[Atypical pain and a unilateral swelling of the neck: a patient with TIPIC-syndrome]. / Atypische pijn en een eenzijdige zwelling in de hals.

BACKGROUND: TIPIC-syndrome (Transient Perivascular Inflammation of the Carotid Artery) as a cause of a painful lump in the neck is not often described in the literature. This self-limiting perivascular inflammation of the carotid bifurcation is relatively unknown. CASE: We describe a 50-year old patient, in whom a CT-scan that was performed because of unilateral pain in the neck and paranasal sinuses revealed the unexpected diagnosis of TIPIC-syndrome. CONCLUSION: Knowledge of the symptoms at presentation and the following clinical course of TIPIC-syndrome can prevent unnecessary use of additional tests.

Management of tympanic membrane retractions: a systematic review.

IMPORTANCE: Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment strategy in the military population who are unable to attend frequent follow-up visits, and who experience relatively more barotrauma at great heights and depths and easily suffer from otitis externa from less hygienic circumstances. OBJECTIVE: To assess and summarize the available evidence for the effectiveness of surgical interventions and watchful waiting policy in patients with a tympanic membrane retraction. EVIDENCE REVIEW: The protocol for this systematic review was published at Prospero (207859). PubMed, Embase, and the Cochrane Database of Systematic Reviews were systematically searched from inception up to September 2020 for published and unpublished studies. We included randomized trials and observational studies that investigated surgical interventions (tympanoplasty, ventilation tube insertion) and wait-and-see policy. The primary outcomes of this study were clinical remission of the tympanic membrane retraction, tympanic membrane perforations and cholesteatoma development. FINDINGS: In total, 27 studies were included, consisting of 1566 patients with TMRs. We included data from 2 randomized controlled trials (76 patients) and 25 observational studies (1490 patients). Seven studies (329 patients) investigated excision of the TMR with and without ventilation tube placement, 3 studies (207 patients) investigated the wait-and-see policy and 17 studies (1030 patients) investigated tympanoplasty for the treatment of TMRs. CONCLUSIONS AND RELEVANCE: This study provides all the studies that have been published on the surgical management and wait-and-policy for tympanic membrane retractions. No high level of evidence comparative studies has been performed. The evidence for the management of tympanic membrane retractions is heterogenous and depends on many factors such as the patient population, location and severity of the TMR and presence of other ear pathologies (e.g., perforation, risk of cholesteatoma and serous otitis media).

Intramuscular corticosteroid injections in seasonal allergic rhinitis: A systematic review.

OBJECTIVE: Seasonal allergic rhinitis (SAR) is an exaggerated immunological reaction to allergens (pollen) in the air. In a small subgroup of patients, SAR can be difficult to control with first-line therapy. Intramuscular corticosteroid injections (IMCIs) are an additional treatment in this subgroup of SAR patients. The aim of this systematic review is to investigate the efficacy and safety of IMCIs in SAR. METHODS: Titles and abstracts were independently screened, followed by full-text screening based on predefined criteria. Included articles were critically appraised using the Cochrane Risk of Bias 2 (RoB 2) tool. The primary outcome is reported as the final conclusion about efficacy that was stated in the included studies. The secondary outcome is the safety of IMCIs with regard to long lasting side-effects. RESULTS: The search yielded 2139 records, of which 10 were relevant and valid for our clinical question. Critical appraisal showed high risk of bias, which was due to unclear description of methods. Four out of four placebo-controlled, randomized controlled trials reported a significant and relevant difference in efficacy in favor of IMCIs compared with placebo. The occurrence of side-effects was not different between IMCIs and placebo or oral corticosteroids (OCs). CONCLUSION: The outcome of this systematic review on trials concerning intramuscular steroid injections, despite being based on individual studies claiming favorable outcome with their use, is "inconclusive." This is because of the epidemiological high risk of bias in these studies that were mostly executed more than 30 years ago. The "inconclusive" rating allows for a description as an "optional therapy" for severe cases in guideline formation.

Entrapment Neuropathy: A Concept for Pathogenesis and Treatment of Headaches-A Narrative Review.

