Ben-Zion Joshua

Adenoidectomy: Long-term Follow-Up

OBJECTIVE: To assess the long-term (3-5 years) success of adenoidectomy and reasons for unsatisfactory results. STUDY DESIGN AND SETTING: The parents of all children who underwent adenoidectomy alone at a major tertiary center from 1998 to 2000 were asked to complete a questionnaire assessing their childs well-being and symptomatology 3-5 years after surgery; some were invited for follow-up. Symptom improvement, persistent symptoms, and adenoid regrowth were evaluated. RESULTS: Among the 206 parents who complied, 74%-87% reported improvement in all main symptoms: nasal obstruction, snoring, chronic rhinorrhea, hyponasal speech, and obstructive sleep disorder. At follow-up (n = 36), the symptomatic patients had significantly more anatomic nasal abnormalities (P = 0.01) and a higher rate of significant adenoid enlargement (P = 0.08), 3 patients (19%) vs none (0%). CONCLUSIONS AND SIGNIFICANCE: Adenoidectomy alone is satisfactory treatment for nasal obstruction and obstructive sleep apnea in selected children. Though some adenoid regrowth is not rare, clinically significant adenoid regrowth is infrequent. Persistent or recurrent symptoms are attributable mainly to nasal pathology.

Acute parotitis as a complication of fine-needle aspiration in Warthin’s tumor. A unique finding of a 3-year experience with parotid tumor aspiration

OBJECTIVE/HYPOTHESIS: Fine needle aspiration (FNA) is an accurate, cost-effective tool for the study of salivary gland lesions. Although complications are extremely rare, salivary gland FNA can lead to hemorrhage, facial nerve injury, and cellulitis at the needle puncture site. Some studies suggest that FNA can cause infarction or metaplastic transformation of benign Warthins tumors. We review our recent experience with FNA of the parotid gland, focusing on possible complications and pitfalls. STUDY DESIGN AND SETTING: The medical records of all patients who underwent FNA of the parotid gland from 2000 to 2002 in the Department of Otolaryngology-Head and Neck Surgery of a major tertiary-care referral center were reviewed. Cytological results were compared to the histological diagnosis and complications were recorded. RESULTS: Of the 256 lesions aspirated, 99 patients (39%), were cytologically diagnosed as benign tumors, including 31 (12%) Warthins tumors, of which 16/17 resected and confirmed histologically. Five patients with Warthins tumor had post-FNA parotitis and were treated accordingly. CONCLUSIONS: The combination of cystic spaces surrounded by oncocytic cells and a poor blood supply makes the tumor susceptible to infarction and inflammation. Our findings indicate that FNA is a strong and reliable tool in the investigation of the salivary glands. Nevertheless, when Warthins tumor is clinically suspected on the basis of its location (tail of the parotid gland), cystic texture, patient sex (male) and age, one should consider parotitis as a possible complication.

Audiometric and imaging characteristics of distal renal tubular acidosis and deafness.

OBJECTIVEnPrimary distal renal tubular acidosis with sensorineural hearing loss is a rare autosomal recessive disease, usually caused by mutations in the ATP6V1B1 gene. The aim of this study was to characterise the phenotype of this disease, with emphasis on the auditory findings, in a cohort of Israeli children.nnnSTUDY DESIGNnProspective study of five children, from three unrelated families, with distal renal tubular acidosis and bilateral sensorineural hearing loss, with mutations in the ATP6V1B1 gene.nnnMETHODSnThe following were collected from patients medical records: biochemical and renal data, age at distal renal tubular acidosis diagnosis, and age at hearing loss. Hearing loss progression as well as current hearing status were assessed, and high resolution computed tomography of the temporal bone was performed. All patients underwent genetic testing.nnnRESULTSnFour patients were diagnosed with distal renal tubular acidosis before the age of six months and one at 24 months. All had the classical findings of low blood pH and inappropriately high urine pH. Hearing loss was diagnosed between the ages of three months and two years. The hearing loss was bilateral, asymmetrical and progressive, occasionally with a conductive component. Two children underwent cochlear implantation, at ages 10 and 15 years. High resolution computed tomography, performed in four patients between the ages of 2.5 and 15 years, showed bilaterally enlarged vestibular aqueducts. This was the only radiological abnormality in the inner ear in all cases. A different mutation in the ATP6V1B1 gene was found in each family.nnnCONCLUSIONnSeveral types of mutations in the ATP6V1B1 gene may cause distal renal tubular acidosis and sensorineural hearing loss. Patients display a typical progressive type of hearing loss and have enlarged vestibular aqueducts, with no other abnormalities being observed on imaging.

