T-tubes Through Cartilage Tympanoplasty: Is It Worth the Perforation Risk?

OBJECTIVE: To review a single surgeon's experience with T-tube placement through cartilage tympanoplasty versus native tympanic membrane for long-term ventilation of the chronic ear and residual perforation rates following tube removal. STUDY DESIGN: Retrospective chart review. SETTING: Two tertiary referral centers. PATIENTS: One hundred sixteen patients (4-71 yr of age) who underwent either total island cartilage tympanoplasty or posterior palisade cartilage tympanoplasty with T-tube placement primarily or secondarily from 1998 to 2016. MAIN OUTCOME MEASURES: Long-term outcome of each T-tube was recorded with respect to retention and patency, and tympanic membrane status following either tube removal or extrusion. Audiometric data, age, sex, diagnosis, and procedure(s) performed were considered. RESULTS: There were 116 patients (122 total ears and 139 total T-tubes) included: 57 ears underwent total island cartilage tympanoplasty with tube placed through cartilage and 65 ears underwent posterior island graft with tube placed through native tympanic membrane. Sixty-eight T-tubes were placed in the total island cartilage group with three (4.4%) residual perforations following removal. Seventy-one T-tubes were placed in the posterior palisade graft group with six residual perforations (8.5%) following removal or extrusion. The mean retention rate for the T-tubes was 3.93 years for the total island tympanoplasty group and 3.58 years for the posterior palisade tympanoplasty group. The mean follow-up for total island tympanoplasty and posterior palisade tympanoplasty was 5.36 and 5.66 years, respectively. CONCLUSION: Our data suggest that T-tube placement through cartilage tympanoplasty is worthwhile providing long-term ventilation to the middle ear and portends no higher risk for residual perforation than T-tube placement through native tympanic membrane.

Outcomes Following Revision Stapes Surgery in Children: A Single-Surgeon, Single-Center 15-Year Experience.

OBJECTIVE: To review a single surgeon experience with revision pediatric stapes surgery for congenital stapes fixation (CSF) and tympanosclerosis (TS). Secondly, to determine whether hearing outcomes following revision surgery may be predicted by a thorough work-up aimed at assessing whether an extruded or malpositioned prosthesis is likely to be encountered intraoperatively. SETTING: Tertiary referral center. STUDY DESIGN: Retrospective chart review. PATIENTS: Fifteen patients having revision surgery for fixation of the stapes footplate over a 15-year period. MAIN OUTCOME MEASURES: Hearing results based on pre- and post-revision pure-tone average air-bone gap (PTA-ABG) and speech recognition threshold testing (SRT). RESULTS: Overall, the mean improvement of PTA-ABG following revision surgery was 11.9 dB (standard deviation [SD] 15.2) while SRTs improved by a mean of 12.3 (SD 19.9). Outcomes were significantly better in patients who reported a history of trauma following their initial surgery, when there was otoscopic evidence of an extruding or extruded prosthesis and/or a pre-revision CT (where performed) suggested an extruded or malpositioned prosthesis. No patients had a significant postoperative sensorineural hearing loss. CONCLUSION: Revision stapes surgery in children is a safe procedure in experienced hands which nonetheless should only be contemplated in patients in whom preoperative work-up suggests an extruded or malpositioned prosthesis is likely to be encountered intraoperatively.

Partial Adenoidectomy in Patients With Palatal Abnormalities.

BACKGROUND: Velopharyngeal insufficiency is a feared complication of adenoidectomies in patients with palatal abnormalities. Thus, the benefits of adenoidectomy in this population are less understood. The techniques of partial adenoidectomy aim to preserve velopharyngeal closure while sufficiently debulking the nasal airway to ameliorate obstruction and snoring. METHODOLOGY: Systematic review of online databases using a combination of search terms including "cleft palate," "submucosal cleft palate," "short palate," "adenoidectomy," "partial adenoidectomy," "subtotal adenoidectomy," and "powered adenoidectomy." Two independent reviewers assessed the eligibility of each study based on predefined inclusion criteria. RESULTS: From 323 studies identified, 8 were included. All were retrospective case series, except 1 prospective study. Study period ranged from 1.1 to 14 years (median 7.5 years). There were 172 patients with a cleft palate (n = 80), submucous cleft palate (n = 67) or another defined palatal abnormality [short soft palate (n = 14), bifid uvula (n = 4), questionable palatal mobility (n = 4) or incomplete CP (n = 3)] identified. Mean age was 5.5 years and just over half were male (58%). Nearly all patients showed improvement in nasal airway obstruction and snoring. The pooled risk for velopharyngeal insufficiency across all studies was 2 out of 122, which approximates to 1.6% of patients. There were very few complications. CONCLUSION: This is the first systematic review of partial adenoidectomy in patients with palatal abnormalities. Sub-total adenoidectomy in patients with submucosal cleft palate or repaired cleft palate appears to be a safe and efficacious procedure. There is; however, a need for prospective data collection using a standardized technique in large patient series required to properly assess outcomes.

