Orbital complications secondary to acute rhinosinusitis in toddlers: A unique age group.

OBJECTIVES: To present the clinical course and management of pediatric orbital complications (OC) secondary to acute rhinosinusitis (ARS), focusing on subperiosteal orbital abscess (SPOA) in toddlers (<2 years). A secondary aim was to identify and evaluate unique variables in toddlers which distinguish them from the older age group. METHODS: A retrospective cohort study of all children with OC secondary to ARS admitted to a secondary medical center between 2005 and 2014 was conducted. Variables analyzed included age, gender, symptoms duration, previous antibiotic therapy, highest recorded temperature, physical and ophthalmologist's examination results, laboratory results and imaging findings. RESULTS: Of the 123 children with OC, 52 (42%) were toddlers. Of them, 30(58%) were boys, with a mean age of 1.4 years. Toddlers presented with higher fever measurements and leukocyte/lymphocyte counts than older children. 69% had Chandler's 1 stage vs 45% in older children (p = 0.015). Ophthalmoplegia was less common in toddlers, who were also less likely to develop late ophthalmoplegia, an important indicator for good treatment response. Eighteen (35%) toddlers underwent computerized tomography (CT) scans, compared to 50 (70%) in the older aged group. Of them, 16/18 (89%) had SPOA. Five (10%) toddlers underwent drainage (31% of Chandler's 3 in this age group) compared to 19 (27%) older patients who underwent surgical treatment (53% of Chandler's 3 in this age group). CONCLUSION: Toddlers with OC have a milder disease and better outcomes, measured in lower rates of delayed ophthalmoplegia, number of CT scans and SPOA rates, and with fewer surgical interventions.

The significance of tissue biopsy for fungi in necrotizing otitis externa.

INTRODUCTION: The conventional treatment for necrotizing otitis externa (NOE) is prolonged anti-pseudomonas therapy, with surgical treatment in non-responsive patients. The aim of the present study is to describe the course of management of patients with non-responsive NOE undergoing hyperbaric oxygen therapy (HBOT), and to investigate the importance of tissue biopsy for fungi in this group of patients. MATERIALS AND METHODS: A retrospective study conducted between January 2010 and December 2013 at an Otolaryngology Head and Neck Surgery Department. Included were all 52 patients with NOE referred to our Medical Centre for further treatment including HBOT. RESULTS: Fifty-two consecutive patients, 29 men and 23 women, with a mean age of 70.6 years, were included in our study. Twenty seven (51.9%) underwent surgical debridement. No significant difference was found between the group having surgical intervention, and those who did not, with regard to sex, age, comorbidities, cranial nerve involvement or laboratory results. However, those who had surgical intervention had a statistically significant higher rate of fungal infection (P = 0.049). After completing 7 weeks of HBOT, a significantly lower WBC count was observed in the fungus-infected group (7000 vs 7.800, P = 0.03), and a tendency towards lower CRP levels in the fungus-infected group (16 vs 58, P = 0.087). CONCLUSION: Patients with NOE should have a comprehensive surgical intervention when delayed healing is observed, because proper fungal culturing might change the course of treatment and improve prognosis. LEVEL OF EVIDENCE: 4.

Post-turbinectomy nasal packing with Merocel versus glove finger Merocel: A prospective, randomized, controlled trial.

Nasal packs are widely used after septoplasty and turbinectomy. We conducted a prospective, randomized, controlled clinical trial including 100 patients who underwent septoplasty with/or without turbinectomy randomized into two groups. In the first group (the Merocel group), a standard tampon was inserted at the end of surgery. In the second group (the glove finger group), the tampon was first placed inside a glove finger. The main outcomes measured were pain and bleeding during the postoperative period and during tampon removal. Consumption of pain killers and tranexamic acid were also recorded. The mean visual analog scale score 12 hours after surgery and during tampon removal in the Merocel group were 6.78 and 8.92, respectively, compared to 4.06 and 5.27, respectively, in the glove finger group (p < 0.001). A statistically significant difference in the bleeding rate and tranexamic acid consumption during tampon removal in favor of the Merocel group was shown (p < 0.001). The use of Merocel in a glove finger is significantly less painful, although a higher chance of bleeding is reported. The influence of the surgeon's experience in using this technique needs further investigation.

