Human Nasal and Lung Tissues Infected Ex Vivo with SARS-CoV-2 Provide Insights into Differential Tissue-Specific and Virus-Specific Innate Immune Responses in the Upper and Lower Respiratory Tract.

The nasal mucosa constitutes the primary entry site for respiratory viruses, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While the imbalanced innate immune response of end-stage coronavirus disease 2019 (COVID-19) has been extensively studied, the earliest stages of SARS-CoV-2 infection at the mucosal entry site have remained unexplored. Here, we employed SARS-CoV-2 and influenza virus infection in native multi-cell-type human nasal turbinate and lung tissues ex vivo, coupled with genome-wide transcriptional analysis, to investigate viral susceptibility and early patterns of local mucosal innate immune response in the authentic milieu of the human respiratory tract. SARS-CoV-2 productively infected the nasal turbinate tissues, predominantly targeting respiratory epithelial cells, with a rapid increase in tissue-associated viral subgenomic mRNA and secretion of infectious viral progeny. Importantly, SARS-CoV-2 infection triggered robust antiviral and inflammatory innate immune responses in the nasal mucosa. The upregulation of interferon-stimulated genes, cytokines, and chemokines, related to interferon signaling and immune-cell activation pathways, was broader than that triggered by influenza virus infection. Conversely, lung tissues exhibited a restricted innate immune response to SARS-CoV-2, with a conspicuous lack of type I and III interferon upregulation, contrasting with their vigorous innate immune response to influenza virus. Our findings reveal differential tissue-specific innate immune responses in the upper and lower respiratory tracts that are specific to SARS-CoV-2. The studies shed light on the role of the nasal mucosa in active viral transmission and immune defense, implying a window of opportunity for early interventions, whereas the restricted innate immune response in early-SARS-CoV-2-infected lung tissues could underlie the unique uncontrolled late-phase lung damage of advanced COVID-19. IMPORTANCE In order to reduce the late-phase morbidity and mortality of COVID-19, there is a need to better understand and target the earliest stages of SARS-CoV-2 infection in the human respiratory tract. Here, we have studied the initial steps of SARS-CoV-2 infection and the consequent innate immune responses within the natural multicellular complexity of human nasal mucosal and lung tissues. Comparing the global innate response patterns of nasal and lung tissues infected in parallel with SARS-CoV-2 and influenza virus, we found distinct virus-host interactions in the upper and lower respiratory tract, which could determine the outcome and unique pathogenesis of SARS-CoV-2 infection. Studies in the nasal mucosal infection model can be employed to assess the impact of viral evolutionary changes and evaluate new therapeutic and preventive measures against SARS-CoV-2 and other human respiratory pathogens.

The admission patterns of octogenerians nonagenerians and centenarians to the Department of Otoloaryngology.

Life expectancy in Israel has risen by almost 6 years during the last 25 years, and the proportion of people 65 years of age or older is expected to reach 12 % of the total population by 2020. A substantial increase in the workload for Otolaryngologists and Head and Neck surgeons is anticipated. Our goal was to characterize the admissions of patients 80 years of age and older to the Department of Otolaryngology, Head and Neck Surgery in a tertiary medical center. The study group included all patients 80 years of age and older who were admitted to the Department of OTOHNS in our institute between 2009 and 2013. There were two control groups for comparison divided by age; one group 40-59 years old and the other group 60-79 years old. There were 385 admissions of 317 patients aged 80-103 years (4.2 % of overall admissions). Over the study period, admissions of patients over 80 years increased on average by 3 % per annum (p = 0.4), and those patients over 90 years old by 52 % per annum (p < 0.001). The most common indication was HN malignancy (28.8 %) followed by otologic disorders (22.0 %). Of the overall 158 operations conducted, 131 patients (82.9 %) underwent elective procedures (mainly oncology) and 27 patients (17.1 %) underwent emergent procedures. The distribution of the reasons for admission of the patients older than 80 years is surprisingly different from that of the "younger" patients. With life expectancy rising, our study predicts a workload increase mainly in the HN oncologic and otologic services.

[PAPILLARY THYROID CARCINOMA TREATMENT - IS THE PENDULUM SHIFTING?]