Outcomes of Primary Pediatric Stapedotomy.

OBJECTIVE: To review a single institution experience with pediatric stapedotomy for juvenile otosclerosis (JO), congenital stapes footplate fixation (CSFF), or tympanosclerosis. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Pediatric patients undergoing surgery for stapes fixation from 2001 to 2017. MAIN OUTCOME MEASURES: Hearing result based on preoperative, first postoperative, and final postoperative pure-tone average air-bone gap (PTA-ABG). Age, sex, diagnosis, procedure performed, prosthesis, and ossicular anomalies were considered. RESULTS: A total of 59 children (4-16 years of age) underwent surgery for stapes fixation (67 ears), with an average postoperative audiogram out to 2.88 years. Final postoperative ABG for tympanosclerosis (30.4 dB ±â€Š10.9 dB) showed some improvement but the outcome was significantly worse than in CSFF (21.0 dB ±â€Š11.4 dB) (p = 0.020) and JO (22.8 dB ±â€Š14.9 dB). CONCLUSION: Our data suggest, that in our clinic, surgery for stapes fixation is safe to perform in children. While we achieved desirable results for JO and CSFF, patients with tympanosclerosis showed a statistically worse hearing outcome. Tympanosclerosis deserves special consideration and may be better served with a malleovestibulopexy, total ossicular replacement prosthesis (TORP), or amplification in lieu of traditional stapes surgery.

Myiasis of the ear: a review with entomological aspects for the otolaryngologist.

OBJECTIVE: Myiasis is the infestation of live humans (or animals) by fly larvae. Although the diagnosis is relatively straightforward, how to best treat aural myiasis has not been well described in the literature. This comprehensive literature review, therefore, was performed to identify current management principles in aural myiasis, especially with regard to the causative fly family. In addition, we explore the possible relationship between aural myiasis and the highly lethal intracranial myiasis. DATA SOURCES: Literature review using the Medline database (PubMed), Scopus, and Google Scholar. REVIEW METHODS: Manuscripts published in the English language between January 1, 1992, and December 31, 2012, were included. RESULTS: Forty-five cases of aural myiasis were reported in 34 manuscripts. Most cases were caused by species of the Sarcophagidae family (n=26/45, 57.8%). The majority of cases (n=40/45, 88.9%) were successfully treated with simple aural toilet and topical treatments alone. No deaths were reported and no cases were seen in conjunction with intracranial myiasis. CONCLUSION: Aural myiasis is a rare but benign fly infestation of the ear, most commonly by species of the Sarcophagidae family. The overwhelming majority of cases can be successfully managed without the need for surgical intervention.

Safety and efficacy of topical bacteriophage and ethylenediaminetetraacetic acid treatment of Staphylococcus aureus infection in a sheep model of sinusitis.

BACKGROUND: Treatment of sinonasal bacterial biofilms continues to be a challenge in modern rhinology. This study's objective was to assess the safety and efficacy of topically applied Cocktail of S. aureus specific phage (CTSA) alone and in combination with ethylenediaminetetraacetic acid (EDTA) for treatment of Staphylococcus aureus biofilms in vivo. METHODS: Using a sheep model of sinusitis, frontal sinuses (n = 6 per treatment) were flushed once daily with a CTSA (2 × 10(6) plaque forming units [PFU]/mL), with or without EDTA (0.075 mg/mL), and compared to a control flush containing saline and heat-inactivated CTSA. Safety was assessed using histology and scanning electron microscopy (SEM) after treatment for 3 days. Efficacy was assessed by quantifying the generation of S. aureus biofilms in the frontal sinuses after 5 days of treatment. Biofilm mass was compared between treatment groups and controls using LIVE/DEAD BacLight staining and confocal scanning laser microscopy to visualize the tissue sections. COMSTAT2 software was used to compute the biofilm mass present on tissue sections. RESULTS: Tissue morphology was conserved, with no significant signs of inflammation, when comparing control and test treatments. Furthermore, SEM analysis indicated test treatments were not toxic or damaging to mucosal cilia. COMSTAT2 quantification of biofilm showed a significant reduction in biofilm levels when comparing the control with CTSA (p = 0.0043), EDTA (p = 0.0095), and CTSA-EDTA (p = 0.0022) treatments. CONCLUSION: Results indicate that CTSA and EDTA are safe and efficacious for short-term topical application against S. aureus infection in a sheep sinusitis model, and have the potential to be translated to a clinical setting.