Indicators for imaging in periorbital cellulitis secondary to rhinosinusitis.

PURPOSE: Our objective was to identify the clinical indicators for subperiosteal orbital abscess (SPOA) among patients who present with periorbital cellulitis secondary to rhinosinusitis, and to evaluate the need for performing a computerized tomography (CT) scan. METHODS: A retrospective cohort study of all patients admitted to our tertiary care emergency department between 2006 and 2014 was conducted. Included were healthy patients with acute periorbital cellulitis secondary to rhinosinusitis. Variables analyzed included age, gender, duration of symptoms, previous antibiotic therapy, highest recorded temperature, physical examination findings, ophthalmologist's examination results, laboratory results, and interpretation of imaging studies, when performed. RESULTS: Of the 123 identified patients, 78 (63%) were males, with a mean age of 4 years (range 1-70). 68 patients were categorized as Chandler's 1 disease, 2 as Chandler's 2, and 53 as Chandler's 3. 68 patients underwent a CT scan, of those 53 had SPOA. Proptosis and ophthalmoplegia were strongly associated with the presence of an abscess (P < 0.001). However, 14 patients with no ophthalmoplegia or proptosis who underwent a CT scan were older (mean age, 10 years; P < 0.028), and had higher neutrophil count of 78 versus 59% (P = 0.01). This group of patients had a clinically rapidly progressive disease, receiving wider broad-spectrum antibiotics or had their antibiotic treatment replaced to broader spectrum antibiotics through their course of treatment (48.2% compared to only 6.1%). CONCLUSIONS: We confirmed that patients with proptosis and/or limitation of extraocular movements are at high risk for developing SPOA, yet many do not have these predictors. Other features can identify patients who do not have proptosis and/or limitation of extraocular movements but do have significant risk of SPOA, and in these cases performing an imaging study is strongly suggested.

Conservative Management for Subperiosteal Orbital Abscess in Adults: A 20-Year Experience.

OBJECTIVE: Orbital complications (OC) secondary to acute rhinosinusitis (ARS) in adults are less common than in children, with assumed worse outcome. MATERIALS AND METHODS: Adults with OC secondary to ARS between 1994 and 2014 were reviewed retrospectively. Parameters recorded included age, gender, clinical symptoms and signs, computed tomography (CT) scan findings, duration of hospitalization, treatment before and during admission, cultures, and outcome. RESULTS: Thirty-seven adults with a mean age of 34.6 years, 27 males and 10 females, were diagnosed with OC, 19 (51.3%) with subperiosteal orbital abscess (SPOA), and none with orbital abscess/cellulitis or cavernous sinus thrombosis. Twelve patients with SPOA were managed conservatively with Amoxicillin-Clavulanate in most cases, and only 7 (36.8%) underwent surgery. A CT scan was performed in 27 cases revealing rhinosinusitis in all patients, including frontal involvement in 19 (51.3%) patients and sphenoid sinus in 16 (43.2%). CONCLUSIONS: A shift toward conservative treatment in cases of SPOA has long been integrated in the management protocols, mainly in children under 9 years old. The presumed worse prognosis in adults is not supported in our study, and a conservative treatment is urged to be considered in this group of patients albeit the more extensive radiologic involvement of their sinuses.

Treatment of Acute Otitis Media in the Pediatric Emergency Department.

BACKGROUND: Over-treatment of acute otitis media (AOM) with antibiotics is common, and poses a high burden on health-care systems. METHODS: Records of children 6-36 months of age with AOM visiting a university-affiliated pediatric emergency department between 2014 and 2016 were reviewed for the treatment given: watchful waiting versus antibiotics. If antibiotics were prescribed, the type and duration were recorded. We evaluated appropriate and inappropriate treatment rates of eligible AOM cases, in respect to the local guidelines, which encourage watchful waiting in most mild-moderate cases. RESULTS: Out of 1493 AOM visits, 863 (57.8%) were boys, with a median age of 14.9 months (interquartile range, 9-19). The overall pre-visit antibiotic rate was 24.1%, but among those children examined by a physician, this rate was 95.2%. Amoxicillin was the most common antibiotic, administered in 66.3% of the cases. Only 21 children (5.8%) had been treated with antibiotics for ≥7 days before their visit, and were considered as treatment failure. Antibiotic therapy upon discharge was recorded in 1394/1449 visits (96.2%), again with amoxicillin as the most common antibiotic therapy, in 80.8% of the cases. In these visits, the average duration of antibiotic treatment was 8.29 days. Appropriateness of treatment (watchful waiting or antibiotics) could be analyzed in 1134 visits; 20.9% were considered as inappropriate. Of them, 98.3% were prescribed with the wrong antibiotic type and duration. CONCLUSIONS: Adherence rate to the local guidelines treatment recommendations for uncomplicated AOM was high, as measured by whether appropriate treatment was given and type and duration of antibiotics.

