Microlaryngeal Laser Surgery Using High-flow Nasal Ventilation at Two Oxygen Concentration Deliveries.

OBJECTIVES: Ventilation using 100% oxygenation creates a risk of fire during laser microlaryngeal surgery (MLS). The purpose of this study is to describe the technique of transnasal high-flow ventilation using laser safe (30%) oxygen conditions, measure the intraoperative real-time laryngeal oxygen concentration, and examine patient saturation status using this technique. METHODS: Prospective IRB approved study of patients undergoing tubeless laser MLS using high-flow nasal oxygenation. Delivered oxygen concentration was reduced from 100% to 30% before lasering using an oxygen-air blender then increased to 100% post-laser procedure. Outcome measures included time for laryngeal oxygen concentration to equalize to laser safe levels; time to, methods of and duration of rescue ventilation; and desaturation rates and apnoeic times at both 100% and 30% oxygen deliveries. RESULTS: Fifty patients were recruited (mean age = 47.4 years). Mean laryngeal oxygen concentration (%) at 100% and 30% deliveries was 98.46 and 31.45, respectively. Mean (SD) of laryngeal oxygen concentration equalization time to 30% (seconds) was 9.4 (3.69). At 30% oxygen delivery desaturation rate was faster and apneic time shorter compared with 100%. Eighteen patients required rescue (jet) ventilation and they had a faster apneic desaturation rate (%/minute) than patients not requiring rescue. Mean (SD) apneic time (minutes) at 30% delivery was 4.56 (2.25) and 4.41 (2.18) in rescue versus non-rescue groups respectively. BMI was the only significant predictor of desaturation rate at 30% oxygen delivery. CONCLUSION: It is possible to achieve a safe time window for use of laser during MLS using transnasal humidified high-flow ventilation by delivering 30% oxygen concentration. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:634-639, 2023.

Clinical parameters predicting tonsillar malignancy.

PURPOSE: Tonsillectomy is indicated in unilateral tonsillar enlargement (UTE) to rule out malignancy, which eventually is found in about 1.4% of the patients. The aim of this study was to evaluate the presenting symptoms of patients who underwent tonsillectomy for UTE and identify parameters that are associated with an increased risk for malignancy, for better assessment and refinement of current management protocols. METHODS: A retrospective chart review of adult patients with UTE who underwent tonsillectomy between 1/1/2006 and 31/12/2016 was conducted. RESULTS: Forty-one patients with a median age of 53 years were included. There were 20 (49%) females and 21 (51%) males. Sixteen (39%) patients were diagnosed as having tonsillar malignancy. Patients with malignancy were older than those in the benign group (p = 0.001), had a previous malignancy (p = 0.006), and were less likely to present as an incidental finding (p < 0.001). Lymphadenopathy, throat pain, suspicious appearance of tonsillar mucosa, and hard consistency were also found to be statistically significant findings in the malignancy group (p = 0.017, p = 0.001, p = 0.01 and p = 0.018, respectively). Multivariable regression showed age, appearance and adjacent tissue involvement to be independently with malignancy. CONCLUSIONS: UTE alone, as an incidental finding, should not be regarded as an indication for tonsillectomy, as the risk for malignancy is low and the morbidity is significant. We suggest integrating the above-mentioned clinical parameters in the decision-making process, which were found to be significantly more frequent in the malignant group.

The yield of respiratory viruses detection testing is age-dependent in children with acute otitis media.

BACKGROUND: Studies of nasopharyngeal secretions serve as reliable surrogate to evaluate the involvement of viruses in acute otitis media (AOM) and upper/lower respiratory tract infections (URIs/LRIs). We explored nasopharyngeal viral studies from children with uncomplicated AOM and examined their cost-effectiveness in relation to their age. METHODS: We identified children aged 0-6 years admitted to our pediatrics department in a university-affiliated, secondary hospital with uncomplicated AOM and concurrent URI/LRI between 2012 and 2017, during October-April, when viral studies are performed. Studies were performed either using antigen detection tests, for respiratory syncytial virus (RSV) and influenza A/B (2012-2016) and for a variety of other common respiratory viruses, utilizing multiplex polymerase chain reaction assays (2017). RESULTS: A total of 249 children were included (median age: 15 months). In 88 (35%) children, viral studies were positive, most of them in children ⩽24 months (78, 89%). RSV was positive in 52 (59%) children, followed by influenza A and B, in 11 (13%) and 5 (6%) children, respectively. First year switch to a molecular assay, 4.5-fold more expensive, resulted in a statistically significant higher yield: 69% positive results in ⩽24 months, and 66% in those aged ⩽12 months (p < 0.05). In those ⩽24 months, US$23 and US$95 were spent for one positive test in the antigen detection years and the polymerase chain reaction year, respectively, whereas in those >24 months, US$83 and US$878 were invested for one positive test in the same year, respectively. CONCLUSION: In cost-effectiveness terms, the greatest benefit of nasopharyngeal studies was highest in children ⩽24 months.

