Malignant external otitis: The shifting treatment paradigm.

IMPORTANCE: Malignant external otitis (MEO) is an aggressive infection occurring in immunocompromised hosts. Increasing antimicrobial resistance is making the disease more difficult to treat. OBJECTIVE: Determine if there has been a shift in the microbiology and outcomes of MEO. DESIGN: A retrospective case series at a tertiary care institution. SETTING: Inpatient and outpatient tertiary care hospital. PARTICIPANTS: 12 cases of recent MEO were reviewed. MAIN OUTCOMES AND MEASURES: The primary outcome was progression of disease. Secondary outcomes were drug resistance and complications of MEO. RESULTS: Only 4 patients were cured of MEO. Four patients expired during the study period and at least one of these deaths was a direct result of the MEO. 7 patients developed Cranial nerve palsies, and 3 patients developed abscesses. CONCLUSIONS: Select cases of MEO now require multi-drug and long-term parenteral antibiotic therapy with extended hospital stays.

Comparison of packing material in an animal model of middle ear trauma.

PURPOSE: To compare the performance of absorbable gelatin sponge (AGS) with polyurethane foam (PUF) as middle ear packing material after mucosal trauma. MATERIALS AND METHODS: Using a randomized, controlled and blinded study design fifteen guinea pigs underwent middle ear surgery with mucosal trauma performed on both ears. One ear was packed with either PUF or AGS while the contralateral ear remained untreated and used as non-packed paired controls. Auditory brainstem response (ABR) thresholds were measured pre-operatively and repeated at 1, 2, and 6weeks postoperatively. Histological analysis of middle ear mucosa was done in each group to evaluate the inflammatory reaction and wound healing. Another eighteen animals underwent middle ear wounding and packing in one ear while the contralateral ear was left undisturbed as control. Twelve guinea pigs were euthanized at 2weeks postoperatively, and six were euthanized at 3days post-operatively. Mucosal samples were collected for analysis of TGF-ß1 levels by enzyme-linked immunosorbent assay. RESULTS: ABR recordings demonstrate that threshold level changes from baseline were minor in PUF packed and control ears. Threshold levels were higher in the AGS packed ears compared with both control and PUF packed ears for low frequency stimuli. Histological analysis showed persistence of packing material at 6weeks postoperatively, inflammation, granulation tissue formation, foreign body reaction and neo-osteogenesis in both AGS and PUF groups. TGF-ß1 protein levels did not differ between groups. CONCLUSION: PUF and AGS packing cause inflammation and neo-osteogenesis in the middle ear following wounding of the mucosa and packing.

The novel endocrine disruptor tolylfluanid impairs insulin signaling in primary rodent and human adipocytes through a reduction in insulin receptor substrate-1 levels.

Emerging data suggest that environmental endocrine disrupting chemicals may contribute to the pathophysiology of obesity and diabetes. In a prior work, the phenylsulfamide fungicide tolylfluanid (TF) was shown to augment adipocyte differentiation, yet its effects on mature adipocyte metabolism remain unknown. Because of the central role of adipose tissue in global energy regulation, the present study tested the hypothesis that TF modulates insulin action in primary rodent and human adipocytes. Alterations in insulin signaling in primary mammalian adipocytes were determined by the phosphorylation of Akt, a critical insulin signaling intermediate. Treatment of primary murine adipose tissue in vitro with 100nM TF for 48h markedly attenuated acute insulin-stimulated Akt phosphorylation in a strain- and species-independent fashion. Perigonadal, perirenal, and mesenteric fat were all sensitive to TF-induced insulin resistance. A similar TF-induced reduction in insulin-stimulated Akt phosphorylation was observed in primary human subcutaneous adipose tissue. TF treatment led to a potent and specific reduction in insulin receptor substrate-1 (IRS-1) mRNA and protein levels, a key upstream mediator of insulin's diverse metabolic effects. In contrast, insulin receptor-ß, phosphatidylinositol 3-kinase, and Akt expression were unchanged, indicating a specific abrogation of insulin signaling. Additionally, TF-treated adipocytes exhibited altered endocrine function with a reduction in both basal and insulin-stimulated leptin secretion. These studies demonstrate that TF induces cellular insulin resistance in primary murine and human adipocytes through a reduction of IRS-1 expression and protein stability, raising concern about the potential for this fungicide to disrupt metabolism and thereby contribute to the pathogenesis of diabetes.

Geriatric Sinus Surgery: A Review of Demographic Variables, Surgical Success and Complications in Elderly Surgical Patients.

