Amine Haddad

Bacterial Flora in Normal Adult Maxillary Sinuses

Background Conflicting data exist about the presence of bacteria in healthy maxillary sinus cavities. This study was designed to determine the bacterial flora and to quantify the level of bacterial presence in healthy maxillary sinus cavities. Method Subjects included 34 patients undergoing Lefort I osteotomy for orthognathic surgery. All patients were preoperatively evaluated by a questionnaire and a complete physical examination including sinus endoscopy. Our exclusion criteria were presence of sinonasal symptoms, asthma, antibiotic treatment in the past 3 months, treatment with local steroids, previous sinonasal surgery, traumatic surgery, and an abnormal CT scan or sinus endoscopy. Washes were obtained from maxillary sinuses before surgery through an antral puncture. The sinus was irrigated with sterile saline followed by aspiration with a syringe attached to the trocar. Basic sterility rules were rigorously applied. Specimens were transported to the laboratory in an air-free syringe. Time between collection of materials and inoculation of the specimen did not exceed 15 minutes. Specimens were inoculated for aerobic and anaerobic organisms. Results After applying the selection criteria, 14 patients (28 sinuses) remained. Eight (57.1%) were men with a mean age of 22.7 years; 82.14% of the specimens were sterile. Bacterial organisms were recovered in only four patients with two different coagulase-negative staphylococci in the same patient: one in each sinus with 200 UFC/mL in the left sinus and 10 UFC/mL in the right sinus, one Citrobacter fundii (70 UFC/mL) and two polymorphic floras. Conclusion This descriptive study shows the large predominance of sterile maxillary sinus cavities in asymptomatic adults with endoscopically normal mucosa.

T4a laryngeal cancer survival: Retrospective institutional analysis and systematic review

To assess the survival outcomes of a homogeneous group of pT4a laryngeal cancer patients treated at our institution by primary total laryngectomy and neck dissection with adjuvant therapy when indicated, and to systematically review studies reporting overall survival outcomes in T4a laryngeal cancer.

Management of Postintubation Tracheal Stenosis: Appropriate Indications Make Outcome Differences

Background: Laryngotracheal stenosis is difficult to treat and its etiologies are multiple; nowadays, the most common ones are postintubation or posttracheostomy stenoses. Objective: To provide an algorithm for the management of postintubation laryngotracheal stenoses (PILTS) based on the experience of a tertiary care referral center. Methods: A retrospective study was conducted on all patients treated for PILTS over a 10-year period. Patients were divided into a surgically and an endoscopically treated group according to predefined criteria. The characteristics of the two groups were analyzed and the outcomes compared. Results: Thirty-three consecutive patients were included in the study: 14 in the surgically treated group and 19 in the endoscopically treated group. Our candidates for airway surgery were healthy patients presenting with complex tracheal stenoses, subglottic involvement or associated tracheomalacia. The endoscopic candidates were chronically ill patients presenting with simple, strictly tracheal stenoses not exceeding 4 cm in length. Stents were placed if the stenosis was associated with tracheomalacia or exceeded 2 cm in total length. In the surgically treated group, 2/14 patients needed more than one procedure versus 8/19 patients in the endoscopically treated group. At the end of the intervention, 50% of the patients were decannulated in the surgically treated group versus 84.2% in the endoscopically treated group (p = 0.03). However, the decannulation rates at 6 months and the symptomatology at rest and on exertion on the last follow-up visit were comparable in the two groups. Conclusion: Our experience in the management of PILTS demonstrates that both surgery and endoscopy yield excellent functional outcomes if the treatment strategy is based on clear, predefined objective criteria.

Exclusive endoscopic resection of juvenile nasopharyngeal angiofibroma: a systematic review of the literature.

