Bacterial findings in patients referred to hospital for the treatment of acute tonsillitis with or without peritonsillar phlegmon.

BACKGROUND: The vast majority of patients with acute tonsillitis (AT) are managed in general practice. However, occasionally patients are referred to hospital for specialized management because of aggravated symptoms and/or findings suggestive of peritonsillar involvement. No prospective studies have been conducted aiming to investigate the prevalent and significant microorganisms in this highly selected group of patients. We aimed to describe the microbiological findings of acute tonsillitis with or without peritonsillar phlegmon (PP) in patients referred for hospital treatment and to point out potential pathogens using the following principles to suggest pathogenic significance: (1) higher prevalence in patients compared to healthy controls, (2) higher abundance in patients compared to controls, and (3) higher prevalence at time of infection compared to time of follow up. METHODS: Meticulous and comprehensive cultures were performed on tonsillar swabs from 64 patients with AT with (n = 25) or without (n = 39) PP and 55 healthy controls, who were prospectively enrolled at two Danish Ear-Nose-Throat Departments between June 2016 and December 2019. RESULTS: Streptococcus pyogenes was significantly more prevalent in patients (27%) compared to controls (4%) (p < 0.001). Higher abundance was found in patients compared to controls for Fusobacterium necrophorum (mean 2.4 vs. 1.4, p = 0.017) and S. pyogenes (mean 3.1 vs. 2.0, p = 0.045) in semi-quantitative cultures. S. pyogenes, Streptococcus dysgalactiae, and Prevotella species were significantly more prevalent at time of infection compared to follow up (p = 0.016, p = 0.016, and p = 0.039, respectively). A number of species were detected significantly less frequently in patients compared to controls and the mean number of species was significantly lower in patients compared to controls (6.5 vs. 8.3, p < 0.001). CONCLUSIONS: Disregarding Prevotella spp. because of the prevalence in healthy controls (100%), our findings suggest that S. pyogenes, F. necrophorum, and S. dysgalactiae are significant pathogens in severe AT with or without PP. In addition, infections were associated with reduced diversity (dysbacteriosis). TRIAL REGISTRATION: The study is registered in the ClinicalTrials.gov protocol database (# 52,683). The study was approved by the Ethical Committee at Aarhus County (# 1-10-72-71-16) and by the Danish Data Protection Agency (# 1-16-02-65-16).

Clinical evaluation of antibiotic regimens in patients with surgically verified parapharyngeal abscess: a prospective observational study.

PURPOSE: We aimed to evaluate the effectiveness of different antibiotic regimens for the treatment of parapharyngeal abscess (PPA) and characterize patients, who suffered potentially preventable complications (defined as death, abscess recurrence, spread of infection, or altered antibiotic treatment because of insufficient progress). METHODS: Sixty adult patients with surgically verified PPA were prospectively enrolled at five Danish Ear-nose-throat departments. RESULTS: Surgical treatment included internal incision (100%), external incision (13%), and tonsillectomy (88%). Patients were treated with penicillin G ± metronidazole (n = 39), cefuroxime ± metronidazole (n = 16), or other antibiotics (n = 5). Compared to penicillin-treated patients, cefuroxime-treated patients were hospitalized for longer (4.5 vs 3.0 days, p = 0.007), were more frequently admitted to intensive care (56 vs 15%, p = 0.006), underwent external incision more frequently (31 vs 5%, p = 0.018), and suffered more complications (50 vs 18%, p = 0.022), including re-operation because of abscess recurrence (44 vs 3%, p < 0.001). Nine patients suffered potentially preventable complications. These patients displayed significantly higher C-reactive protein levels, received antibiotics prior to admission more frequently, underwent external incision more commonly, and were admitted to intensive care more frequently compared to other patients. CONCLUSION: The majority of patients with PPA were effectively managed by abscess incision, tonsillectomy, and penicillin G ± metronidazole. Cefuroxime-treated patients were more severely ill at time of admission and had worse outcome compared to penicillin-treated patients. We recommend penicillin G + metronidazole as standard treatment for patients with PPA, but in cases with more risk factors for potentially preventable complications, we recommend aggressive surgical and broadened antibiotic therapy, e.g. piperacillin-tazobactam.

