Abraham Goldfarb

Changing Trends of Acute Otitis Media Bacteriology in Central Israel in the Pneumococcal Conjugate Vaccines Era

Background: The widespread use of 7-valent pneumococcal conjugate vaccine (PCV7) has changed acute otitis media (AOM) bacteriology. Only scattered data with regard to this effect of PCV13 have been published so far. Methods: We retrospectively identified children <6 years of age who presented to our hospital with AOM, and had middle ear fluid (MEF) cultures obtained during tympanocentesis or from spontaneous otorrhea during 2008–2013, when PCV7 (2009) and PCV13 (2010) were gradually introduced in the Israeli National Immunization Program. Data were extracted for demographics, clinical and microbiologic parameters, according to vaccination status. Results: Of the 295 eligible AOM episodes reported in 279 children, 224 (76%) had MEF cultures from tympanocentesis and 71 (24%) from spontaneous otorrhea. Boys and children <2 years of age contributed 178 (60%) and 219 (74%) AOM episodes, respectively. Acute mastoiditis complicated 58 (20%) of these episodes. None of the children were PCV immunized in 2008, but >90% had received ≥1 PCV dose(s) by 2011 or later. Of the 106 (36%) MEF cultures which tested positive for otopathogens, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and multiple bacteria grew in 60 (57%), 39 (37%), 2 (2%) and 5 (5%) episodes, respectively. S. pneumonia-positive MEF culture rate in unimmunized children (31, 69%) was significantly higher than in PCV7-immunized children (22, 59%) or PCV13-immunized children (12, 50%), P = 0.04 and P = 0.02, respectively. Conclusion: PCV7 and PCV13 implementations in the Israeli National Immunization Program were associated with a rapid reduction of “severe” pneumococcal AOM episodes.

Luc's Abscess: The Return of an Old Fellow

Objective: Mastoiditis, subperiosteal abscess and sigmoid vein thrombosis are the most common suppurative complications of acute otitis media (AOM). Lucs abscess, a subperiosteal temporal collection, is an infrequent complication with a particularly benign course. Patients: Two children, aged 5 years, presented with AOM complicated by an atypical abscess deep to the temporalis muscle, with no evidence for mastoid or zygomatic arch involvement. Intervention(s): Computed tomographic scan was performed in only 1 child. In both children, treatment included antibiotic therapy, grommet insertion, and local surgical drainage of the temporalis abscess. In addition, a cortical mastoidectomy was performed in the patient who did not undergo computed tomography, based on clinical assessment. Main Outcome Measure(s): Clinical improvement, resolution of symptoms. Results: Both patients recovered shortly following the surgical drainage. Mastoidectomy was poor in findings and was concluded as redundant. Conclusion: Lucs abscess is associated with relatively little morbidity and requires a more limited surgical intervention. Computed tomographic scan is of great value to evaluate the extent of the disease and prevent needless mastoidectomy.

GENETICS OF DEAFNESS: RECENT ADVANCES AND CLINICAL IMPLICATIONS

Genetic research into the causes of deafness has advanced considerably in the last years. Progress has been made in both discovering loci and cloning genes associated with syndromic and non-syndromic hearing loss. To date, close to 75 loci have been identified and 29 genes have been cloned for non-syndromic deafness. The proteins these genes encode range from transcription factors to molecular motors to ion channels. We review the recent discoveries and discuss the impact of this research.

To proceed or not to proceed: ENT surgery in paediatric patients with acute upper respiratory tract infection.

BACKGROUND Upper respiratory tract infection is the most common non-preventable cause of surgery cancellation. Consequently, surgeons and anaesthesiologists involved in elective ENT surgical procedures frequently face a dilemma of whether to proceed or to postpone surgery in affected children. METHODS A literature review was conducted and a practical assessment algorithm proposed. CONCLUSION The risk-benefit assessment should take into consideration the impact of postponing the surgery intended to bring relief to the child and the risks of proceeding with general anaesthesia in an inflamed airway. The suggested algorithm for assessment may be a useful tool to support the decision of whether to proceed or to postpone surgery.

Impact of Pneumococcal Conjugate Vaccines on Selected Head and Neck Infections in Hospitalized Israeli Children.