Objective To systematically review the exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma in the literature to define the clinical features in terms of staging and the treatment outcomes in terms of bleeding, recurrence, residual tumor, and complications. Data Sources Online databases, including PubMed and EMBASE, were used. Reference sections of identified studies were examined for additional articles. Review Methods The literature was searched by 2 reviewers with the following inclusion criteria: English or French language and exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma. We were only able to perform a meta-analysis on the categorical outcomes using DerSimonian and Laird random effects models. Results Ninety-two studies were included with a majority of retrospective studies (54/92; 58.6%). No randomized controlled trials were found. A total of 821 patients were identified. The Radowski classification was the most commonly used (29/92; 31.15%). The mean operative blood loss was 564.21 mL (minimum, 20 mL; maximum, 1482 mL). It was 414.6 mL (minimum, 20 mL; maximum, 1000 mL) and 774.2 mL (minimum, 228 mL; maximum, 1482 mL), respectively, in the group with and without embolization. No conclusion could be made because it was not stratified by tumor stage and because of the absence of randomized controlled trials. The random effect estimate of recurrence was 10% (95% confidence interval [CI], 8.3-11.7). It was 9.3% (95% CI, 7.2-11.5) for complications and 7.7% (95% CI, 5.4-10.1) for residual tumor. Conclusion The endoscopic treatment is an evolving modality. It is considered today the treatment of choice. A new classification system based on the endoscopic approach should be proposed in future studies.

Lateral sinus thrombosis in the pediatric population: multiple presentations for a potentially lethal disease.

Lateral sinus thrombosis complicating head and neck infections is a rare but potentially life-threatening condition. We report 4 pediatric cases of lateral sinus thrombosis occurring in different settings (2 patients with acute otitis media, 1 patient with chronic otitis media, and another with acute tonsillitis) to emphasize the nonspecific clinical presentation of this complication. In all our cases, early diagnosis was missed. Keeping a high index of suspicion when dealing with these infections is a reasonable approach.

Sulfuric acid ingestion.

CLINICAL PRESENTATION A 36-year-old jeweler was admitted to our emergency department 30 minutes after he accidentally ingested highly concentrated solution of sulfuric acid. He suffered immediate cutaneous burns of varying extent and depth on his face, neck, thorax, and abdomen. He was gasping; arterial blood gas showed mixed acidosis with pH, 6.85; Pao2, 60 mm Hg; PaCO2, 53 mm Hg; and bicarbonate, 9.3 mEq/L. Laboratory tests showed leucocytosis, thrombocytopenia with prothrombin time 29%, partial thromboplastin time 37/100, amylase 430 IU, lipase 3,386 IU, and LDH 3,131 IU. He had a severe trismus with insensitive yellowish spongy tongue, gums, buccal mucosa, and palate (Fig. 1). He underwent urgent tracheotomy; his trachea was necrotic with a merely opened lumen. Despite aggressive resuscitation, he continued to decompensate hemodynamically and developed acute respiratory distress syndrome, acute renal failure, disseminated intravenous coagulation, bilateral pneumothorax, and cardiac arrest. Unfortunately, he did not survive this disastrous accident.

Giant cell granuloma: Report of a rare location in the hard palate and review of the literature

Abstract Giant cell granulomas (GCG) are rare tumors affecting the head and neck region and other sites of the body. Their occurrence in the hard palate is highly uncommon. We present the case of a 15-year-old female patient who presented with a hard palate mass that was confirmed to be a GCG following surgical excision. A review of all cases of GCG in the hard palate reported in the literature till date is presented with an update on differential diagnosis and treatment modalities.

Parotid Tumors : Is Surgery Always the Only Way ?

AIM OF THE STUDY To analyze the characteristics and management of parotid tumors in a tertiary care center. STUDY DESIGN Retrospective cohort study. METHODS All cases of parotid tumors (or masses) in our department between Jan 1, 1999 and December 31st, 2012 were studied. Demographic data, clinical characteristics, histopathology and management were analyzed. We also evaluated the diagnostic value of fine needle aspiration cytology (FNAC) in our center. RESULTS Of the 216 parotid tumors, 164 underwent parotidectomy and 52 were not managed surgically; 73.1% had a benign tumor (36.6% had Warthins tumor) and 16.7% had a malignant one. In our center, FNAC was found to have a sensitivity for reporting malignancy of 71.4% and a specificity to rule in malignancy of 100%. CONCLUSION In our series, Warthins tumor was the most frequent mass probably related to the high tobacco use. The prevalence of malignant tumors was relatively high in our series. Primary malignant tumors and pleomorphic adenomas should always be treated surgically, however, lymphomas, metastatic and benign inflammatory masses and cases of Warthins tumors could be managed nonsurgically.