Microbiology of parapharyngeal abscesses in adults: in search of the significant pathogens.

We aimed to describe the microbiology of parapharyngeal abscess (PPA) and point out the likely pathogens using the following principles to suggest pathogenic significance: (1) frequent recovery, (2) abundant growth, (3) growth in relative abundance to other microorganisms, (4) percentage of the isolates recovered in both absolute and relative abundance, (5) more frequent recovery in PPA pus compared with tonsillar surface and tissue. Comprehensive bacterial cultures were performed on specimens obtained from adult patients (n = 60) with surgically verified PPA, who were prospectively enrolled at five Danish ear-nose-throat departments. The prevalent isolates (in PPA pus) were unspecified anaerobes (73%), non-hemolytic streptococci (67%), Streptococcus anginosus group (SAG) (40%), Corynebacterium spp. (25%), Neisseria spp. (23%), Fusobacterium spp. (22%), Fusobacterium necrophorum (17%), Prevotella spp. (12%), and Streptococcus pyogenes (10%). The bacteria most frequently isolated in heavy (maximum) growth were unspecified anaerobes (60%), SAG (40%), F. necrophorum (23%), and Prevotella spp. (17%). The predominant microorganisms (those found in highest relative abundance) were unspecified anaerobes (53%), SAG (28%), non-hemolytic streptococci (25%), F. necrophorum (15%), S. pyogenes (10%), and Prevotella spp. (10%). Four potential pathogens were found in both heavy growth and highest relative abundance in at least 50% of cases: F. necrophorum, Prevotella spp., SAG, and S. pyogenes. SAG, Prevotella spp., F. necrophorum, S. pyogenes, and Bacteroides spp. were recovered with the same or higher frequency from PPA pus compared with tonsillar tissue and surface. Our findings suggest that SAG, F. necrophorum, Prevotella, and S. pyogenes are significant pathogens in PPA development.

Prevalence of various etiologies of hearing loss among cochlear implant recipients: Systematic review and meta-analysis.

OBJECTIVE: To investigate the etiology of deafness in cochlear implanted children and to address the question whether there is a need for more thorough diagnostics, especially concerning genetics. DESIGN: Systematic review. Four databases were searched for studies (year 2000-2014) on cochlear implanted children (n > 100). Studies were excluded if etiology had influenced their inclusion criteria. Eligibility and methodological quality were assessed independently by three authors. The studies' description of diagnostic evaluation was categorized in three groups. STUDY SAMPLE: Sixteen studies were included (5069 children). RESULTS: The most common etiological categories were 'Unknown' 40.3% (95% CI 32.8 to 48.0), 'Non-syndromic' 22.4% (95% CI 17.1 to 28.2), and 'Postnatal' 11.3% (95% CI 7.2 to 16.2). Studies published after 2006 had a lower proportion of 'Unknown' etiology 35.3% (95% CI 28.0 to 42.8) than older 45.5% (95% CI 31.0 to 60.4). Important information was missing from several studies: 11 (69%) studies did not provide detailed description on diagnostic evaluation of the etiology of deafness and had a higher proportion of 'Unknown' etiology. CONCLUSIONS: In order to ensure a higher level of comparability in future studies, we recommend agreement upon an international standard of diagnostics and the introduction of an international standard for reporting etiology.

Adding Kinetic Energy Does Not Further Improve Treatment Outcomes With a Mechanical Reposition Chair: A Randomized Controlled Trial.

