Demographics and microbiology of otorrhea through patent tubes failing ototopical and/or oral antibiotic therapy.

OBJECTIVES: Posttympanostomy tube otorrhea (PTTO) results in significant health care cost and decreased satisfaction with care. The authors reviewed PTTO failing initial ototopical and/or oral antibiotic therapy and microbiology/susceptibility data from cultures. STUDY DESIGN: Case series with chart review. SETTING: A community university satellite ambulatory clinic and the outpatient clinic of a children's hospital. METHODS: Review of 202 patients with 228 discrete episodes of culture-positive otorrhea from January 2004 to January 2009. RESULTS: PTTO occurred an average of 13 months after tube placement. Median otorrhea duration was 21 days (mean, 42 days). A mean of 1.6 visits (range, 1-6) to the pediatric otolaryngology office was required for PTTO resolution. Ototopical therapy was reported used in 198 of 228 (87%) episodes of otorrhea prior to pediatric otolaryngology visit. Nearly 50% of patients were prescribed at least 1 or more courses of systemic antibiotics. Staphylococcus aureus accounted for 52% of the organisms cultured, with 57% methicillin-resistant S aureus (MRSA). S aureus resistance to clindamycin was high (49%) and resistance to levofloxacin was low (1.8%). MRSA was 68% clindamycin resistant, much higher than both ours and the children's hospital's clindamycin resistance rate of MRSA cultured from all other body sites. CONCLUSIONS: PTTO that presents as having failed ototopical and/or oral antibiotics most commonly consists of S aureus, Streptococcus pneumoniae, and Pseudomonas aeruginosa. MRSA is highly prevalent in this population. It is not necessary to culture PTTO that presents to an otolaryngology office, as resistance to levofloxacin was only 1.8%. It is unclear why the same fluoroquinolone ototopical therapy that failed initially is often successful in treating PTTO after otolaryngologist visit.

Pseudoangiomatous stromal hyperplasia of the breast in pediatric patients: an underrecognized entity.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign lesion consisting of mammary stromal proliferation with anastomosing slits mimicking vascular spaces. Grossly, it most often resembles fibroadenoma, but may commonly be confused with angiosarcoma and other types of benign vascular proliferations. While PASH has been described in female and male adults since the mid-1980s, there have been only a few accounts in the pediatric population. We present a series of 12 pediatric patients with PASH, including a 3-year-old male, who we believe to be the youngest patient to present with this entity. In our study, PASH was found in 12% of tumors diagnosed preoperatively as fibroadenomas and in 12% of cases diagnosed preoperatively as gynecomastia. Our series documents that PASH is not uncommon in pediatric breast pathology and delineates important differences between adult and pediatric presentations of this entity.

An objective evaluation of breast symmetry and shape differences using 3-dimensional images.

BACKGROUND: The concept of natural breast asymmetry is well known; however, actual documentation in the literature is limited. New technology is currently available which provides 3-dimensional surface images of the breast and the ability to qualitatively determine differences in breast size, shape, and contour. The purpose of this report is to objectively determine the extent to which this natural breast asymmetry exists. METHODS: Eighty-seven women without a history of breast cancer or previous breast surgery were included. Images were obtained using 3dMD technology. Data points queried included age, parity, body mass index (BMI), ethnicity, and bra size. Left/right images were superimposed and the distance between the 2 surfaces, and contour was calculated. The degree of asymmetry was determined and comparisons were made. Similar differences in nipple-to-notch measurements were calculated and compared. Subjective evaluations were included for clinical relevance. RESULTS: The average age was 49.6 years (range: 19-77), with an average BMI of 25 (range: 18.5-36.7). The average nipple to notch on the left was 24.3 cm and 23.8 cm on the right. The nipple-to-notch asymmetry was on average 3.2%, with the left breast measurement being greater the majority of the time (62%). The mean distance between each breast demonstrated consistent breast asymmetry, with an average measurement of +0.5 mm (left breast being larger than the right). The degree of breast asymmetry was documented by a root mean square value (RMS) of 5.93 mm. This was not related to age, parity, or ethnicity; however, it was significantly higher in those patients with larger BMI, cup size, and chest-wall circumference. Only 10% of women were found to have severe breast asymmetry on subjective evaluation, which correlated objectively with the RMS in that group being significantly higher at 9.8 mm (P < 0.05). There were no predictable patterns of asymmetry; however, the most common pattern was larger laterally and smaller medially, found in 32% of the women. CONCLUSION: Natural breast asymmetry does exist, demonstrated objectively using 3-dimensional surfaces images. The left breast is on average larger than the right, with differences in size and shape being consistent but fairly unpredictable. It is important that we know baseline differences in breast symmetry prior to objectively analyzing results following esthetic and reconstructive breast surgery.