of the parotid gland, both consistent with synchronous Warthin tumors. Analysis of the upper jugular lymph nodes was consistent with reactive lymphoid hyperplasia. Although the true incidence of multicentricity in ipsilateral Warthin tumors may be underappreciated and underreported, this entity should remain in the differential diagnosis for unilateral parotid masses.

Acute glutaraldehyde mucosal injury of the upper aerodigestive tract due to damage to the working channel of an endoscope.

OBJECTIVES: Glutaraldehyde (Cidex) is a commonly used agent for cold sterilization of endoscopes despite its known irritative, allergic, and carcinogenic potential. This report details the clinical course of 2 patients who suffered acute glutaraldehyde exposure during office injection procedures. METHODS: Clinical records of 2 outpatients undergoing office injection procedures were reviewed. One patient underwent bilateral injections of hydroxyapatite, and 1 underwent voice gel injection. RESULTS: Both patients developed acute mucosal injury in the form of supraglottitis and laryngitis. Both patients required inpatient admission with airway monitoring (1 requiring admission to the intensive care unit) and were treated with steroids and antibiotics. The same channel endoscope was used for both procedures and was noted after careful examination to have retained glutaraldehyde inside the scope due to a perforation of the lining of the working channel. CONCLUSIONS: Glutaraldehyde can cause acute mucosal injury to supraglottic and glottic structures, and diligent procedures must be maintained for flushing the channels and monitoring glutaraldehyde retention in the channels. Great care should be taken to avoid damage to the lining of working channels from instrumentation.

Ergonomic analysis of microlaryngoscopy.

OBJECTIVES/HYPOTHESIS: To apply ergonomic principles in analysis of three different operative positions used in laryngeal microsurgery. STUDY DESIGN: Prospective case-control study. METHODS: Laryngologists were studied in three different microlaryngeal operative positions: a supported position in a chair with articulated arm supports, a supported position with arms resting on a Mayo stand, and a position with arms unsupported. Operative positions were uniformly photographed in three dimensions. Full body postural data was collected and analyzed using the validated Rapid Upper Limb Assessment (RULA) tool to calculate a risk score indicative of potential musculoskeletal misuse in each position. Joint forces were calculated for the neck and shoulder, and compression forces were calculated for the L5/S1 disc space. RESULTS: Higher-risk postures were obtained with unfavorably adjusted eyepieces and lack of any arm support during microlaryngeal surgery. Support with a Mayo stand led to more neck flexion and strain. Using a chair with articulated arm supports leads to decreased neck strain, less shoulder torque, and decreased compressive forces on the L5/S1 disc space. Ideal postures during microlaryngoscopy place the surgeon with arms and feet supported, with shoulders in an unraised, neutral anatomic position, upper arms neutrally positioned 20 degrees to 45 degrees from torso, lower arms neutrally positioned 60 degrees to 100 degrees from torso, and wrists extended or flexed <15 degrees. CONCLUSIONS: RULA and biomechanical analyses have identified lower-risk surgeon positioning to be utilized during microlaryngeal surgery. Avoiding the identified high-risk operative postures and repetitive stress injury may lead to reduced occupationally related musculoskeletal pain and may improve microsurgical motor control.

Cervical thymic remnants in children.

OBJECTIVE: Define the clinical presentation, diagnostic value of preoperative imaging, surgical management, and outcomes of treatment of congenital cervical thymic remnants in children. DESIGN: Retrospective cohort. SETTING: Single tertiary care institution. PATIENTS: 20 children who underwent excision of cervical thymic remnant, 1975-2006. MAIN OUTCOMES MEASURED: Utility of preoperative imaging to diagnose cervical thymic anomalies; success of surgical treatment of cervical thymic remnants. RESULTS: A total of 20 children were identified, with an average age of 6.98+/-5.63 years. All ectopic thymus tissue was found in the embryonic distribution area associated with the third branchial pouch. Fourteen patients underwent excision of a cystic ectopic thymus. Four of these patients exhibited lesions isolated to the cervical region, and 10 patients displayed lesions involving cervicomediastinal areas. Six patients underwent excision of solid ectopic cervical thymus, and each of these was an unanticipated mass encountered during surgical dissection for other procedures. 83% of patients with solid ectopic cervical thymus presented at age 3 or younger. Physical exam and preoperative imaging correctly diagnosed thymic remnants in 15% patients. Resection of thymic remnants was successful in all patients, and there were no recurrences. CONCLUSIONS: Though rare, thymic remnants should be considered in the differential diagnosis of masses presenting in locations associated with derivatives of the third branchial pouch. Though preoperative imaging is helpful in identifying the extent of these lesions, congenital thymic remnants prove difficult to diagnosis radiologically. Surgical excision is the diagnostic and therapeutic treatment of choice in the management of cervical thymic remnants.