Background: Streptococcus pneumoniae is a major pathogen of pediatric head and neck infections (HNIs), for example, acute otitis media (AOM), acute mastoiditis, acute bacterial sinusitis and meningitis. The aim of this study was to characterize the epidemiology of pneumococcal HNIs (pHNIs) before, during and after the introduction of pneumococcal conjugate vaccines (PCVs). Methods: Children 0–16 years of age, who were hospitalized with HNIs in the pediatrics department in a general hospital between January 1, 2007, and December 31, 2014, were retrospectively identified. Study years were categorized according to the PCV introduction timeline: 2007–2008: “pre-PCV years”; 2009–2011: “transition years” and 2012–2014: “post-PCV years.” pHNIs episodes were defined if pneumococcal culture or urine antigen was positive. Children who received ≥2 doses of PCV7/PCV13 were considered as immunized. All other children were considered as unimmunized. Results: HNIs accounted for 2.5%–4.7% of the total admissions; 3%–17% of them were pHNIs. Eighty-seven pHNI episodes were identified: AOM (n = 42), acute mastoiditis (n = 28) and meningitis (n = 17). There was a downward trend in the overall incidence of HNIs, and particularly of pHNIs, in the post-PCV years. The average age and hospitalization duration of children with HNIs/pHNIs remained stable during the study years. In 2009–2010, pHNIs incidence sharply decreased, from 7 to 1.74/1000 hospitalized children/year, due to ~55% reduction of pneumococcal AOM episodes. An additional decrease was observed in the post-PCV years (1.62/1000 hospitalized children/year). Immunized children were less likely to present with pHNIs (P = 0.001) but were more likely to undergo surgery (P = 0.042). Conclusion: We observed a reduction in pHNIs incidence after PCV program implementation.

Cardiovascular Risk Factors Among Patients With Vestibular Neuritis

Objective: To investigate the correlation between cardiovascular risk factors (CVRFs) and vestibular neuritis (VN) in hospitalized adult patients. Methods: A cross-sectional retrospective study was conducted in a tertiary hospital setting. The medical records of patients (aged over 18 years old) who were hospitalized between the years 2005 and 2014 with the diagnosis of VN were retrieved. Inclusion criteria were: (1) acute vertigo lasting for at least 24 hours, (2) absence of auditory complaints, (3) horizontal unidirectional nystagmus present during physical examination, and (4) absence of neurological symptoms or signs. The ratio of CVRFs among VN patients was compared to the ratio of those among the general Israeli population. Results: A significantly higher prevalence of CVRFs was found among VN hospitalized patients in comparison to the general population (P < .05). Furthermore, a significant correlation (P < .001) was found between the patients’ age and the number of CVRFs (r = .387). A positive correlation (r = .643) was found between the number of CVRFs and VN in each age group (P = .119). Conclusion: There may be a possible interrelation between CVRFs and VN. This correlation can be caused by occlusion of small blood vessels leading to labyrinthine ischemia and apparition of symptoms of VN.

Intra-Auricular Sinus: First Description of a Variant of the Pre-Auricular Cyst

OBJECTIVE The aim of this study was to describe a rare intra-auricular sinus. An otherwise healthy 15-year-old girl presented with recurrent infections in her right pinna from early infancy. Physical examination revealed a draining sinus which opened to the descending helical limb, while its cystic component was entrapped within the cartilaginous antitragus. Comprehensive surgical excision was performed after the tract and the more distal cyst was delineated. Surgical pathology revealed a true sinus, measuring 2 cm. Follow-up was unremarkable. DISCUSSION In addition to the two previously described variants of pre-auricular cyst: the classic variant (the pit is anterior to the external auditory canal) and the postauricular variant (the pit is behind the ascending limb of the helix), we suggest a third variant which opens to the descending helical rim.

The Middle Ear Cleft Status in a “Natural” Cohort With Eustachian Tube Dysfunction