Entrapment neuropathy is a known cause of neurological disorders. In the head and neck area, this pathophysiological mechanism could be a trigger for headache. Over the last few decades, injection of botulinum toxin type A in the muscles that are causing the compression as well as surgical decompression have proved to be effective treatment methods worldwide for large numbers of patients with daily headaches. In particular the entrapment of the supraorbital nerves in the glabellar musculature and the occipital nerves in the neck musculature are triggers for headache disorders for which many patients are still seeking an effective treatment. This article reviews the literature and aims to bring the concept of neural entrapment to the attention of a wider audience. By doing so, we hope to give more exposure to an effective and relatively safe headache treatment.

A systematic review on the surgical outcome of preauricular sinus excision techniques.

OBJECTIVES/HYPOTHESIS: Preauricular sinuses are benign congenital malformations of preauricular soft tissues. Complete excision using either sinectomy or supra-auricular approach is advised to prevent recurrence. Reported recurrence varies between 0 and 42%. We evaluated which surgical technique resulted in lowest complication and recurrence rates. STUDY DESIGN: PubMed, Embase, Scopus, Web of Science. METHODS: Two authors appraised studies on directness of evidence and risk of bias. Original data were extracted and pooled when I(2) was smaller than 50%. Results are reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: Fourteen high directness of evidence studies were included. Reported complication rates were similar: sinectomy [0-31.4%] and supra-auricular approach (SAA) [0-18.2%]. Pooled recurrence rates showed that sinectomy resulted in significantly (P = .04) more recurrence 5.5% (95% confidence interval [CI] 3.6-8.3%) than SAA 2.2% (95% CI 0.7-7.0). Sinectomy using the microscope resulted in the lowest sinectomy recurrence rates (1.9%). SAA in combination with a Penrose drain resulted in 0% recurrence in revision cases. Drain use resulted in the lowest SAA recurrence rates; however, drain application was not advised due to higher complication rates (frequent wound infection [P = .003] and more [P = .002] and longer [P = .001] compression dressing use). CONCLUSION: SAA could be the preferable technique for preauricular sinus removal. If despite evidence, sinectomy is elected over SAA, microscope use can further decrease recurrence rates comparable to SAA levels. Level of included evidence (Ib-IV) indicates the need for a prospective study comparing surgical outcomes between techniques. Laryngoscope, 126:1535-1544, 2016.

Hyperbaric Oxygen Therapy in Acute Acoustic Trauma: A Rapid Systematic Review.

In this rapid systematic review, we studied the clinical question, What is the effect of hyperbaric oxygen therapy on hearing thresholds in patients who suffered a recent acute acoustic trauma? After screening for eligible titles and abstracts and extracting duplicates, 6 original research papers could be found. The general methodology of the studies was weak and the differences between these studies were too profound to pool the data, especially because of heterogeneity in adjuvant therapies, follow-up, and treatment protocol. The mean dB of hearing recovery in these studies ranged from 17 to 47 dB in the groups treated with hyperbaric oxygen versus 5 to 46 dB in the groups who did not receive hyperbaric oxygen therapy. We conclude that the effect of hyperbaric oxygen therapy on hearing thresholds in patients with hearing loss caused by a recent acute acoustic trauma remains unclear. A well-designed randomized controlled trial with enough power is advised to answer this clinical question.

Good agreement between parents and physician in the assessment of ear discharge in children.

Physicians often rely on parental observation of ear discharge in the follow-up after its treatment, but little is known about the reliability of this assessment. Follow-up data of trial participants treated for acute or chronic ear discharge showed a good agreement between parents' and physician's assessment, with high positive predictive values, but lower negative predictive values.

A small effect of adding antiviral agents in treating patients with severe Bell palsy.

