Chanan Shaul

Shifting trends: mastoiditis from a surgical to a medical disease.

OBJECTIVE The aim of this study is to review the outcome of pediatric patients suffering from acute mastoiditis treated conservatively and to correlate this to the evolution of our understanding of the shift in which mastoiditis has been transformed from a surgical to a medial disease. METHODS We performed a retrospective review patient files hospitalized in our tertiary-care center between 2005-2008. We examined the data concerning the infection which included: presenting signs/symptoms, prior otologic history, treatment (including both surgical and conservative) prior to hospitalization and during hospitalization, computed tomography (CT), hospital duration, complications and overall outcome. This data was analyzed and compared between different patients who underwent different treatment strategies. RESULTS Fifty-one patients were included in this retrospective review. Initially, forty-nine patients admitted to our hospital were treated conservatively. This treatment included intra-venous antibiotics, myringtomy and if needed subperiosteal abscess incision and drainage. Only 2 patients underwent CT scanning on admission. Further on, during hospitalization 4 additional patients underwent CT scanning due to continued fever or progression of local disease. All four CT scans showed no intra-cerebral complications, and so all continued with conservative treatment. CONCLUSION Most cases of acute mastoidits may be treated with a conservative therapy regime. This regime, in our opinion, should include three branches: the first intravenous antibiotic therapy using a broad spectrum antibiotic. The second is myringotomy and the third branch is incision and drainage of subperiosteal abscess when needed.

Is Needle Aspiration for Peritonsillar Abscess Still as Good as We Think? A Long-term Follow-up:

Objective: The aim was to study the therapeutic management, recurrence, and need for tonsillectomy in patients who underwent needle aspiration for peritonsillar abscess (PTA). Methods: A prospective observational design study was performed. Patients hospitalized in Shaare Zedek Medical Center between the years 2004 and 2007 with a diagnosis of PTA who underwent needle aspiration obtaining pus were included. A minimum 5-year follow-up was required for all patients. Recurrences, complications, the need for a repeated surgical procedure, length of hospital admission, and tonsillectomy were the primary end points. Results: The study included 117 patients. One hundred four patients (88.9%) improved after 1 needle aspiration without any other intervention, whereas 13 patients (11.1%) required an additional procedure. Broad spectrum antibiotics showed a statistical advantage over penicillin only, regarding need for recurrent procedure (14.7% vs 4.7%, P = .02). No short- or long-term complications were documented. Seventeen patients (14.5%) had any recurrence. Primary recurrent tonsillitis, female sex, and younger age were predictive risk factors for recurrent events of PTA (32% vs 10%, P < .01). A total of 18 patients (15.4%) eventually underwent tonsillectomy. Conclusion: Needle aspiration is an effective first line procedure for patients with PTA. Tonsillectomy is not necessary in most cases. In our study, young age, female sex, and recurrent tonsillitis are negative prognostic factors for recurrence. These patients should be managed accordingly. Broad spectrum antibiotics may offer additional advantages when compared to penicillin only.

Starplasty tracheostomy: case series and literature review

ObjectivesThe starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center.MethodsA retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012.ResultsAmong the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3–207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred.ConclusionsIn our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.

Revision Cochlear Implantation Using a Double-Array Device in the Post-meningitis Ossified Cochlea

Objectives: Describe the surgical technique and outcome in a series of patients who underwent revision cochlear implantation using a double-array or split electrode device. All patients had an ossified cochlea due to meningitis and were functioning poorly with a standard electrode cochlear implant. Methods: Four patients between the ages of 4-15 years underwent revision with 5 double-array cochlear implant devices in our center during the years 2010-2012. One patient underwent bilateral revision surgery. All patients suffered from meningitis with computed tomography and magnetic resonance imaging studies that demonstrated an ossified cochlea. The time interval between the disease and initial cochlear implantation was 4 months to 4 years. Patients data were retrospectively analyzed with emphasis on the surgical technique, number of electrodes inserted, and number of active electrodes at follow-up. In addition, pre and post revision surgery function was compared. Results: The revision surgery was carried out 4 to 10 years after the initial surgery. Two tunnels, basal and apical, were drilled in the ossified cochlea. In each of the tunnels 5 to 12 electrodes were inserted. While the number of active electrodes before revision was 0-5, after revision with the double array it increased to 8-16. This resulted in increased auditory and speech function. Conclusions: The double-array device can provide good outcome in the post-meningitis ossified cochlea. In many of these cases function can be better than with a single electrode device.

When Can Acute Supraglottitis Patients Be Discharged from Intensive Care

Objectives: Acute supraglottitis in adults is usually managed by admitting the patient for airway monitoring in the intensive care unit (ICU). However, data are lacking on when patients could be transferred from the ICU to the ward. Our aim is to suggest decision criteria for transferring patients to the regular ward. Methods: A retrospective review of medical records from adult patients admitted for supraglottitis to our center was conducted. The information obtained included airway management, length of stay in the ICU and in the ward, clinical condition of the patients at the time of their transfer from the ICU to the ward, and outcome. Results: Between 2006 and 2012, 38 adult patients were treated in our department for supraglottitis with antibiotics and systemic steroids. All patients were admitted to the ICU for monitoring. Fiberoptic laryngoscopy was performed every 12 hours. 5 patients required intubation at admission. 33 patients were admitted to the ICU for monitoring and did not require further intubation. Average time in the ICU was 27.4 hours. We observed that all patients who had a mild swelling regression did not deteriorate or require re-intubation or re-admission to the ICU. They were all discharged from the regular ward without any complications. Conclusions: Patients without severe airway compromise could undergo monitoring in the ICU without intubation. Since all patients who began to improve did not suffer from deterioration afterwards, we suggest that even mild airway improvement could be considered as a sufficient criterion for safe transfer of patients to the regular ward.