Malignant external otitis: analysis of severe cases.

Objective. To study the effect of specific clinical, laboratory, and imaging parameters on the course of severe (type 1) malignant external otitis (MEO). Study Design. Case series with chart review. Setting. Tertiary, university-affiliated medical center. Subjects and Methods. Fifty-seven patients hospitalized with severe MEO were followed for disease course and survival in a tertiary center between 1990 and 2008. Results. In 20% of patients, disease was persistent and/or aggressive despite prolonged and extensive treatment. Of this subgroup, 45% died of the disease. Prognostic factors of persistent/aggressive disease were facial nerve paralysis, bilateral disease, and significant major computed tomography findings (temporomandibular joint destruction, infratemporal fossa or nasopharyngeal soft tissue involvement). Cultures grew fungi in 5 patients, and follow-up imaging revealed disease progression. The overall 5-year survival was 55% for patients with short-term disease and 40% for patients with persistent/ aggressive disease (P = .086). By age, 5-year survival was 75% in patients younger than 70 years old and 44% in older patients (P = .029). Conclusions. A significant subset of patients with MEO has a prolonged, aggressive, and highly fatal disease that needs to be identified early. These patients more frequently have bilateral disease, cranial nerve paralysis, and positive computed tomography findings. Their follow-up should routinely include imaging studies to evaluate disease progression, and every effort should be made to identify and treat underlying fungal infection.

Primary hyperparathyroidism in young adults.

OBJECTIVE: The purpose of this study was to compare the incidence of multiglandular disease and rate of treatment failure between younger and older patients with primary hyperparathyroidism. STUDY DESIGN AND SETTING: The medical charts of patients who underwent surgery for primary hyperparathyroidism at our tertiary-care institution between 1995 and 2001 were reviewed. RESULTS: Three hundred nineteen patients were identified, of whom 33 were aged 40 years or less. There were no statistically significant differences between the younger and older groups in the incidence of multiglandular disease (9.1% for both, P = 1.00) or in the treatment failure rate (12.1% and 8%, respectively, P = 0.43). Sonography was significantly more sensitive than technetium Tc-sestamibi in the younger group (96% vs 57%, P < 0.05). Parathyroid hormone level and gland weight were significantly higher in the older group (P = 0.004). CONCLUSION: Our results suggest that the same treatment strategy should be applied to all patients with primary hyperparathyroidism. Ultrasound appears to be the localization procedure of choice in younger patients.

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.

Epiglottic abscess as a complication of acute epiglottitis.

OBJECTIVEnAn epiglottic abscess is considered a life-threatening medical situation that can cause death by obstruction the upper airways. We describe a 58-year-old man who presented to our hospital with sore throat, dysphagia and dysphonia.nnnMATERIALS AND METHODSnA fiberoptic laryngoscope (FOL) demonstrated beefy red edematous epiglottis with edema extending from the base of the tongue to the aryepiglottic folds and arytenoids. CT scan showed multiple air bubbles inside the swollen epiglottis, in keeping with the diagnosis of necrotizing epiglottic abscess.nnnRESULTSnUnder local anesthesia we performed puncture of the abscess at the tip of the epiglottis. He was dismissed 5days from his admission to the hospital after an improvement was noticed in his epiglottis.nnnCONCLUSIONnTreatment consists of airway management if needed under anesthesia and draining of the abscess. An IV antibiotics plus corticosteroids should be administrated the moment a suspicion of epiglottitis is present.