In this evidence-based case report, the authors studied the following clinical question: What is the effect of adding antiviral agents to corticosteroids in the treatment of patients with severe or complete Bell palsy? The search yielded 250 original research articles. The 6 randomized trials of these that could be used all reported low-quality data for answering the clinical question; apart from apparent flaws, they did not primarily include patients with severe or complete Bell palsy. Complete functional facial nerve recovery was seen in 75% of the patients receiving prednisolone only and in 83% with additional antiviral treatment. The pooled risk difference of 7% (95% confidence interval, -1% to 15%) results in a number needed to treat of 14 (ie, slightly favors adding an antiviral agent). The authors conclude that although a strong recommendation for adding antiviral agents to corticosteroids to further improve the recovery of patients with severe Bell palsy is precluded by the lack of robust evidence, it should be discussed with the patient.

The diagnostic value of diffusion-weighted magnetic resonance imaging in detecting a residual cholesteatoma.

In this evidence-based case report, we address the following clinical question: What is the predictive value of diffusion-weighted magnetic resonance imaging (DW MRI) for detecting a residual cholesteatoma in patients with chronic otitis media with cholesteatoma who have previously undergone a canal-wall-up procedure? We searched for relevant synonyms for the determinant, MRI, and for the outcome, cholesteatoma, and retrieved relevant publications in Embase, PubMed, Cinahl, and Web of Science by using search terms in the title and abstract fields. The search yielded 683 records, of which 11 were relevant and valid for our clinical question. We pooled the data of the MRI findings of the included studies by adding the two-by-two tables of the individual studies. For the eight echo planar imaging (EPI) DW MRI studies, this resulted in a pooled sensitivity, specificity, positive predictive value, and negative predictive value of 68 percent, 87 percent, 81 percent, and 78 percent, respectively. For the three non-echo planar (non-EPI) DW MRI studies, the sensitivity, specificity, positive predictive value, and negative predictive value were 97 percent, 97 percent, 97 percent, and 97 percent, respectively. DW MRI, especially the non-EPI DW MRI, appears to be a rather accurate method, as opposed to a standard second-look operation, for the follow-up of patients who have undergone a canal-wall-up procedure for a chronic otitis media with cholesteatoma and who have no clinical signs of recurrent cholesteatoma.

Effect of long-term trimethoprim/sulfamethoxazole treatment on resistance and integron prevalence in the intestinal flora: a randomized, double-blind, placebo-controlled trial in children.

OBJECTIVES: The aim of this study was to test the hypothesis that trimethoprim/sulfamethoxazole selects for integron-positive and multidrug-resistant Enterobacteriaceae in the intestinal flora. METHODS: During 1 year of follow-up, antibiotic susceptibility and the presence of integrons were determined in faecal Enterobacteriaceae isolated from 99 children with chronic active otitis media, randomly assigned to treatment with trimethoprim/sulfamethoxazole or placebo (http://www.clinicaltrials.gov/; trial registration number NCT00189098). RESULTS: At 6 and 12 weeks of follow-up, 32 (91%) and 24 (67%) children in the trimethoprim/sulfamethoxazole group carried trimethoprim/sulfamethoxazole-resistant Enterobacteriaceae versus 10 (21%) and 8 (17%) children in the placebo group [rate differences (RDs): 70 (95% CI: 55; 85) and 50 (95% CI: 31; 69)], respectively. Multiresistance also increased during trimethoprim/sulfamethoxazole treatment. At 6 weeks of follow-up, the integron prevalence was 26 (79%) in the trimethoprim/sulfamethoxazole group and 10 (22%) in the placebo group [RD: 57 (95% CI: 39; 75)]. After 12 weeks the integron prevalence, and after 1 year the susceptibility levels, had returned to baseline values. CONCLUSIONS: Initially, trimethoprim/sulfamethoxazole usage was strongly associated with the appearance of integron-positive (multi)drug-resistant Enterobacteriaceae in the intestinal flora. After prolonged exposure to trimethoprim/sulfamethoxazole, however, this population of Enterobacteriaceae was substituted by a population with non-integron-associated resistance mechanisms. After trimethoprim/sulfamethoxazole was discontinued, susceptibility rates to all antibiotics returned to baseline levels.

Trimethoprim-sulfamethoxazole in children with chronic otitis media: a randomized comparison of costs and effects.