Intraoperative PTH: effect of sample timing and vitamin D status.

OBJECTIVE: To assess the effect of timing of intraoperative parathormone (iPTH) samples and 25-hydroxyvitamin D (25-OHD) status on decision-making during parathyroidectomy. METHODS: A total of 77 patients with primary hyperparathyroidism and iPTH levels (preincision, preremoval, 5 (T5) and 10 (T10) minutes postremoval) performed during parathyroidectomy were reviewed. RESULTS: Forty-one percent of patients were 25-OHD insufficient. We noted a significant correlation between preoperative 25-OHD and preincision iPTH (P=0.002) but not iPTH at postremoval levels (T5, P=0.89; T10, P=0.42). When compared with preincision iPTH, the use of either the higher preincision or preremoval iPTH baseline significantly improves the assay sensitivity from 83% to 93% at T5 (P=0.01) and 87% to 97% at T10 (P=0.02). Surgical cure was obtained in 98% of patients. CONCLUSION: Obtaining preremoval iPTH allowed earlier decision with respect to operative completion in 38% of cases. 25-OHD status does not appear to significantly affect interpretation of iPTH levels. SIGNIFICANCE: Obtaining both baseline levels significantly improves sensitivity in iPTH monitoring.

Who should be a stapes surgeon? An otologist or a generalist?

PURPOSE OF REVIEW: The overall experience with stapes surgery has declined, both within residency training programs, as well as in clinical practice. Does this change in the environment suggest that subspecialists rather than generalists manage patients with otosclerosis? RECENT FINDINGS: A decreasing availability of patients with clinical otosclerosis has encouraged trainees and practitioners to adopt strategies that will enable the maintenance of quality care to these patients. SUMMARY: Well trained generalists should be prepared to perform stapes surgery. Lack of experience or infrequent exposure to disease suggests that optimal care can be achieved by referring the patient to an experienced otologic surgeon.

Adenotonsillectomy for obstructive sleep apnea syndrome in young children: prevalence of pulmonary complications.

OBJECTIVE: To determine, in a series of children younger than 6 years undergoing adenotonsillectomy for treatment of clinical obstructive sleep apnea syndrome (OSAS), the effect of age on prevalence of postoperative respiratory complications. The primary objective was to define a practice standard for postoperative hospital admission. DESIGN: Retrospective analysis. SETTING: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. PATIENTS: All children younger than 6 years who underwent adenotonsillectomy to treat OSAS from June 1, 1999, to May 31, 2001. MAIN OUTCOME MEASURES: The percentage of children younger than 3 years undergoing adenotonsillectomy to treat OSAS who experience a postoperative respiratory complication. RESULTS: Of 2315 patients younger than 6 years undergoing an adenotonsillectomy for treatment of OSAS, 149 (6.4%) developed a postoperative respiratory complication. Even though there was a lower incidence of comorbid medical conditions in this cohort, children younger than 3 years were at a greater risk for developing a postoperative respiratory complication compared with those aged 3 to 5 years (9.8% vs 4.9%, P<.001). Logistic regression analysis revealed that children younger than 3 years had a nearly 2-fold increased risk for respiratory complications postoperatively (odds ratio, 1.98; 95% confidence interval, 1.41-2.77) when controlling for race and sex. CONCLUSIONS: Adenotonsillectomy to treat OSAS is associated with a significantly higher rate of postoperative respiratory complication in children younger than 3 years compared with children aged 3 to 5 years. Our results support hospital admission for all patients younger than 3 years undergoing adenotonsillectomy for treatment of OSAS.