Involvement of Minor Salivary Glands in the Pathogenesis of Peritonsillar Abscess

Objectives To study the relationship between peritonsillar abscess (PTA) and minor salivary glands surrounding the palatine tonsils. Study Design Prospective population-based study. Settings Tertiary care university hospital. Subjects and Method Prospective study including 41 patients with PTA and 6 patients with a neck abscess. Amylase levels of the pus and serum were measured and compared between the 2 groups. Clinical data regarding hospitalization length and recurrence rate were also collected. Results Of the 41 patients with PTA, 7 suffered from recurrent PTA. Average level of amylase in the pus of the PTA group was 3841 U/L versus 7.7 U/L in the neck abscess group (P < .001; median, 62 vs 9.5). Serum amylase was higher in the PTA group (49.3 U/L vs 37.3 U/L; P = .008). There were no recurrences in PTA patients with amylase greater than 65 U/dL in the pus in 0 of 20 (0%) versus 7 of 21 (33%) for amylase lower than 65 U/L (P = .01). Conclusion High amylase in the pus lends further support for involvement of minor salivary glands. However, high recurrence rates related to low amylase in the pus imply an additional pathogenesis possibly related to tonsillar infection. It is possible that both minor salivary glands as well as tonsillar infection play a role in the pathogenesis of peritonsillar infections.

Randomized study comparing inflammatory response after tonsillectomy versus tonsillotomy.

To determine if there was a difference in the inflammatory reaction after tonsil surgery with “traditional” techniques (tonsillectomy and adenoidectomy or TA) compared to partial intracapsular tonsillectomy and adenoidectomy (PITA). Design: Randomized, double-blind study. Setting: tertiary care academic hospital. Children under the age of 16xa0years with a diagnosis of obstructive sleep disordered breathing were randomly allocated into three study groups: TA with electrocautery (nxa0=xa034), PITA with CO2 laser (nxa0=xa030) and PITA with debrider (nxa0=xa028). All of the children underwent adenoidectomy with a current at the same surgical procedure. Main outcome measure: c-reactive protein level (CRP) was the primary endpoint. In addition, the following were assessed: white blood cells (WBC), neutrophils (NEU), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Pre- and post-procedure measurements were compared between the groups. Parents filled out a questionnaire daily during the first postoperative week assessing pain, swallowing and snoring. CRP levels ascended higher in the PITA groups after surgery (pxa0=xa00.023), WBC and NEU showed the same pattern, IL-6 levels were higher in PITA group and there was no difference in TNF-alpha levels between the two types of procedures. Postoperative pain and postoperative hemorrhage were significantly lower in the PITA groups as compared to the TA group (pxa0=xa00.01 and 0.048). PITA in comparison to TA is associated with lower morbidity; however, the inflammatory response does not differ significantly in the first 24xa0h after surgery. Additional long-term studies assessing efficacy of PITA are warranted. Level of evidence: Level 1, prospective randomized controlled trial.

Late Prevertebral and Spinal Abscess following Chemoradiation for Laryngeal Squamous Cell Carcinoma

Objective. Advanced primary supraglottic tumors (i.e., T3 or T4) have traditionally been treated surgically and postoperative radiotherapy. In the last 2 decades, some patients were treated with chemoradiation avoiding surgery. Case Report. We describe a 55-year old female who presented with respiratory distress and paraplegia seven years after treatment for a T3N0M0 supraglottic squamous cell carcinoma. CT scan showed prevertebral and intraspinal air descending from C4 to D3 vertebras. Epidural and prevertebral abscesses were confirmed by neck exploration. Necrosis was observed in the retropharyngeal, prevertebral, and vertebral tissues. Conclusion. Prevertebral and spinal abscess may result from chemotherapy and radiotherapy to the head and neck. Physicians caring for head and neck cancer patients treated with chemotherapy and radiation should be aware of this rare severe complication.