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.

Open tracheostomy training: a nationwide survey among Otolaryngology-Head and Neck Surgery residents.

The aim of this study was to examine the training methods and needs of Otolaryngology-Head and Neck Surgery (OTO-HNS) residents to independently perform open tracheostomy (OT). An anonymous 26-items questionnaire pertaining to OT teaching aspects was distributed to all 93 Israeli OTO-HNS residents during March-June 2016. Residents were categorized as 'juniors,' if they were in their post-graduate year (PGY)-1 and PGY-2; 'mid-residency' (PGY-3 and PGY-4); or 'seniors' (PGY-5 and PGY-6). Response rate was 74% (n = 69). There were 25 'juniors' (36%), 24 'mid-residency' (35%) and 20 'seniors' (29%). Overall, the responses of the 3 groups were similar. Forty-seven (68%) residents estimated that there are ≥ 50 tracheostomies/year in their hospital, which roughly corresponds to an exposure of ~ 8 tracheostomies/year/resident. There was an inconsistency between the number of teaching hours given and the number of hours requested for OT training (23% received ≥ 5 h, but 82% declared they needed ≥ 5 h). Eighty-two percentage reported that their main training was conducted during surgery with peer residents or senior physicians. Forty-five (65%) feel competent to perform OT, including juniors. Due to the need to perform OT in urgent scenarios, the competency of OTO-HNS resident is crucial. Training for OT in Israeli OTO-HNS residency programs is not well structured. Yet, residents reported they feel confident to perform OT, already in the beginning of their residency. Planned educational programs to improve OT training should be done in the beginning of the residency and may include designated 'hands-on' platforms; objective periodic surgical competence assessments; and specialist's feedback, using structured assessment forms.

Computerized dynamic posturography for evaluating dizziness in patients with scarred orbital content.

Our objective was to assess the capability of computerized dynamic posturography (CDP) to evaluate dizziness in blind patients who lack corneoretinal potential. We performed a retrospective analysis of 2 young blind subjects with intraorbital scarring who complained of dizziness and underwent CDP. Tests were carried out at our center for balance disorders using the NeuroCom's EquiTest System version 4.0. CDP demonstrated vestibular dysfunction and revealed it to be severe. We conclude that CDP can serve as a potentially reliable tool for assessing dizziness in blind patients who have no corneoretinal potential.

Adherence to acute otitis media diagnosis and treatment guidelines among Israeli otolaryngologists.

INTRODUCTION: The recent Israeli acute otitis media (AOM) guidelines, drafted mainly by pediatricians and family physicians in 2013, addressed diagnostic and therapeutic issues, in order to reduce over-diagnosis and treatment. These guidelines are considered as the 'standard of care' for AOM management. While the adherence rate of pediatricians to previous Israeli AOM guidelines (2004) was reported to be high (>85%), the compliance of otolaryngologists has not been studied. METHODS: An anonymous 19-item questionnaire was circulated among practicing Israeli otolaryngologists (residents [n = 93], specialists [n = 283]). All the items were scored according to the number of correct answers in line with the guidelines, and summed on a 0-100 scale. RESULTS: Response rate was 34% (n = 127). Overall, scores of correct answers of residents (n = 48, 52% of all residents) and specialists (n = 79, 28% of all specialists) were similar, and showed comparable moderate adherence to both guidelines: 55.7 vs 58.3 (p = 0.26). Residents were more likely to adhere to the U.S. guidelines, when compared to specialists (score difference 6.1 vs 2.8, p = 0.008). Responders preferred the microscope for diagnosis (48%), over the recommended (pneumatic) otoscope (62%) (p = 0.05), and were more likely to start antibiotic therapy (62%), rather than the 'watchful waiting' (38%) (p = 0.03). Concerning antibiotic treatment, 50% of otolaryngologists prescribed amoxicillin as recommended, at 60-80 mg/kg/d. CONCLUSION: The moderate adherence rate suggests that the guidelines were partially adopted by otolaryngologists, who use different instrumentation than recommended, and treat more severe/complicated cases. Over-treatment with antibiotics and inaccurate dosing regimens are still common. Better implementation of the AOM guidelines among otolaryngologists should be performed in designated training platforms.