Pediatric neck abscesses: No increase in methicillin-resistant Staphylococcus aureus.

INTRODUCTION: Recent studies from Western countries showed an increased incidence rate of methicillin-resistant Staphylococcus aureus (MRSA) isolated from pediatric neck abscesses cultures. We sought to examine the microbiology and antibiotic susceptibility of such samples over a 10-year period, and particularly of Staphylococcus aureus (SA), in order to determine whether a similar trend exists in our institution. METHODS: A retrospective chart review of children ≤18 years that underwent needle aspiration or surgical drainage of neck abscesses, including suppurative lymphadenitis, retropharyngeal abscesses, and parapharyngeal abscesses was conducted between 1/1/06-31/12/15. RESULTS: Sixty-two children were identified with a male predominance (34, 55%). The median age was 2 years. There were 37 (60%) suppurative lymphadenitis, 15 (24%) parapharyngeal abscess, and 10 (16%) retropharyngeal abscess cases. Twenty-nine (47%) children received antibiotic treatment prior to admission, most commonly ß-lactam agents. Of them, 15 (52%) had positive cultures, including 7 (47%) with SA. On admission, 45 (73%) children had already received amoxicillin-clavulanate. Of those who did not improve, 16 (26%) received ceftriaxone and clindamycin. Twenty-one (38%) cultures were negative. The most common isolated bacteria were SA in 13 (24%), Streptococcus pyogenes in 7 (13%), and Streptococcus viridians group in 9 (16%). Of the SA isolates, there was only 1 (8%) case of MRSA; however, there were 4 (31%) clindamycin-resistant SA isolates. CONCLUSION: Unlike previously published data, there was no increase in MRSA incidence at our institution. However, the high prevalence of clindamycin-resistant SA was in line with previous reports. These findings should be considered when starting empirical therapy in pediatric neck abscesses.

Sudden sensorineural hearing loss in children: Etiology, management, and outcome.

BACKGROUND AND OBJECTIVES: Pediatric sudden sensorineural hearing loss (SSNHL) is uncommon, and the current guidelines for its management refer to adults. Our objective was to review cases of SSNHL in children and examine their etiologies, management, and outcome. METHODS: We performed a retrospective chart review of all children under the age of 18 years treated for SSNHL between January 2003 and September 2014. Data recorded included age, gender, symptoms, onset of hearing loss, audiometric results, diagnostic studies, treatment, and outcome. RESULTS: Nineteen children were included. Mean age was 14 years (range 7-18 years). Male: female ratio was 9:10. Degree of hearing loss varied from mild to profound across the tested frequencies. Most common accompanying symptom was tinnitus. Serologic tests demonstrated recent Epstein-Barr virus infection in one patient and previous cytomegalovirus infection in six patients. Imaging studies included computed tomography scan (n=3) and/or magnetic resonance imaging (n=12). All imaging studies did not demonstrate any pathology. Treatment included systemic steroids in 19 (100%) children and intratympanic steroids in eight (42%). Hearing completely improved in three (16%) children, partially improved in nine (47%), and there was no improvement in six (32%). One child was lost to follow-up. CONCLUSIONS: Viral infection was a common finding in children with SSNHL and no pathological changes were demonstrated on imaging studies. In most patients (63%), hearing improvement was observed. Intratympanic steroid injection can benefit these children. Further studies are required to investigate the etiologies and establish guidelines for the management of SSNHL in children.

Human parechovirus type 3 central nervous system infections in Israeli infants.

INTRODUCTION: Human parechoviruses (HPeV) have been recognized as the causative agents of central nervous system (CNS) infection of infants and young children in different parts of the world. The role of HPeV in CNS infection of Israeli infants and children is unknown. OBJECTIVES: To assess the detection rate of HPeV in enterovirus RT-PCR-negative cerebrospinal fluid (CSF) samples obtained during the years 2007-2009 from children 0-5 years old with suspected CNS infection or from very young infants with unexplained fever in four medical centers in Israel. STUDY DESIGN: A total of 367 CSF samples were retrospectively tested for the presence of HPeV RNA using nested RT-PCR assay. Positive samples were further typed on the basis of molecular sequencing. Retrospective analysis of the medical charts was performed. RESULTS: HPeV3 RNA was detected in CSF obtained between May and September 2008 in 13 patients, all of whom were <3 months old (3.5% of all CSFs; 11.3% of all infants<3 months in 2008). The HPeV-positive CSF samples were without pleocytosis. All HPeV3-positive patients recovered without obvious short term sequelae. CONCLUSION: HPeV infection could play an important role in summertime febrile/CNS illness in young infants during specific years with high HPeV activity. PCR detection of parechoviral RNA in CSF should be included in the diagnostic evaluation of fever or CNS infection of neonates and very young infants. The rapid identification of HPeV in CSF could curtail unnecessary empirical antibiotic treatment and shorten hospital stay in selected patients.