Safety and long-term efficacy of tonsillectomy versus subtotal tonsillectomy in children with sleep disordered breathing.

OBJECTIVES: to compare safety and long-term symptoms after TE compared to Subtotal Tonsillectomy (STT). METHODS: A retrospective review data of 412 patients, one to twelve years old that underwent either TE or STT, as treatment for sleep disorder breathing, at two different medical centers. Symptoms were assessed by a questionnaire 3-5 years post-surgery. Additionally, data regarding immediate post-operative symptoms and complications were also collected. RESULTS: Long-term symptoms score was significantly lower in the TE group: 1.585 (±1.719) compared to 1.967 (±1.815) in the STT group (p = 0.033); 51.3% of patients in the ST group presented long-term SDB symptoms, compared to 40.6% in the TE group (p = 0.035); The main difference between the groups was snoring as 49% of the STT group suffered from snoring, versus 28.9% in the TE group (p < 0.001). CONCLUSIONS: TE showed an advantage over STT in resolving snoring in the long term.

Pediatric cochlear implants in prelingual deafness: medium and long-term outcomes.

Unfortunately, no large-scale, well-designed, comprehensive studies on medium and long-term effect of cochlear implants in prelingual children exist. Furthermore, the few studies listed have addressed different aspects of this issue, in a non-standardized manner. With the question of outcomes becoming so important in modern medicine, standardized reporting methods are essential. This would enable a fair comparison between the different commercial devices and between rehabilitation-education methods. The studies presented above were published between 1999 and 2008. Due to the long follow-up period required for reporting medium and long-term outcomes, they actually represent patients implanted one and two decades ago. At present and in the near future, we may expect better results from patients who were implanted in the last few years for several reasons: a) superior cochlear implants with better coding strategies; b) developments in rehabilitation and higher awareness among parents and staff; c) better health care and universal screening programs, leading to implants being performed in an earlier age; and d) a high rate of performing bilateral cochlear implants (either simultaneously or sequentially) in the last decade, which accomplishes even better results compared to unilateral implants. From the studies reviewed above, mainstreaming the child who has auditory-verbal and oral communication is the preferred educational setting for maximizing the medium and long-term benefit from a cochlear implant. Hearing and speech skills continue to improve many years after the implant. Non-use and failure rates (as reported by the authors from the medical centers and not solely by the cochlear implant manufacturers) are low, ranging from 1% to 2.7% per year. Overall, patients have a high rate of employment, close to that of the general population. However, they may be less satisfied, as the individual and the parents may feel compromised by their communication skills.

[The Hebrew dizziness handicap inventory].

BACKGROUND: The dizziness handicap inventory (DHI) has become a well accepted method for specifically assessing the quality of life among dizzy patients and in evaluating the results of different types of therapy, especially of vestibular rehabilitation programs. OBJECTIVE: To assess the reliability of a translated Hebrew version of the DHI (HDHI) on a cohort of patients attending a tertiary dizziness clinic. METHODS: A double translation method was applied on the original DHI. Consecutive patients with symptoms of dizziness lasting at least six months were included. HDHI questionnaires were completed by patients on three occasions: while waiting to be examined, after the examination and one week later. Internal consistency reliability of each questionnaire and test- retest reliability between the questionnaires were analyzed on the total score and for each of the emotional, functional and physical subgroups of the questionnaires. RESULTS: Thirty-one patients completed all three questionnaires. Internal consistency reliability of the three subgroups of questions: physical, emotional and functional in each of the three questionnaires were all high (Cronbach's Alpha coefficient 0.83-0.96). The test- retest reliability, the correlation between the total DHI scores of the first and second questionnaire (same day) showed a correlation coefficient of 0.96, and between the first and third questionnaire (7 days apart) was 0.94, with P values of < 0.01. The correlation coefficient of the subgroups ranged from 0.93 to 0.97. CONCLUSION: The HDHI is a reliable test of dizzy patients' symptoms and may be applied in patient care and for reporting on their follow-up.

Rates of tympanic membrane closure in double-tympanocentesis studies.