Comparison of first year of life acute otitis media admissions before and after the 13-valent pneumococcal conjugate vaccine.

BACKGROUND: Acute otitis media (AOM) is a common childhood infection, which is usually managed in the outpatient setting. Yet, the more severe cases are referred for inpatient treatment. We hypothesized that pneumococcal conjugate vaccines (PCVs), administered during the first year of life, would decrease AOM admissions rate in this age group. We studied the characteristics of infants admitted with AOM and acute mastoiditis (AM) in the PCV13 era, routinely given from November 2010 to all infants. METHODS: Charts of infants ≤1 year that were hospitalized during 1/1/2010-31/12/2015 with AOM, with or without AM, were retrieved using hospitalization codes. We compared 2010-11 (transition years, from PCV7 to PCV13) to 2012-15 (post-PCV13 marketing years). RESULTS: AOM was the primary/secondary discharge diagnosis in ∼4% of all admitted infants ≤1 year. Boys had more admissions than girls (62% vs 38%). Accuracy of AOM diagnoses substantially increased in the post-marketing years. The average hospitalization duration slightly shortened, from 3.21 (2010-11) to 2.99 days (2012-15) (p = 0.52). Despite considerably modest pre-admission antibiotic treatment rate (<30%), AM was infrequent (∼3.4% of AOM admissions). Amoxicillin was the most common antibiotic therapy given before admission and during hospitalization. The number of myringotomies, usually reserved for treatment failure cases, significantly declined, and there were almost no cases of resistant bacteria. Respiratory syncytial virus was detected in ∼20% of collected respiratory samples, and influenza A/B viruses in ∼8%. CONCLUSIONS: AOM is still a major cause for hospitalization of infants in the PCV13 era. Yet, complications are infrequent, and AM rate is low.

The efficacy of extended Draf IIb procedure by partial nasal septectomy: long-term follow up.

Draf IIb procedure is mostly used in a very narrow frontal recess and in a revision frontal sinus surgery. In most cases, the contralateral sinus is not involved. In order to avoid Draf III procedure's reported disadvantages we have commenced the use of the extended Draf IIb procedures in our center. Patients treated with extended Draf IIb procedure at our center between the years 1997 and 2012 were retrospectively evaluated. This procedure includes further widening of the frontal ostium and recces by excising the adjacent most superior nasal septum. Included in our study were patients who have failed previous Draf IIb procedure or had a small and narrow frontal sinus. Collected data included demographics, prior sinus pathology, previous surgical treatment, surgical complications and further treatment if required. All were evaluated by the SNOT-22 questioner pre and post-operatively and all were endoscopically evaluated during the follow up period. 15 patients and 18 frontal sinuses were included in our study, eight males and seven females with a mean age of 50.3 years. The mean pre-operative SNOT-22 fell from 46 to 24 and all patients improved clinically. No surgical complications were reported except for one case of postoperative maxillary sinusitis. Only one patient required further surgical intervention. In most cases the patients had a patent frontal sinus ostium after a follow up of 3-8 years. Extended Draf IIb procedure is less traumatic, safe and effective in the treatment of persistent frontal sinus disease, without surgically involving the healthy contralateral frontal sinus, and may obviate the need for Draf III procedure.

Decrease in Pneumococcal Otitis Media Cultures With Concomitant Increased Antibiotic Susceptibility in the Pneumococcal Conjugate Vaccines Era.