Suicidal hanging attempt: poor symptoms for a potentially lethal injury

A 26-year-old man walked into our emergency department 30 minutes after failure of his suicidal hanging attempt. His initial evaluation was unremarkable except for a mild hemoptysis. Physical examination revealed an overall swollen neck with a thin circumferential hemorrhagic mark around the prelaryngeal area and both mastoid tips. A dull tenderness was noted on laryngeal palpation. Both carotid pulses were perceived, and no neurologic deficit was found. The cervical spine was secured. A fiberoptic laryngoscopy objected a mild swelling of the ventricular folds, along with a backward flip of the epiglottis and a mild supraglottic mucosal bleeding. However, the overall airway was patent, and the vocal folds aspect and mobility were normal. Because of the emergent airway threat, a fiberoptic nasotracheal intubation was performed with no significant difficulties. A CT scan of the neck revealed a diffuse emphysema dissecting the paralaryngeal and prevertebral soft tissues without any clear evidence of injury to the pharyngo-larynx, major vessels, or cervical spine (Fig. 1). After performing a tracheotomy under general anesthesia, neck exploration identified bilateral sternocleidomastoid muscle hematomas, left hypopharyngeal rupture, along with a complete supraglottic rupture (Fig. 2). The laryngeal framework was restored through an anterior laryngofissure approach. The postoperative course was uneventful, and the patient was decannulated after 6 weeks with excellent functional outcomes. When dealing with a hanging attempt, the emergency physician should never be fooled by the paucity of symptoms. The cervical spine, major vessels, and airway should be systematically evaluated, even though spinal and vascular injuries, in this setting, have been rarely reported in the literature.1,2 Airway compromise should always be the primary focus because strangulation has been involved in three types of injuries: laryngotracheal disruption, supraglottic (thyrohyoid membrane) rupture, or subglottic (cricothyroid membrane) rupture.3 The most constant indicators of laryngotracheal injury are hemoptysis and emphysema; their presence should always warrant a fibroscopic laryngeal examination. In this case, neither significant mucosal lacerations nor airway narrowing were noticed, so an endotracheal intubation was possible. Otherwise, the only alternatives to secure the airway would have been a cricothyrotomy or a tracheotomy under local anesthesia. The assessment of hanging injuries must be precise and quick. When appropriately managed, 90% of victims recover without any neurologic deficit.4

S117 – Gastropharyngeal Reflux and Eustachian Tube Dysfunction

Objectives Determine the response of gastropharyngeal reflux (GPR) in the pathogenesis of Eustachian tube dysfunction (ETD) in adults, using a therapeutic trial. Methods 18 adult outpatients with symptoms of ETD (associated or not to GPR symptoms) were randomized into two groups: The first group received nasal corticosteroids and Rabeprazole 20mg once daily for 6 weeks. The second group received nasal corticosteroids and placebo for 6 weeks. Symptoms’ severity was evaluated before and after treatment by a tympanometry and a self-administered questionnaire of 7 items focusing on the severity of ETD. Each of the items was scored on a numeric scale. The local ethics committee approval was obtained and patients signed an informed consent before their participation in the study that was conducted between November 2002 and May 2003. Results 8 patients were on Rabeprazole, 10 were on placebo. Patients in the 2 groups were comparable for all the variables except for the severity of symptoms. On enrollment, patients under Rabeprazole had more severe symptoms than those under placebo (SR = 12.4, SP = 7.15 with p = 0.035). At the end of the trial, the improvement of the symptom score under Rabeprazole was significantly higher than that of patients under placebo, using the Mann Whitney test (SR’ = 6.13, SP’ = 11.56 with p = 0.026). Conclusions By showing a significant improvement of ETD symptoms in patients under Rabeprazole compared to controls, this study suggests the response of GPR in the pathogenesis of ETD, but larger studies are needed.