Bacterial-induced epithelial damage promotes fungal biofilm formation in a sheep model of sinusitis.

BACKGROUND: Fungal biofilms have been discovered in chronic rhinosinusitis (CRS) patients, but factors contributing to their establishment are obscure. A recent animal study showed bacterial co-inoculation was required. We examine the role of 4 bacterial species and a cilia toxin on fungal biofilm formation in a sheep sinusitis model. The importance of epithelial integrity on fungal biofilm formation is also examined. METHODS: Forty-eight frontal sinuses were inoculated with Aspergillus fumigatus alone, with 1 of 4 bacteria, or a cilia toxin. Bacterial and fungal biofilm was determined using confocal scanning laser microscopy. Inflammation and cilia integrity were assessed using light microscopy and transmission electron microscopy, respectively. RESULTS: No fungal biofilm formed when inoculated alone. Florid fungal biofilm developed in more than 75% of sinuses associated with bacterial biofilm of all species, except Haemophilus influenzae, which failed to establish bacterial biofilm. Fungal biofilm also established in association with cilia toxin. Significant cilial damage was incited by all bacterial biofilms and cilia toxin, and was associated with fungal proliferation. Fungal biofilm formation did not significantly increase mucosal inflammation or epithelial damage over that caused by the bacteria or cilia toxin alone. CONCLUSION: Bacterial biofilms cause sinonasal mucosal inflammation and epithelial injury, which provides conditions appropriate for fungal biofilm proliferation. The role of cilia in sinonasal mucosal defense against fungal organisms has been demonstrated. Without such an insult, fungal biofilms fail to proliferate in occluded sinuses. Improving cilial recovery postoperatively and treating bacterial biofilms may be key factors in reducing recalcitrance in allergic fungal rhinosinusitis patients.

A randomized trial of mupirocin sinonasal rinses versus saline in surgically recalcitrant staphylococcal chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Chronic rhinosinusitis (CRS) recalcitrant to surgery is a frustrating clinical entity. Recently, mupirocin sinonasal rinses have been suggested as an efficacious treatment alternative in these patients where Staphylococcus aureus infection is demonstrated. To our knowledge, how best to treat this S aureus reservoir has not been previously evaluated in a double-blinded, randomized, placebo-controlled trial. STUDY DESIGN: Prospective, double-blinded, placebo-controlled study. METHODS: Twenty-five S aureus-positive CRS patients with persistent sinonasal infection despite endoscopic sinus surgery received either a 1-month, twice-daily treatment course of mupirocin sinonasal rinses (MUP) or saline rinses (CON). The primary outcome was S aureus-culture negativity at the conclusion of treatment; secondary rhinological outcomes included subjective and objective measures of rhinosinusitis. RESULTS: Twenty-two patients satisfactorily completed the treatment period. Of CON patients, 0/13 (0.0%) returned an S aureus-negative sinonasal culture at 1 month, compared to 8/9 (88.9%) of MUP patients (P < .01). Improvements in rhinological outcomes observed in MUP patients following treatment were not subsequently evident when these patients were followed up at a delayed assessment 2 to 6 months after completing treatment. CONCLUSIONS: Mupirocin sinonasal rinses are an effective short-term anti-S aureus treatment in surgically recalcitrant CRS as assessed by microbiological and selected rhinological outcomes, although the latter improvements may not be durable with time.

Microbiological outcomes following mupirocin nasal washes for symptomatic, Staphylococcus aureus-positive chronic rhinosinusitis following endoscopic sinus surgery.