OBJECTIVE: To study the change in the incidence and antibiotic susceptibility patterns of Streptococcus pneumoniae (Spn) in cultures obtained from children with otitis media (OM) during the pneumococcal conjugate vaccines (PCVs) era. STUDY DESIGN: Retrospective. SETTING: Secondary medical care center. PATIENTS: Children less than 8 years who presented with OM and had positive pneumococcal cultures during January 1, 2007 to December 12, 2014 were identified. Data recorded included demographics, preadmission antibiotics, culture source, and antibiotic susceptibility tests. We compared the pre-PCV years (2007-2008) with the transition years (2009-2011) and the post-PCV13 years (2012-2014). INTERVENTIONS: PCV7 (2009), PCV13 (2010), therapeutic. MAIN OUTCOME MEASURE(S): Annual rate of Spn cultures, antibiotic susceptibility patterns. RESULTS: We identified 134 children (76 boys, 57%) who contributed 162 pneumococcal cultures. There was a downward trend in the annual incidence rate of Spn cultures between the pre-PCV years, transition years, and post-PCV13 years: 11.12, 8.48, and 4.11/1000 hospitalized children/year, respectively (p = 0.08, p = 0.04). Had there been no interventions, and based on the 2007 to 2009 average, the observed over the expected Spn cultures ratio rates for 2010 to 2014 were 0.59, 0.45, 0.40, 0.40, and 0.25, respectively. In parallel, the susceptibility of Spn strains to four commonly tested antibiotics significantly increased from the pre-PCV years to the transition years and the post-PCV13 years. In each period, Spn strains were penicillin sensitive in 37, 51, and 100%; for erythromycin, 46, 71, and 82%; for trimethoprim/sulfamethoxazole, 32, 71, and 97%; and for ceftriaxone, 95, 96, and 100%, respectively. CONCLUSION: The introduction of PCVs significantly decreased the incidence rate of pneumococcal OM, and increased Spn susceptibility to common antibiotics.

Gender differences in the bacteriology of rhinosinusitis.

Evaluating gender differences in pathogens involving sinonasal tract disease in patients undergoing nasal surgery for chronic and recurrent rhinosinusitis (C/R RS). Retrospective analysis of 164 positive sinonasal swab cultures taken during endoscopic sinonasal surgery between the years 2006 and 2013. Study population included 79 (48.8%) female patients and 84 (51/2%) males with a mean age of 47.3 (13-88) years. Positive Staphylococcal growth was found in 38 (23.2%) patients, positive anaerobic growth in 25 (15.2%) patients and 67 (40.9%) patients had polymicrobial growth. Staphylococcal growth in the male population was significantly higher compared to the female population (p = 0.04). Odds ratio for a polymicrobial infection in males over 60 years old compared to females was 2.17 (CI 0.63-8.08, 95%). Anaerobes were found to be more frequent in males (17.9%) than in females (12.5%). Species of Streptococci showed no difference between gender and age groups. The results obtained suggest a difference between the causing pathogens in C/R RS between females and males. In the male population, staphylococcal species were found to be significantly more common with a greater tendency to polymicrobial pathogens and higher rates of anaerobes. These results might suggest different management protocols perioperatively in males and females.

Nasal Fibrolipomatous Hamartoma, an Idiosyncratic Connective Tissue Malformation in an Infant.

We describe a congenital mass in the nasopharynx of an infant presenting with dyspnea and feeding difficulties. Magnetic resonance imaging demonstrated 2 separate polypoid nasal cavity masses that were endoscopically resected. Histologically, both lesions were composed of mature adipose tissue with broad fibrous bands and several foci of brown fat. PLAG-1 and HMGA-2 were negative by immunostains. The best diagnosis was a fibrolipomatous hamartoma.

Hyperbaric oxygen therapy for maxillary bone radiation-induced injury: A 15-year single-center experience.

BACKGROUND: Although hyperbaric oxygen therapy (HBOT) is used to treat chronic radiation tissue injury, clinical evidence supporting its use in maxillary bone osteoradionecrosis (ORN) is lacking. Therefore, the purpose of this study was to report our results of collected patient outcomes from a single center's large experience using HBOT to treat maxillary bone ORN. METHODS: From 1999 to 2015, 21 patients received treatment for maxillary bone ORN at our center. The medical records were retrospectively reviewed for the following variables: age, sex, comorbidities, tumor stage and site, previous surgery, previous radiotherapy or chemoradiation therapy, HBOT data, response to treatment and further management. RESULTS: A positive clinical outcome from HBOT occurred in 85.7% of patients with ORN and was proven radiologically in 14 of 15 patients (93.3%). In 5 patients, reconstructive surgery was required thereafter. CONCLUSION: Controversy exists regarding the management of ORN of the maxillofacial skeleton. Our large, single-center experience probably supports the efficacy of HBOT for maxillary bone ORN. © 2016 Wiley Periodicals, Inc. Head Neck 39: 275-278, 2017.