INTRODUCTION: The incidence of papillary thyroid carcinoma has been on the rise in the past few decades while the disease specific mortality remains stable. During prophylactic central neck dissection (level 6), an average of 60% positive occult lymph nodes metastasis are found, hence the justification for performing a prophylactic central neck dissection. The opponents for performing neck dissection claim that the disease specific mortality is low regardless of the operation and that adding a neck dissection will, significantly, increase surgical morbidity. Guidelines regarding prophylactic central neck dissection differ between countries and cultures. The difficulty to determine unequivocal guidelines is due to the scarcity of randomized controlled trials to assess the effectiveness of prophylactic neck dissection. In this literature review we will explore data in favor and against prophylactic central neck dissection for patients with papillary thyroid carcinoma.

Why do geriatric patients attend otolaryngology emergency rooms?

BACKGROUND: With an aging population, health care of the elderly population is becoming increasingly important; however, the principles of geriatric medicine and issues of concern specific to geriatric otolaryngologic patients have not been widely applied. OBJECTIVES: To qualitatively analyze otolaryngological (EN1) emergencies in a geriatric population in an ENT emergency department (ED). METHODS: In this retrospective study the medical records of patients > or = 65 years of age who attended our ENT-ED between 3 pm and 8 am and who were observed and/or treated by the on-call otorhinolaryngologist at Sheba Medical Center in 2009 were reviewed for age, gender, main complaint, and preliminary diagnosis. Allergic reactions, balance disorders, epistaxis, head/facial trauma and swallowing-related complaints were considered true emergencies. RESULTS: The staff in the ENT-ED examined and treated 1-10 geriatric patients daily (mean 2.35). A total of 597 subjects met the study entry criteria (median age 75 years); 16.6% were > or = 85 years old. There was approximately equal gender representation. More elderly patients presented to the ENT-ED on the weekends (37.9% of the total) compared to weekdays (62.1%). There were 393 patients (65.8%) with true emergencies, of which epistaxis, balance disorders and head and facial trauma were the most common diagnoses (20.1%, 15.75% and 13.7%, respectively), while 46.5% of all vestibulopathy cases involved benign paroxysmal positional vertigo. CONCLUSIONS: More than 65% of visits of the elderly presenting to ENT-ED involve true emergencies. This growing population may benefit from the presence of geriatric specialists in emergency departments.

Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?

OBJECTIVES: Airway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy. METHODS: Retrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1st 2010 and October 31st 2019 in our center. RESULTS: One-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Patients who didn't receive an elective tracheostomy were younger and had a shorter duration of postoperative hospitalization. Seven patients suffered from tracheostomy- related complications, all of them underwent elective tracheostomy and none were from the late tracheostomy group. CONCLUSIONS: Our results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis.

The role of economics and weekend meals in impacted fish bone occurrence in central Israel.

BACKGROUND: The fish-eating habits of Israelis who present with impacted fish bones in the aerodigestive tract are unknown. OBJECTIVES: To retrospectively investigate the relation between an impacted fish bone in the aerodigestive tract, the species of fish, and the place of occurrence in an Israeli population. METHODS: The current prospective observational study included all patients with aerodigestive impacted fish bones who were treated in our emergency department from 1 September 2008 to 30 September 2009. The data retrieved from their medical records included age, gender, place of event (at home or elsewhere), species of fish, and method of removing the bone. RESULTS: A total of 108 patients--aged 1.5-87 years (median 48 years), 52.8% female--met the study criteria. Most (87%) of the events occurred at home, and 50.9% occurred during the weekend (Friday-Saturday). The bones were from low-priced fish (e.g., carp, hake) in 62% of the cases, high-priced fish (e.g., salmon, red snapper) in 30.5%, and of unknown species in 10.2%. The proportion of cases in which the fish bone was from a high-priced fish eaten out of the home was significantly higher than the cases in which a low-priced fish was eaten at home (64.3% vs. 22.3%, P = 0.04). One hundred bones were removed during direct oral inspection and 8 bones were removed under general anesthesia by endoscopy. CONCLUSIONS: Most fish bone impactions in the aerodigestive tract in central Israel involve low-priced fish and take place at home over the weekend.

Obviating the need for sternotomy: Safety and effectiveness of microdebrider use for retrosternal goiter.