OBJECTIVE: To study the cost-effectiveness of a 6- to 12-week course of high-dose oral trimethoprim-sulfamethoxazole in children with chronic active otitis media (COM). STUDY DESIGN: Cost-effectiveness study including both direct and indirect costs alongside a randomized placebo-controlled trial. SETTING: Tertiary care university hospital in the Netherlands. PATIENTS: One hundred one children aged 1 to 12 years with a documented history of COM for at least 3 months. INTERVENTION: Six to 12 weeks of oral trimethoprim-sulfamethoxazole 18 mg/kg twice daily versus placebo. MAIN OUTCOME MEASURES: Incremental cost-effectiveness in terms of costs per number needed to treat (NNT) to cure 1 patient (incremental cost-effectiveness ratio [ICER]). Curation was defined as no otomicroscopic signs of otorrhea in either ear. RESULTS: After 6 weeks of follow-up, the difference in mean cost per patient between the trimethoprim-sulfamethoxazole and placebo groups was Euro100 (US $126). The NNT was 4 (clinical effect), and the corresponding ICER was Euro400 (US $504), that is, the average extra costs to cure 1 child from otorrhea is Euro400 (US $504). After 12 weeks of follow-up, the difference in mean costs between both groups was Euro159 (US $201), the NNT was 7, and the corresponding ICER was Euro1,113 (US $1,407).The mean costs after 1 year of follow-up were Euro1,601 (US $2,021) in the trimethoprim-sulfamethoxazole group and Euro1,164 (US $1,469) in the placebo group. Because the clinical effect of trimethoprim-sulfamethoxazole disappeared after its discontinuation, we did not calculate an ICER at 1 year of follow-up. CONCLUSION: In children with active COM, direct and indirect costs of a 6- to 12-week course of high-dose oral trimethoprim-sulfamethoxazole are modest in the light of its short-term clinical benefit.

Effectiveness of trimethoprim/sulfamethoxazole for children with chronic active otitis media: a randomized, placebo-controlled trial.

OBJECTIVE: The goal was to determine the clinical effectiveness of prolonged outpatient treatment with trimethoprim/sulfamethoxazole for children with chronic active otitis media. METHODS: We performed a randomized, placebo-controlled trial with 101 children (1-12 years of age) with chronic active otitis media (defined as otorrhea for > or =12 weeks). In addition to a short course of steroid and antibiotic eardrops, children were assigned randomly to receive 6 to 12 weeks of orally administered trimethoprim/sulfamethoxazole (18 mg/kg, 2 times per day) or placebo and were monitored for 1 year. RESULTS: At 6 weeks, 28% of children in the trimethoprim/sulfamethoxazole group and 53% of children in the placebo group had otomicroscopic signs of otorrhea. At 12 weeks, these values were 32% and 47%, respectively. At 1 year, the numbers of children with otorrhea were similar in the 2 groups (25% and 20%, respectively). One child in the trimethoprim/sulfamethoxazole group developed a skin rash. Vomiting or diarrhea was reported for 9% of the trimethoprim/sulfamethoxazole group and 2% of the placebo group. Pure-tone hearing levels and health-related quality of life improved during the study but did not differ between the trimethoprim/sulfamethoxazole group and the placebo group. Pseudomonas aeruginosa was the most frequently isolated bacteria in the otorrhea samples from both groups. CONCLUSIONS: A 6- to 12-week course of high-dose, orally administered trimethoprim/sulfamethoxazole therapy is beneficial for children with chronic active otitis media. The treatment effect is most pronounced with the shorter course and disappears if administration of the medication is discontinued.

Predictors of chronic suppurative otitis media in children.