BACKGROUND The Eustachian tube (ET) has a major role in the middle ear (ME) pressure homeostasis. ET dysfunction is the accepted paradigm for pressure-related ME disorders. We studied the ME status in patients with severely diminished ET opening abilities, and anticipated to find ME disorders in most of them. PATIENTS AND METHODS ME status was evaluated in unconscious adults, who were hospitalized in a rehabilitation center with severe brain damage, requiring tracheotomy and gastrostomy. These patients were unable to swallow, produce valsalva, yawn, and needed oral suctioning. Examination included fiberoptic nasopharyngoscopy, gag reflex and soft palate assessments, otoscopy, and tympanometry. RESULTS Nineteen patients (38 ears) were evaluated: 14 men and 5 women, aged 18 to 93 years (average 59). Duration of gastrostomy and tracheotomy were between 3 months and 18 years. All the patients lacked gag reflex, palatal movements, or supraglottic sensation. Eighteen ears (47%) had otitis media with effusion (OME) (versus ∼3% in the general population, p = 0.00001), none had significant tympanic membrane atelectasis, but 20 (53%) ears were normal. Twenty-two ears (59%) had tympanometry types B/C and 16 (41%) had type A. Cerumen impaction incidence (26 ears, 68%) was significantly higher than in normal adults (10%), mentally retarded (36%), and nursing homes residents (57%). CONCLUSIONS A dysfunctional ET predisposed ME disorders. Yet, ∼50% of the ears were normal, in contrast to the current paradigm. This implies that ME pressure homeostasis is maintained by factors that can compensate for ET dysfunction. Treating cerumen impaction and OME may be beneficial for rehabilitation.

Characteristics of Supraglottitis in Adults

Objectives: Describe the demographics, clinical presentation, interventions, and outcomes of adult patients diagnosed with acute supraglottitis. Methods: We retrospectively identified adult patients with acute supraglottitis during the years 1990 through 2013 by using relevant International Classification of Disease codes. Data were extracted for demographic and clinical information. Results: A total of 288 eligible patients were enrolled. Diagnosis was made by either indirect or fiber-optic laryngoscopy (or both modalities). The incidence rate of acute supraglottis was 4.3 out of 100,000 patients/year, with a steep rise during the years 1999 through 2013. A slight male predominance was observed (n = 160, 56%). The mean age was 50 ± 16 years, and 77% were 30 to 70 years old. Sore throat (94%) and dysphagia (88%) were the most common presenting symptoms, which had begun 2 days prior to hospitalization. Comorbidities were reported in 62% of the patients. Swabs were obtained in 17% of patients, of those 23% were positive. Patients were hospitalized either in the otolaryngology department (n = 255, 89%) or in the intensive care unit (ICU) (n = 33, 11%). Of the ICU patients, 19 (58%) had an airway securing intervention procedure (84% upon admission, 16% during initial 24 hours surveillance). Amoxicillin-clavulanate was administered in 61% of patients. Intravenous and inhalational corticosteroids were administered in 190 (66%) patients. The mortality rate was 0.003%. Conclusions: The signs and symptoms of supraglottitis in adults are different from those in the pediatric population. Patients presenting with sore throat, dysphagia, or odynophagia should be cautiously suspected for supraglottitis until proven otherwise. Treatment includes intravenous antibiotics and steroids and outcomes are excellent.

Acute Mastoiditis in the Pneumococcal Conjugate Vaccines Era

Objectives: (1) Describe the changing trends in mastoiditis incidence and bacteriology in the pneumococcal conjugate vaccine (PCV) era. Methods: PCV-7 and PCV-13 have been gradually implemented in the Israeli national immunization program in 2009 and 2010, respectively. We retrospectively identified children aged 0-6 years who had middle ear cultures obtained from “severe” acute otitis media (AOM) episodes, defined as AOM requiring tympanocentesis or presenting with spontaneous otorrhea, during the years 2008-2013. Of those, we identified children with acute mastoiditis. Data were extracted for demographic, clinical and microbial information. Results: Data from 295 eligible AOM episodes reported in 279 children were collected. Of those, 56 children with 57 episodes of acute mastoiditis were identified. Of these 36 were boys (64%) and 37 (66%) were <2 years old. During the pre-PCV and the PCV introduction period (January 2008-November 2010), mastoiditis incidence rate was significantly higher than the post-PCV introduction era (December 2010-December 2013) incidence, 0.23 versus 0.16/“severe” AOM episode, respectively (P = .04). Mastoiditis developed despite adequate systemic antibiotic therapy for AOM in 28 (49%) patients. Of the 21 (37%) positive cultures, Streptococcus pneumoniae was the most common bacteria, which was solely isolated in 17 (81%) episodes and in combination of Haemophilus influenzae in 1 (5%) episode. Notably, there were no isolates of S pneumoniae from mastoiditis patients following the first year after PCV-13 introduction. Conclusions: Mastoiditis incidence complicating “severe” AOM decreased after the introduction of PCVs, which can be directly attributed to their effectiveness in reducing pneumococcal-related AOM burden and complications.