OBJECTIVE: To test if the addition of abrupt deaccelerations (kinetic energy) during treatment with a mechanical repositional chair (MRC) provides improved treatment efficacy with treatment of posterior benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Randomized two-armed parallel open-labeled clinical trial. SETTING: Tertiary referral center. PATIENTS: Seventy patients diagnosed with posterior canalolithiasis BPPV were included. INTERVENTIONS: All patients underwent diagnostics and treatment with an MRC. Patients were randomized to either a traditional Epley maneuver or a potentiated version of the Epley maneuver where kinetic energy was applied in five positions with 45-degree turns between each step. MAIN OUTCOME MEASURES: Primary endpoint was the number of treatments needed before complete resolution of both subjective symptoms and objective signs of BPPV within the semicircular canal of interest. Secondary endpoints included the following: 1) number of patients requiring more than 10 treatments, 2) length of treatment in days before treatment(s) were successful, and 3) changes in total Dizziness Handicap Inventory scores before and after treatment. RESULTS: No significant difference in the number of required treatments between the two treatment arms was found. Approximately three of four subjects were cured after two repositional maneuvers regardless of type of treatment. An equal length of treatment was seen with both groups, and the Dizziness Handicap Inventory scores were significantly lowered after treatment with no significant differences between the two types of treatment. CONCLUSIONS: Both the traditional and the potentiated Epley maneuver are efficient in treatment of canalolithiasis of the posterior semicircular canals with MRC. Addition of kinetic energy with this subgroup of BPPV patients does not seem to add further efficacy to the treatment.

Acute airway obstruction due to spontaneous intrathyroidal haemorrhage.

A woman in her mid-80's collapsed while home due to a sudden onset of swelling on her neck compromising the airway. She was intubated on-site and brought to the trauma-centre where she was diagnosed with an intrathyroidal bleeding with compression of the trachea. A subacute left sided thyroid lobectomy was performed, giving immediate relief to the displaced and compressed airway. The patient was discharged after 3 days. The final histopathological examination revealed a microfollicular adenoma with extensive bleeding.

Characteristics of CI children with complicated middle ear infections.

OBJECTIVE: To describe cases of complicated middle ear infections in children with cochlear implants (CI), i.e., episodes of acute otitis media (AOM) and acute mastoiditis (AM), resulting in hospitalization. METHODS: A total of 206 children under 16 years (300 implantations) were implanted between 1 January 2008 and 31 December 2014 at the West Danish CI Center, Department of Otorhinolaryngology Head and Neck Surgery, Aarhus, Denmark. By means of two prospective local databases, episodes of AOM or AM and demographics were retrieved including biochemistry, microbiology, length of follow- up, and variable treatment modalities (intravenous (IV) antibiotics, revision mastoidectomy, and insertion of ventilation tubes). RESULTS: Overall rate of AOM and/or AM was 9.2% (AOM: 9%, AM: 1.9%). Mean age at CI was 46 months. Mean follow-up was 45 months. Mean time from CI operation to AOM or AM was 3 and 4 months, respectively. Children younger than 2 years were at highest risk of AOM and/or AM. All had antibiotics prescribed before admittance, and two- thirds of infected ears had already ventilation tubes inserted. Bacteria could not be detected in more than half of cases. The most frequently isolated strains were pneumococci and nontypable Haemophilus influenzae. The majority of patients were successfully treated with IV cefuroxime (64% of cases) and insertion of ventilation tubes. None of the children developed facial nerve paralysis, intracranial infections, or septicemia. DISCUSSION: Almost 10% of CI children required at least one hospitalization due to AOM and/or AM compared with 0.1 per thousand of non-CI children. This discrepancy can be explained by a low threshold for active treatment of otitis media in CI children and hence referral to a CI center. The results suggest that benzylpenicillin might be an appropriate initial treatment of AOM and AM. However, cephalosporin was the most preferred antibiotic. Most CI children were already treated with ventilation tubes at admission and almost all children without ventilation tubes, had a tube inserted during admission. Insertion of ventilation tubes is still much debated and more research in this field is needed. CONCLUSION: AOM and/or AM were seen in Danish children with CI as often as in other western countries. Treatment of complicated middle ear infections was sufficient with IV cephalosporin and ventilation tube insertion. Special attention should be paid to children younger than 4 years and the associated microbiology including serotyping should be monitored.