BACKGROUND: Data on the outcome of tympanic membrane (TM) closure after tympanocentesis in acute otitis media (AOM) patients is limited. OBJECTIVES: To analyze the dynamics of TM perforation closure after 1 or 2 tympanocentesis procedures performed at diagnosis and during AOM treatment. PATIENTS AND METHODS: Study population included 113 children enrolled in 4 double-tympanocentesis studies. Only the files of patients whose first and second examination were performed by the same 2 otorhinolaryngologists were analyzed. Middle ear fluid (MEF) was cultured on day 1 and days 4-6, the latter only in initially culture-positive patients. Patients were also examined on days 11-14 and followed until days 22-28. RESULTS: Ninety-three (82%) patients underwent tympanocentesis on days 4-6; 103 (91%) and 95 (84%) were evaluable on days 11-14 and 22-28, respectively. One hundred seventy-three ears underwent tympanocentesis on day 1 and 139 on days 4-6. Ninety-seven (86%) patients had positive MEF cultures. One hundred fifty-three (88%) tympanocentesis procedures performed at enrollment were closed on days 4-6. No differences were recorded in the closure rates as function of patient age, previous AOM history, MEF culture positivity, pathogens isolated at enrollment, and pathogen eradication on days 4-6. The 20 eardrums still open on days 4-6 were closed on days 11-14. Eleven (9%) of the evaluable ears tapped on days 4-6 were not closed on days 11-14 and 9 of 10 were closed on days 22-28. CONCLUSIONS: TM perforation closed in most cases within a few days regardless of patient and disease characteristics, and 2 consecutive tympanocentesis procedures performed at short-time intervals are associated with good TM closure rates.

A prospective randomized double-blind trial of fibrin glue for reducing pain and bleeding after tonsillectomy.

OBJECTIVES: Varying surgical techniques as well as a large selection of analgesics and other medications have been evaluated over the years in the hopes of reducing post-tonsillectomy pain. Several publications in recent years have demonstrated the efficacy of fibrin glue in reducing post-tonsillectomy bleeding and pain. The objectives of this study were to evaluate the effect of fibrin glue on pain and bleeding after tonsillectomy. STUDY DESIGN: A prospective randomized double-blind study was performed on 168 consecutive patients undergoing tonsillectomy for obstructive sleep apnea and chronic tonsillitis. METHODS: Patients were randomly assigned to the treatment protocol. In the study group, the tonsillar beds were coated with fibrin glue (Quixil, OMRIX biopharmaceuticals) at the end of the operation. Patients in the controlled group underwent tonsillectomy without the use of fibrin glue. The patients were then monitored for postoperative bleeding, and a patient-based pain assessment instrument was used to evaluate pain, ability to eat and analgesics consumption for 10 days after surgery. RESULTS: Ninety-six patients returned for postoperative follow up and filled in the questionnaire. As our medical center is the only hospital in the southern district of Israel and we hospitalize every person who presents with post-tonsillectomy bleeding, we can assume that any patient from either group who presented with post-tonsillectomy bleeding would be familiar to us. Analysis showed that no statistically significant differences relating to postoperative pain, bleeding, use of analgesics and postoperative eating resumption were detected between the patients treated with fibrin glue and controls. CONCLUSIONS: We cannot substantiate a significant beneficial effect of fibrin glue in post-tonsillectomy pain control, prevention of bleeding or facilitating eating and thus find no indication for the routine use of fibrin glue in tonsillectomy.

Cleidocranial dysplasia - review with an emphasis on otological and audiological manifestations.

Cleidocranial dysplasia is a rare developmental abnormality of bone that affects both the skeleton and the temporal bone. It is genetically characterized and the clinical signs and symptoms can be diverse. Aural pathologies may be the presenting symptoms of the disease. We reviewed the up to date literature on the syndrome with an emphasis on the otological and audiological manifestation.

Bilateral consecutive blindness due to sphenoid sinus mucocele with unilateral partial recovery.

BACKGROUND: We present an interventional case report of a rare occurrence of sphenoid sinus mucocele causing bilateral consecutive blindness with unilateral partial recovery after endoscopic surgery. METHODS: A 64-year-old woman with known sphenoid sinus mucocele and right blindness was referred because of an acute drop of vision to hand motion in her only-seeing left eye over 5 days. Imaging revealed a large mucocele enlarging the sphenoid sinus, eroding the base of the skull, protruding into the cranial cavity, and compressing the left optic nerve. RESULTS: Urgent endoscopic sphenoidotomy was performed. Several hours after the procedure, visual acuity was partially recovered in the left eye. INTERPRETATION: Sphenoid sinus mucoceles can cause bilateral blindness. A high index of suspicion and urgent imaging studies are necessary. Because visual recovery depends on prompt diagnosis and surgical intervention, a close collaboration between otolaryngologists and ophthalmologists is crucial.