Brain Positron Emission Tomography-Computed Tomography Gender Differences in Tinnitus Patients.

BACKGROUND: Increased metabolism in the left auditory cortex has been reported in tinnitus patients. However, gender difference has not been addressed. PURPOSE: To assess the differences in Positron emission tomography-computed tomography (PET-CT) results between the genders in tinnitus patients. RESEARCH DESIGN: Retrospective cohort. STUDY SAMPLE: Included were patients referred to our clinic between January 2011 and August 2013 who complained of tinnitus and underwent fluorodeoxyglucose (FDG)-PET to assess brain metabolism. DATA ANALYSIS: Univariate and multivariate nominal logistic regressions were used to evaluate the association between upper temporal gyrus (UTG; right and left) and gender. RESULTS: Included were 140 patients (87 males) with an average age of 52.5 yr (median = 53.1). Bilateral tinnitus was found in 85 patients (60.7%), left sided in 30 (21.4%), and right sided in 21(15%). Increased uptake in the UTG was found in 60% of the patients on either side. Males had a statistically significant increased uptake in the UTG in those with unilateral tinnitus and in the entire population. CONCLUSIONS: We present the largest study reported so far on tinnitus patients who have undergone FDG-PET-CT. We found a statistically significant difference between the genders in FDG uptake by the UTG. Further investigations should be undertaken to reveal the etiologies for these differences and to assess different therapeutic protocols according to gender.

The Role of Bacteriologic Studies in Predicting Recurrent Mastoiditis in 456 Patients.

OBJECTIVES: To evaluate the effect of microbiologic growth on the recurrence rate of mastoiditis. MATERIALS AND METHODS: A historical prospective study on all cases of children with acute mastoiditis (AM) admitted between 2000 and 2015, was performed. The following data were collected in the recurrent AM (rAM) group: age, sex, and medical history, antibiotic therapy before hospitalization, clinical presentation at admission including symptoms and signs, blood test results, computed tomography (CT) imaging, microbiological findings, treatment, complications, outcome, and follow-up duration. RESULTS: Four hundred fifty six consecutive hospitalizations because of mastoiditis were identified; 22 patients were found to have rAM. The median age at first episode in the rAM group was 1 year (range, 1-11 years), and the median period from one episode to the next was 2 months. There were 15 men and 7 women. The right ear was involved in 11 cases in the first and in the second episode. The rate of Pseudomonas aeruginosa growth in the rAM group was significantly higher compared with the AM group (40.9 and 8.9%, respectively) (p = 0.001) as was found in anerobic growth (15 vs. no growth) (p < 0.001) and in polymicrobial growth (59% vs. 3.6%) (p < 0.001). CONCLUSION: Patients with P. aeruginosa growth, anaerobic bacteria, and polymicrobia infection cultured in an AM infection, are prone to have rAM, and therefore antibiotic adjustments according to their bacteriologic studies should be considered even if clinical improvement is encountered, or surgical intervention during the first AM episode, and closer follow up with proper antibiotic treatment when signs of recurrent ear infection are encountered.

Hyperbaric oxygen therapy as an alternative to surgery for non-healing pharyngocutaneous fistula.

The aim of the study is to examine the utilization of hyperbaric oxygen treatment (HBOT) as an alternative to surgical treatment for non-healing postoperative phayngocutaneous fistula (POPCF). A retrospective study was conducted between 2012 and 2014 of referred patients who had failed conservative treatment for POPCF at other medical centers. Reevaluation at our department was followed by therapeutic management including daily HBOT. Eight male patients with a mean age of 62.3 years were included. The average period of conservative treatment was 1 month before admittance to our department. All patients were managed with HBOT and local debridement. Closure of the POPCF was proved by a barium swallow test in seven patients (87.5 %). HBOT is recommended for patients who have failed conservative treatment for POPCF post-laryngectomy, due to a high rate of successful (87.5 %) closure and should be considered as an alternative to surgical treatment.

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.