OBJECTIVE: Demonstrate feasibility, safety and outcome metrics of geriatric sinus surgery (GESS). STUDY DESIGN: Retrospective review of patients undergoing sinus surgery for indication of chronic rhinosinusitis with and without nasal polyposis. SETTING: Tertiary referral center. PARTICIPANTS: Patients who underwent FESS from 2008-2017; excluding skull base, craniofacial, or oncologic surgery. Primary study group were patients aged 65 years and older. Patients aged 40-64 years of age were included for comparison.Main Outcomes and Measures: Multivariate analysis was performed to identify independently associated patient characteristics and perioperative variables. Preoperative medical and treatment history, revision and primary surgery, preoperative and post-operative SNOT-22 and NOSE scores, Lund-McKay scores were recorded when available. Post-operative data was assessed at a minimum of two months after the index procedure. Post-operative complications were included. RESULTS: Ninety-one (91) patients met criteria. 21.2% of the geriatric patients were taking systemic anticoagulation prior to surgery, and underwent treatment with nasal steroids (25.0%), oral antibiotics (67.7%), nasal irrigations (48.4%), and systemic steroids (37.5%) over an average of 7.3 months prior to surgery. There was an average post-operative reduction of 15.0 points (p < 0.0001) and 42.5 points (p = 0.0008) for SNOT-22 and NOSE scores, respectively. Average operative time was 117.4 minutes in geriatric patients compared to 183.4 minutes in younger patients (p = 0.004), with an average estimated blood loss of 55.6 milliliters (mL) compared to younger patients (111.8 mL) (p = 0.04). Linear regression identified revision surgery as associated with reductions in Sinonasal Outcome Test (SNOT-22) scores (p = 0.011). Geriatric patients had a shorter operative time (p = 0.011) while male sex was associated with a longer operative time (p = 0.014). Patients over 65 had fewer minor complications (p = 0.01), and there were no major complications in either group. CONCLUSIONS AND RELEVANCE: Geriatric sinus surgery is effective and safe in this cohort of patients.

Topical antibiotic therapy in chronic rhinosinusitis: an update.

BACKGROUND: Topical antibiotic therapies have been investigated for their use in chronic rhinosinusitis (CRS). However, society guidelines and evidence-based medicine reviews have recommended against the use of topical antibiotic therapy based on randomized controlled trials (RCTs). The purpose of this article is to review recent clinical research published since the aforementioned guidelines were published. METHODS: A structured literature review was performed on clinical studies published in the last 5 years investigating the use of topical antibiotic therapies. RESULTS: One double-blinded, randomized controlled trial (DB-RCT) supported the use of tobramycin using a vibrating aerosolizer; 1 non-blinded non-randomized controlled prospective trial lent support to use of topical ofloxacin for its anti-biofilm properties; and 1 meta-analysis found mupirocin irrigations to be beneficial in the short term. One Cochrane Review was unable to make a recommendation as no trial met the inclusion criteria. An additional systematic review found limited evidence to support the use of topical antibiotics with the exception of mupirocin irrigations that may be considered in Staphylococcus aureus infections. Two retrospective studies found that topical antibiotics change bacterial cultures of the sinuses. CONCLUSION: There is additional evidence to support continuing investigation of topical antibiotic therapies. Further, larger RCTs are required to establish the efficacy of topical antibiotic therapies.

Sinonasal malignancies: Endoscopic treatment outcomes.

Sinonasal malignancies are rare and heterogeneous cancers located adjacent to critical neurovascular structures. Proximity to the orbit, brain, cranial nerves, and carotid arteries make surgical resection technically challenging and potentially morbid. The gold standard surgical procedure for these cancers has traditionally been the open craniofacial resection. Endoscopic endonasal approaches emerged in the last two decades as a viable alternative for carefully selected patients. The rarity and heterogeneity of the cancers precludes randomized controlled trials. Evidence for surgical approaches is based on case series and multi-analyses. Current evidence demonstrates that endoscopic approaches do not compromise survival and have lower complication rates. This article provides an update of the current literature examining outcomes for the endoscopic treatment of sinonasal malignancies.

Association of Surgical and Hospital Volume and Patient Characteristics With 30-Day Readmission Rates.

Importance: Thirty-day readmission rates have been suggested as a marker for quality of care. By investigating the factors associated with readmissions in all otolaryngology subspecialties we provide data relevant for the development of risk stratification systems to improve outcomes. Objective: To establish the association of surgical and hospital volume and patient characteristics with 30-day readmission rates to guide the development of otolaryngology-specific risk stratification models. Design, Setting, and Participants: A retrospective cohort study including adult patients who underwent inpatient otolaryngology surgery in New York State between 1995 and 2015 was conducted using the Statewide Planning and Research Cooperative System (SPARCS). Regression techniques were used to describe relationships of patient-level factors, hospital, and surgeon volume to 30-day readmission rates in New York State. Main Outcomes and Measures: The main outcome measures were patient-, surgeon-, and hospital-level risk factors for readmission. Secondary outcome measures were rate of readmissions by subspecialty procedure and by diagnosis on readmission. Results: We identified 254 257 cases of otolaryngology surgery (147 065 women [58%], mean [SD] age 50 [17] years). The 30-day readmission rate was 6%. In a multivariable model, odds ratios (ORs) identified Medicaid insurance (OR, 1.46; 99% CI, 1.36-1.57), Medicare insurance (OR, 1.32; 99% CI, 1.24-1.42), bottom quartile income (OR, 1.08; 99% CI, 1.01-1.15), patient comorbidities measured by the Charlson Comorbidity Index (CCI) (CCI >1; OR, 2.31; 99% CI, 2.16-2.47), length of stay (LOS) (LOS >10 days; OR, 2.29; 99% CI, 2.00-2.45), rhinology (OR, 1.37; 99% CI, 1.24-1.51), laryngology (OR, 1.98; 99% CI, 1.62-2.43), and head and neck cancer (OR, 1.27; 99% CI, 1.17-1.37) procedures as readmission predictors. High-volume surgeons were protective of 30-day readmission (OR, 0.67; 99% CI, 0.635-0.708) relative to low volume. Hospital volume was not significantly associated to readmissions. The most common causes of readmission included wound- (2682 patients, 18%), respiratory- (1776 patients, 12%), cardiovascular- (1210 patients, 8%), and volume- (1089 patients, 7%) related disorders. Conclusions and Relevance: This study evaluated the combined effects of patient-, surgeon-, and hospital-level factors on 30-day readmission after otolaryngology surgery. Socioeconomic factors, patient comorbidities, surgeon volumes, and procedure were significantly associated with 30-day readmission. Though the cause of 30-day readmission is multifactorial, a large portion is driven by socioeconomic factors. Addressing these disparities at the system level is necessary to address the described readmission disparities. The development of risk-stratification models based on patient-, procedure-, and surgeon-level factors may help facilitate resource distribution.