The silent sinus syndrome.

Patients with silent sinus syndrome typically present for investigation of facial asymmetry. Unilateral, spontaneous enophthalmos and hypoglobus are the prominent findings at examination. Imaging of the orbit and sinuses characteristically show unilateral maxillary sinus opacification and collapse with inferior bowing of the orbital floor. It has been suggested that SSS is due to hypoventilation of the maxillary sinus secondary to ostial obstruction and sinus atelectasis with chronic negative pressure within the sinus. Treatment involves functional endoscopic sinus surgery for reestablishing a functional drainage passage, and a reconstructive procedure of the floor of the orbit for repairing the hypoglobus and cosmetic deformity. Ophthalmologists, otorhinolaryngologists, and radiologists must be familiarized with this relatively newly reported disease.

Rhinolithiasis: a very late complication after dacryocystorhinostomy with rubber-gum and polyethylene stenting.

PURPOSE: To describe a rare case of rhinolith formation 21 years after dacryocystorhinostomy (DCR) with rubber gum and polyethylene tubing surgery. DESIGN: Interventional case report. METHODS: A 23-year-old-woman underwent uneventful left DCR with rubber gum and polyethylene tubing for chronic dacryocystitis. Twenty-one years later, she presented with purulent rhinorrhea, nasal obstruction, and facial pain. Computed tomography revealed a radiopaque density in the left nasal cavity. RESULTS: A rubber gum foreign body embedded with granulation tissue and a huge rhinolith was removed endoscopically through the anterior nares. After surgery, the patient reported immediate and complete relief of symptoms. CONCLUSION: Rhinoliths can develop progressively several years after DCR as a result of foreign body reaction to rubber gum or polyethylene tubing. This rare complication should be ruled out in patients complaining of purulent rhinorrhea who underwent DCR with tubing before the early 1980s.

Endoscopic orbital decompression for Graves' ophthalmopathy.

BACKGROUND: In patients with Graves' ophthalmopathy, orbital decompression surgery is indicated for compressive optic neuropathy, severe corneal exposure, or for cosmetic deformity due to proptosis. Traditionally this has been performed through a transantral approach, but the associated complication rate is high. More recently, endoscopic orbital decompression has been performed successfully with significantly fewer postoperative complications. OBJECTIVE: To report our experience of endoscopic orbital decompression in patients with severe Graves' ophthalmopathy. METHODS: Three patients (five eyes) underwent endoscopic orbital decompression for Graves' ophthalmopathy at Soroka Medical Center between the years 2000 and 2002. The indications for surgery were compressive optic neuropathy in three eyes, severe corneal exposure in one eye, and severe proptosis not cosmetically acceptable for the patient in one case. An intranasal endoscopic approach with the removal of the medial orbital wall and medial part of the floor was performed. RESULTS: In all five eyes an average reduction of 5 mm in proptosis was achieved. Soon after surgery, visual acuity improved in the three cases with compressive optic neuropathy, and exposure keratopathy and cosmetic appearance also improved. The diplopia remained unchanged. No complications were observed postoperatively. CONCLUSIONS: Endoscopic orbital decompression with removal of the medial orbital wall and medial part of the floor in the five reported eyes was an effective and safe procedure for treatment of severe Graves' ophthalmopathy. A close collaboration between ophthalmologists and otorhinolaryngologists skilled in endoscopic sinus surgery is crucial for the correct management of these patients.

Acute mastoiditis in children under 15 years of age in Southern Israel following the introduction of pneumococcal conjugate vaccines: a 4-year retrospective study (2009-2012).