OBJECTIVE: To determine which factors predict development of chronic suppurative otitis media (CSOM) in children. DESIGN: Case-control study, with univariate and multivariate logistic regression analysis applied to determine which factors independently predict CSOM. SUBJECTS: Prognostic factors for CSOM were identified in (1) 100 children with CSOM and 161 controls aged 1 to 12 years and (2) 83 children who developed CSOM in the presence of a tympanostomy tube and 136 children with tympanostomy tubes who did not develop CSOM. RESULTS: Independent predictors for CSOM were previous tympanostomy tube insertion (odds ratio [OR], 121.4 [95% confidence interval {CI}, 38.9-379.3]); having had more than 3 upper respiratory tract infections in the past 6 months (OR, 12.2 [95% CI, 3.5-42.3]); having parents with a low education level (OR, 14.1 [95% CI, 2.9-68.6]); and having older siblings (OR, 4.4 [95% CI, 1.6-12.6]). Independent predictors for CSOM after tympanostomy tube insertion were having experienced more than 3 episodes of otitis media in the past year (OR, 4.9 [95% CI, 2.2-11.0]; attending day care (OR, 3.6 [95% CI, 1.7-7.8]); and having older siblings (OR, 2.6 [95% CI, 1.2-5.5]). CONCLUSIONS: Treatment with tympanostomy tubes is the most important prognostic factor for CSOM in children. In children who are being treated with tympanostomy tubes for persistent middle ear effusion, the most important prognostic factor for CSOM is a history of recurrent episodes of acute otitis media. This information should be taken into consideration and discussed with parents when considering insertion of tympanostomy tubes in children.

Influence of sampling technique on detection of potential pathogens in the nasopharynx.

OBJECTIVES: To determine the optimal approach for nasopharyngeal culture and to establish which approach children tolerate best. DESIGN: Cross-sectional study. SETTING: A pediatric otolaryngology department of a Dutch tertiary care hospital. PATIENTS: A cohort of 42 children with chronic suppurative otitis media. INTERVENTION: Paired nasopharyngeal samples were collected transorally and transnasally and cultured for potential aerobic pathogens. MAIN OUTCOME MEASURES: The isolation rate of both samples and the amount of discomfort measured by the visual analog scale. RESULTS: Forty-six (87%) of 53 samples obtained transnasally were culture positive vs 40 (75%) of 53 samples obtained transorally (P = .20). Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus were found more frequently with the transnasal than with the transoral approach: 34% vs 13% (P = .003), 62% vs 51% (P = .20), 30% vs 19% (P = .15), and 21% vs 11% (P = .18), respectively. Mean (SD) visual analog scale scores were 5.3 (1.0) and 3.4 (1.7) (P<.001) for the transnasal and transoral approaches, respectively. CONCLUSIONS: Although the transoral approach is better tolerated in children, the isolation rate of the transnasal approach is higher, especially for S. pneumoniae. The transnasal sampling technique should therefore be the preferred approach for detection of potential pathogens in the nasopharynx in children.

Chronic suppurative otitis media: a review.

OBJECTIVES: Chronic suppurative otitis media (CSOM) remains one of the most common childhood chronic infectious diseases worldwide. Although microbial, immunological, and genetically determined factors, as well as Eustachian tube characteristics, are supposed to be involved in the pathogenesis of CSOM, many aspects of the pathogenesis of CSOM still need to be clarified. Optimal treatment strategy has not been established yet. The objective of this review is to present and evaluate the current state of knowledge of CSOM. DESIGN: Systematic narrative review. METHODS: A PubMed search (1966-January 2005) was performed for studies on epidemiology, pathogenesis, clinical management, and complications of CSOM. All included articles were categorized according to level of evidence. RESULTS: Five hundred and fifty papers were identified, of which 79 were found to be relevant for this review. The definition of CSOM was found to vary. CSOM is a multifactorial disease. Regarding management of CSOM, there is no consensus as to what the optimal management strategy should entail. No convincing evidence is available for most medical and surgical therapies. Topical quinolones have proven effective, but need further monitoring regarding adverse effects. CONCLUSIONS AND RECOMMENDATIONS: Important goals in research of CSOM should be achieving consensus about the definition of CSOM and gaining more in-depth knowledge of the pathogenesis of CSOM, especially the role of innate and adaptive immunity. There is also a need for further well-designed studies on the effectiveness of various management strategies for CSOM.