BACKGROUND: Persistent infection following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) is a frustrating entity for the patient and rhinologist alike. Mupirocin nasal washes have been proposed as an efficacious treatment in such patients. Two small studies have reported excellent short-term posttreatment outcomes; however, the long-term microbiological outcomes following treatment are not known; likewise, the rate of mupirocin-resistance following treatment has not been explored. METHODS: This was a retrospective chart review of 61 patients with Staphylococcus aureus (S. aureus)-positive surgically-recalcitrant CRS having undergone 0.05% mupirocin nasal rinse treatment, twice daily for 4 weeks. Specific outcomes reported included posttreatment culture results, time to first posttreatment S. aureus culture, and mupirocin-sensitivity following treatment. RESULTS: Of 57 patients meeting minimal posttreatment follow-up criteria, 42 (73.7%) progressed to microbiological failure by subsequently cultured S. aureus. Mean time to first positive culture was 144 days. Of the 42 patients who progressed to microbiological relapse, full antibiotic sensitivity data was available for 41; of these, only 1 was found to subsequently harbor a mupirocin-resistant strain of S. aureus, thus yielding a posttreatment resistance rate of 2.4%. CONCLUSION: Treatment with mupirocin nasal washes in S. aureus-positive, surgically recalcitrant CRS has a high microbiological failure rate, with 73.7% of patients subsequently re-culturing S. aureus. Our current treatment regime of 0.05% nasal washes twice daily for 4 weeks is associated with a posttreatment resistance rate that is consistent with other studies of topical mupirocin use, suggesting that mupirocin washes are no more likely to induce resistance than nasal vestibule decolonization in the high-risk medical or surgical patient.

Staphylococcus aureus biofilms: Nemesis of endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Chronic rhinosinusitis (CRS) patients with biofilms have persistent postoperative symptoms, ongoing mucosal inflammation, and recurrent infections. Recent evidence suggests that biofilms of differing species confer varying disease profiles in CRS patients. We aimed to prospectively investigate the effects of Staphylococcus aureus, Pseudomonas aeruginosa, Haemophilus influenzae, and fungal biofilms on outcomes following endoscopic sinus surgery (ESS). STUDY DESIGN: Prospective blinded study. METHODS: In this prospective blinded study, 39 patients undergoing ESS for CRS assessed their symptoms preoperatively using internationally accepted standardized symptom scoring systems and quality-of-life measures (10-point visual analog scale, Sino-Nasal Outcome Test-20, global severity of CRS). Their sinonasal mucosa was graded (Lund-Kennedy scale) and extent of radiologic disease on computed tomography scans scored (Lund-McKay scale). Random sinonasal tissue samples were assessed for different bacterial species forming biofilms by using fluorescent in-situ hybridization and confocal laser microscopy. For 12 months after surgery, CRS symptoms, quality of life, and objective evidence of persisting disease were assessed by using the preoperative tools. RESULTS: Different bacterial species combinations were found in 30 of 39 patients; 60% of these 30 biofilms were polymicrobial biofilms and 70% had S aureus biofilms. Preoperative nasendoscopy and radiologic disease severity were significantly worse in patients with multiple biofilms (P = .02 and P = .01, respectively), and they had worse postsurgery mucosal outcomes on endoscopy (P = .01) requiring significantly more postoperative visits (P = .04). Those with S aureus biofilms progressed poorly with their symptom scores and quality-of-life outcomes, with significant differences in nasendoscopy scores (P = .007). CONCLUSIONS: S. aureus biofilms play a dominant role in negatively affecting outcomes of ESS with persisting postoperative symptoms, ongoing mucosal inflammation, and infections.

Do biofilms contribute to the initiation and recalcitrance of chronic rhinosinusitis?

Chronic rhinosinusitis is a common disease whose underlying aetiopathogenesis has not been completely understood. Amongst a range of other potential environmental triggers in this disease, a role has recently been proposed for bacterial biofilms. Adopting the biofilm paradigm to explain the initiation and maintenance of this disease may help to clarify previous inconsistencies in this disease that have resulted in the role of bacteria being questioned. Of particular interest is the association of bacterial biofilms with recalcitrant disease states. Over the last five years, research has progressed rapidly since biofilms were first identified on the surface of diseased sinonasal mucosa. Their presence there has now been associated with more severe disease that is often recalcitrant to current management paradigms. Technological advances are allowing accurate characterization of the bacterial and fungal species within these biofilms, which would appear to be an important step in improving our understanding of how these bacterial communities might interact with the host to cause disease. This is an unanswered, yet highly important, question in this field of research that will undoubtedly be an area of investigation in the near future. As the body of evidence suggesting biofilms may be involved in this disease grows, research interest has switched to the development of antibiofilm therapies. Given the unique properties of bacteria existing in this form, biofilm eradication strategies will need to incorporate novel medical therapies into established surgical practices as we attempt to improve the outcomes of our most difficult patients.