BACKGROUND: Most retrosternal goiter surgical removal can be performed via a transcervical approach. However, it is often a challenging procedure, which might include sternotomy. METHODS: We describe a surgical technique using a microdebrider for intracapsular volume reduction that precedes an extracapsular thyroidectomy, thereby avoiding the need for sternotomy, with decreased morbidity and risk. The procedure is described in detail with 2 representative cases and a summary of our experience in 26 cases. RESULTS: Twenty-six patients with retrosternal goiters are included in our cohort. None of the patients needed a sternotomy, and no major or permanent complications occurred. The average length of hospital stay was 4.30 days after total thyroidectomy and 2.57 days after hemithyroidectomy. CONCLUSION: The use of a microdebrider for intracapsular volume reduction thyroidectomy is extremely helpful for transcervical removal of retrosternal goiters in selected cases, and avoids the need for sternotomy, which is especially beneficial in elderly patients, and those with comorbidities for whom sternotomy should be avoided.

Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?

Abstract Objectives: Airway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy. Methods: Retrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1st 2010 and October 31st 2019 in our center. Results: One-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Conclusions: Our results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis. Level of evidence: 4. HIGHLIGHTS Airway management following maxillofacial microvascular reconstruction is complex. Lack of consensus exists regarding the optimal airway management perioperatively. Routine use of tracheostomy is unnecessary. Tracheostomy should be considered on a case-to-case basis.

Medical Information Exchange: Pattern of Global Mobile Messenger Usage among Otolaryngologists.

OBJECTIVE: Information technology has revolutionized health care. However, the development of dedicated mobile health software has been lagging, leading to the use of general mobile applications to fill in the void. The use of such applications has several legal, ethical, and regulatory implications. We examined the experience and practices governing the usage of a global mobile messenger application (WhatsApp) for mobile health purposes in a national cohort of practicing otolaryngologists in Israel, a known early adaptor information technology society. METHODS: Cross-sectional data were collected from practicing otolaryngologists and otolaryngology residents via self-administered questionnaire. The questionnaire was composed of a demographic section, a section surveying the practices of mobile application use, mobile health application use, and knowledge regarding institutional policies governing the transmission of medical data. RESULTS: The sample included 22 otolaryngology residents and 47 practicing otolaryngologists. Of the physicians, 83% worked in academic centers, and 88% and 40% of the physicians who worked in a hospital setting or a community clinic used WhatsApp for medical use, respectively. Working with residents increased the medical usage of WhatsApp from 50% to 91% (P = .006). Finally, 72% were unfamiliar with any institutional policy regarding the transfer of medical information by personal smartphones. DISCUSSION: Mobile health is becoming an integral part of modern medical systems, improving accessibility, efficiency, and possibly quality of medical care. IMPLICATIONS FOR PRACTICE: The need to incorporate personal mobile devices in the overall information technology standards, guidelines, and regulation is becoming more acute. Nonetheless, practices must be properly instituted to prevent unwanted consequences.

Is laterality of malignant otitis externa related to handedness?

Malignant otitis externa (MOE) usually affect patients with systemic diseases, especially diabetes mellitus. MOE is a mainly unilateral disease. Given that around 90% of human adults are right-handed we hypothesized that hand preference might be one of the factors involved in the development of MOE. All 38 of the patients whom we treated for MOE between August 2009 and November 2012 (28 males and 10 females, age range 43-91 years) had poorly controlled diabetes mellitus, and all of them reported itching in the involved ear. The difference in the laterality of MOE among our right- and left-handed subjects was significant: right hand dominance was associated mostly with right-sided MOE (24/34) and left hand dominance was associated with occurrence of MOE only in the left ears (4/4, p=0.006). These findings point to an unexpectedly strong relationship between the patient's handedness and laterality of his/her MOE, leading us to hypothesize that the development of MOE might be attributable to self-inflicted local trauma to the ear canal on the same side as the dominant hand.

Suprameatal approach for cochlear implantation in children: our experience with 320 cases.