Transmastoid Repair of Spontaneous Cerebrospinal Fluid Leaks.

Objective Determine the efficacy of using a purely transmastoid approach for the repair of spontaneous cerebrospinal fluid (CSF) leaks and further elucidate the relationship of elevated body mass index (BMI) and skull base thickness in our patient population. Method We conducted a retrospective chart review of patients treated for spontaneous temporal bone CSF leaks at our tertiary care institution from the years 2006 to 2015. Cases were categorized as primary or secondary. We analyzed success rates, length of stay, use of lumbar drains, BMIs, and rates of meningitis. Skull base thickness was compared with BMI in each case. Results We identified 26 primary operations for spontaneous CSF leaks and 7 secondary operations. Twenty-three of 33 repairs were performed via the transmastoid approach alone with an 87% success rate (20/23). Of the10 repairs including a middle cranial fossa (MCF) or combined MCF-transmastoid approach, 2 failed for an 80% success rate (8/10). Five transmastoid repairs underwent placement of a lumbar drain versus all 10 repairs employing an intracranial exposure. Average length of stay for those undergoing a transmastoid approach (1.7 days) was significantly shorter than for patients undergoing a MCF repair (6.3 days). Four patients presented with meningitis. Average BMI was 35.3. No correlation was established between BMI and skull base thickness ( R2 = 0.00011). Conclusion The transmastoid approach is effective in the majority of cases and prevents the need for an intracranial operation, resulting in lower morbidity and a shorter length of stay. We believe that this is the preferred primary approach in most patients with spontaneous CSF leaks.

Anesthesia for functional endoscopic sinus surgery.

PURPOSE OF REVIEW: The present article summarizes anesthetic techniques used during functional endoscopic sinus surgery to decrease bleeding and aid in creating a clear surgical field. The applicable physiology behind these anesthetic techniques is reviewed with emphasis on the effect on bleeding and the surgical field. Deliberate hypotension, reverse Trendelenburg positioning, regional anesthesia, and cerebral monitoring are discussed. RECENT FINDINGS: There are mixed data as to whether traditional inhalation anesthesia or total intravenous anesthesia is superior with respect to better surgical fields and decreased blood loss. A review of the literature tends to favor total intravenous anesthesia. Cerebral oximetry and transcranial Doppler ultrasound are emerging techniques to monitor cerebral perfusion during deliberate hypotension. SUMMARY: Total intravenous anesthesia using propofol and remifentanil is the current favored technique for producing deliberate hypotension during endoscopic sinus surgery due to its hemodynamic stability and smooth rapid emergence.

A systematic review of the quality of randomized controlled trials in head and neck oncology surgery.

OBJECTIVES/HYPOTHESIS: To determine the quality of randomized controlled trials (RCTs) in head and neck surgery in which surgery was a primary intervention. DATA SOURCES: Potential articles were identified in PubMed without publication date restrictions. REVIEW METHODS: Articles were scored using the CONSORT checklist and the relationship between the checklist score and whether the first and/or last authors were surgeons was investigated. Differences in the checklist score based on how many surgeons were among the first and last authors of the study were analyzed using the Kruskal-Wallis test. Fisher's exact test was used to examine if there was a significant difference of the reporting of individual items from the checklist between surgeons and nonsurgeons. A nonparametric trend test was used to determine whether there was a difference in the reporting of individual items based on whether there were none, one, or two surgeons among first and last authors. RESULTS: A total of 38 publications satisfied the inclusion criteria. There was a trend toward lower quality for studies in which surgeons were either first, last, or both first and last authors compared to studies that were first-authored and last-authored by nonsurgeons (P = 0.068). Nonsurgeons were more likely to report on critical elements regarding hypothesis, sample size determination, randomization, and eligibility of centers (P = 0.023-0.058). CONCLUSION: The quality of RCTs in head and neck surgery is poor. Improved training in conducting and reporting clinical research is needed in otolaryngology residencies.