Methylglyoxal-infused honey mimics the anti-Staphylococcus aureus biofilm activity of manuka honey: potential implication in chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Low pH, hydrogen peroxide generation, and the hyperosmolarity mechanisms of antimicrobial action are ubiquitous for all honeys. In addition, manuka honey has been shown to contain high concentrations of methylglyoxal (MGO), contributing the relatively superior antimicrobial activity of manuka honey compared to non-MGO honeys. In high concentrations, manuka honey is effective in killing Staphylococcus aureus biofilms in vitro. Lower concentrations of honey, however, are desirable for clinical use as a topical rinse in chronic rhinosinusitis in order to maximize the tolerability and practicality of the delivery technique. This study, therefore, was designed to evaluate the contribution of MGO to the biofilm-cidal activity of manuka honey, and furthermore determine whether the antibiofilm activity of low-dose honey can be augmented by the addition of exogenous MGO. STUDY DESIGN: In vitro microbiology experiment. METHODS: Five S. aureus strains (four clinical isolates and one reference strain) were incubated to form biofilms using a previously established in vitro dynamic peg model. First, the biofilm-cidal activities of 1) manuka honey (790 mg/kg MGO), 2) non-MGO honey supplemented with 790 mg/kg MGO, and 3) MGO-only solutions were assessed. Second, the experiment was repeated using honey solutions supplemented with sufficient MGO to achieve concentrations exceeding those seen in commercially available manuka honey preparations. RESULTS: All honey solutions containing a MGO concentration of 0.53 mg/mL or greater demonstrated biofilm-cidal activity; equivalent activity was achieved with ≥1.05 mg/mL MGO solution. CONCLUSIONS: MGO is only partially responsible for the antibiofilm activity of manuka honey. Infusion of MGO-negative honey with MGO, however, achieves similar cidality to the equivalent MGO-rich manuka honey.

What is the origin of Staphylococcus aureus in the early postoperative sinonasal cavity?

BACKGROUND: Despite increasing evidence of a role for Staphylococcus aureus (S. aureus) biofilms in chronic rhinosinusitis (CRS), the origin of this organism in the postsurgical sinonasal cavity had been unclear. Recently, we suggested that the increased culture rate of S. aureus following endoscopic sinus surgery (ESS) may be related to biofilm activity. This study, therefore, was designed to evaluate the origin of early postoperative sinonasal S. aureus and assess the early postoperative outcomes in patients culture-positive for this organism. METHODS: Twenty-nine patients undergoing ESS for medically-recalcitrant CRS were prospectively enrolled. A comprehensive intraoperative S. aureus screening protocol was followed for all patients (including swabs for culture and tissue for fluorescence in situ hybridization [FISH] S. aureus biofilm analysis); early postoperative management included endoscopically-guided swabs for culture in all patients. RESULTS: Twenty of 29 (69.0%) patients cultured S. aureus postoperatively, of which 17 of 20 (85.0%) were screen-positive at surgery. Seven of 11 (63.6%) intraoperatively biofilm-positive but culture-negative patients progressed to culture S. aureus post-ESS. S. aureus culture was associated with selected poorer early post-ESS outcomes. CONCLUSION: S. aureus persists in the sinonasal cavity despite ESS. The postoperative culture of sinonasal S. aureus in patients previously biofilm-positive but culture-negative may reflect the dynamic ability of S. aureus to adapt to the surgically-altered microenvironment with subsequent biofilm dispersal and release of planktonic clones.

Impaired mucosal healing and infection associated with Staphylococcus aureus after endoscopic sinus surgery.

BACKGROUND: Differentiating normal nasal discharge and postoperative crust from infection after endoscopic sinus surgery (ESS) can be difficult. We investigated whether bacteria cultured at operation was predictive for postoperative mucosal infection-defined as frank pus, thick mucus, and/or abnormal crusting seen on endoscopic examination associated with positive microbiology. METHODS: The records of 48 patients with chronic rhinosinusitis (CRS) with infection at the time of ESS were retrospectively reviewed. Results of intraoperative cultures were compared with those taken at the time of postoperative mucosal infection. RESULTS: Fourteen of 16 patients (87.5%) with intraoperative infection with Staphylococcus aureus progressed to postoperative mucosal infection with S. aureus, whereas patients who cultured "other" bacteria intraoperatively progressed to postoperative mucosal infection in 6/19 cases (31.6%), with S. aureus cultured in only 3/19 cases (15.8%; p=0.0001). CONCLUSION: S. aureus infection at ESS predicts for abnormal, S. aureus-associated mucosal healing and infection post-ESS. Although a prospective trial is warranted, these findings suggest a future role for aggressive anti-S. aureus therapy peri- and/or postoperatively in patients who culture positive for this organism to improve postsurgical outcomes.