OBJECTIVE: To summarize our experience with the 320 children who underwent cochlear implantation by the suprameatal approach (SMA). METHOD: The SMA involves entering the middle ear by retroauricular tympanotomy. After drilling of the cochleostomy and of the suprameatal tunnel, the electrode is passed through the suprameatal tunnel underneath to the chorda tympani and lateral to the incus into the cochleostomy. RESULTS: The following implant-related complications required explantation with subsequent reimplantation: foreign body reaction (0.6%), allergy to implant (0.3%), and protrusion of the positioner (0.3%). Post-traumatically displaced magnets were reinserted in 3 (0.9%) children. All the vestibular (5.3%) and wound (3.1%) problems were considered as being patient-related and resolved spontaneously or were managed conservatively. There were no surgery-related complications and no cases of mastoiditis developed among the children implanted with the SMA. CONCLUSIONS: The SMA enables a decreasing the rate of surgery-related complications and safe electrode insertion.

Surgical and medical complications in different cochlear implant devices.

CONCLUSION: There were no surgery-related complications among the patients in the current study. Positioner and removable magnets have been associated with postoperative problems, and the silicone devices were the only ones found by us to cause foreign body and allergic reactions. OBJECTIVES: To evaluate the complication rate in patients who were implanted with cochlear devices manufactured by different companies. PATIENTS AND METHODS: This retrospective study included all the patients who underwent cochlear implantation (138 Nucleus, 105 Med-El and 14 Clarion devices) via the suprameatal approach in our department during 2001-2007 and followed up for at least 18 months. Complications such as magnet displacement, foreign body reaction and protrusion of the positioner were considered as being implant-related. Allergy to implant, cholesteatoma, perforated tympanic membrane, intraoperative cerebrospinal fluid (CSF) leakage, wound breakdown, haematoma or seroma, and vestibular disturbances were considered to be patient-related. RESULTS: Vestibular and wound problems emerged as the most common complications, but there were no significant differences in their rate of occurrence among the various devices. Explantation of the device was required in one case of foreign body reaction, one case of allergy to implant and one case of extrusion of the positioner followed by device failure.

Less education and blue collar employment are related to longer time to admission of patients presenting with unilateral sudden sensorineural hearing loss.

OBJECTIVES/HYPOTHESIS: To investigate the relation between demographic characteristics and time to admission following unilateral sudden sensorineural hearing loss (SSNHL). STUDY DESIGN: Prospective observational study. METHODS: All patients with unilateral SSNHL in our departmental database (June 1, 2006-June 31, 2008) were studied. Data on their age, gender, marital status, household density, educational status, occupation, time to admission, and audiologic findings were retrieved from their medical records and compared. The study cohort was divided into two groups according to occupation, blue collar or white collar, and years of academic education. A comparative analysis between multiple variables and occupational groups and a multivariate analysis were conducted. RESULTS: Of the cohort aged 24 to 78 years, 46% were categorized as white collar. Within no more than 3 days from the first presenting symptom of SSNHL, 71.7% of the white collar group were admitted, as compared to 29.5% of the blue collar group. Multivariate analysis for late admission (>3 days) end-point prediction showed that lower education level was associated with a later admission time (odds ratio 0.15, 95% confidence interval 0.03-0.74; P = .02), even after adjusting for confounding factors (e.g., degree of hearing loss). CONCLUSIONS: Less educated individuals or blue collar workers who suffer a unilateral SSNHL tend to seek medical help later compared to more highly educated or white collar workers.

Adverse outcomes in patients with community acquired pneumonia discharged with clinical instability from Internal Medicine Department.

There are well established admission criteria for patients suffering from community-acquired pneumonia, yet the clinical tool for decision to discharge the hospitalized patient is lacking. Continuous pressure to reduce hospital expenditures can lead to a premature discharge of unstable patients. The current study assessed the impact of clinical instability at discharge on short-term outcomes. Demographic data, background disease, laboratory tests results and PORT score were assessed prospectively. On the last day of the hospitalization 7 physiological parameters of instability were evaluated. 60 d composite mortality and readmission rate was a primary outcome measure. Of the 373 patients, 22% were discharged with 1 or more instabilities, of whom 26.8% reached primary outcome within 60 d, compared to 8.2% of patients with no instabilities. 60 d death rate was 2.1% in the former group, compared to 14.6% in the unstable patients (p<0.001). Instability on discharge remained a significant prognosticator of adverse outcome (odds ratio 3.5; 95% CI 1.8-6.8) after adjustment for pneumonia severity and baseline comorbidity. We concluded that discharging an unstable patient hospitalized with pneumonia is associated with elevated risk of death or readmission within 60 d. Pneumonia guidelines should include objective criteria for judging patients' stability and promptness for discharge.