OBJECTIVES: To describe the epidemiologic, microbiologic, clinical and therapeutic aspects of acute mastoiditis (AM) in children <15 years of age during the 4-year period (2009-2012) following the introduction of pneumococcal conjugate vaccines in Israel. PATIENTS AND METHODS: The medical records of all children with a discharge diagnosis of AM were reviewed. RESULTS: A total of 66 AM episodes occurred in 61 patients. Forty-four (66.6%) cases occurred among patients <4 years, recent acute otitis media (AOM) history was reported in 27.1% and 28.8% patients received previous antibiotics for AOM. Postauricular swelling, postauricular sensitivity, protrusion of auricle and postauricular edema (93.8%, 90.6%, 85.9% and 95.7%, respectively) were the most common signs of AM. Leukocytosis >15,000 WBC/mm(3) was found in 39 (59.1%) cases. Cultures were performed in 52/66 episodes (positive in 27, 51.92% episodes), with recovery of 32 pathogens. The most frequently isolated pathogens were Streptococcus pneumoniae (15/52, 28.85%), Streptococcus pyogenes (9, 17.3%) and nontypeable Haemophilus influenzae (5, 9.62%). Eight (53.3%) S. pneumoniae isolates were susceptible to penicillin. Mean incidence of overall and pneumococcal AM were 11.1 and 2.58 cases/100000, with no significant changes during the study years. Surgical intervention was required in 19 (28.8%) patients. CONCLUSIONS: (1) AM occurs frequently in patients without previous AOM history and with no previous antibiotic treatment; (2) S. pneumoniae and S. pyogenes continued to be the main etiologic agents of AM during the postvaccination period; (3) No changes were recorded in overall AM incidence and in pneumococcal AM incidence during the postvaccination period.

Beneficial effects of caloric vestibular stimulation on denial of illness and manic delusions in schizoaffective disorder: a case report.

INTRODUCTION: Preliminary data suggests that caloric vestibular nerve stimulation (CVS) single session application of cold water to the left ear induces a clinically significant, short-lived beneficial effect on specific types of illness denial (i.e., anosognosia) and delusions (i.e., somatic type). METHODS: We recently studied the effect of left versus right ear ice water (4°C) CVS on delusions and insight of illness in a patient with manic episode due to schizoaffective disorder. The patient was evaluated at baseline, immediately after the CVS, and then at 20 minutes, 60 minutes, and 24 hours. The method was first applied to one ear and 4 days later to the other. To assess whether the effect is specific to mania we employed the same procedure in two other patients with schizophrenia who also demonstrated delusions and impaired insight. RESULTS: All three patients showed a difference favoring left versus right ear CVS that was maintained for 20 minutes, and diminished over a 60 minute period. EEG analyses showed a numerically non-significant increase in bilateral frontal and central alpha EEG band activation (more pronounced in the right hemisphere) with left but not right ear CVS 5 minutes after the CVS, and that diminished after 20 minutes. DISCUSSION: The results suggest that left versus right CVS may have a short lived beneficial effect on manic delusions and insight of illness that seem to appear in other types of psychoses (i.e., schizophrenia). CONCLUSION: These preliminary results suggest that single session CVS may have short lived beneficial effects in mania and perhaps in other types of psychoses. Further research is mandatory.

Relation between peritonsillar infection and acute tonsillitis: myth or reality?

OBJECTIVE: To investigate the relationship between tonsillar and peritonsillar infections. STUDY DESIGN: Retrospective population-based study and a retrospective case series review. SETTINGS: Tertiary academic medical facility. SUBJECTS AND METHODS: All individuals hospitalized with peritonsillar abscess (PTA) or peritonsillar cellulitis (PTC) during 2004-2008 were reviewed. Patient age, gender, diagnosis of PTA or PTC, recurrence, and date of presentation were recorded. In addition, a database of patients diagnosed in the community with acute tonsillitis (AT) was reviewed for the same time period. The weekly number of patients with AT was recorded, and a comparison between incidence of tonsillar infections and peritonsillar infection was performed. RESULTS: A total of 685 patients were hospitalized with either PTA (467) or PTC (218). Incidence of both upper respiratory infections and AT peaked in January and February of every year with a nadir in August. In contrast, PTA and PTC showed a consistent rate of infection throughout the year. Likewise, assessment based on weekly intervals showed that peaks of PTA and PTC did not follow those of acute tonsillitis with a 1 to 2 weekly lag as would be expected if peritonsillar infection is a complication of AT. Rather, an association between peritonsillar infection and tonsillitis was found within the same week (P = .04). CONCLUSION: Higher rates of occurrence of PTA or PTC following AT outbreaks were not found. These results lend further support to the theory that peritonsillar infection is associated not only with complications of AT but may occur from infection of Weber glands or other unknown causes.