Daniel M. Kaplan

Otogenic lateral sinus thrombosis in children

INTRODUCTION The clinical picture of lateral sinus thrombosis (LST) has changed with the advent of antibiotics, as have the utility of various diagnostic tests. LST may appear in children as a complication of acute otitis media, but nowadays it is more frequently encountered in adults with long-standing chronic ear disease. METHOD A retrospective study of all the pediatric patients with LST between 1982 and 1997. RESULTS Thirteen cases of LST were diagnosed and treated by our department. In six cases, LST was due to acute otitis media and in the remaining cases it was due to chronic otitis media. Headache, fever, aural discharge and mastoid tenderness were the most frequent findings in these patients and four patients were initially diagnosed with meningitis. In the majority of the patients, LST was accompanied with other intracranial complications, such as perisinus abscess, brain abscess and meningitis. One patient with multiple brain abscesses, unresponsive to several drainage procedures, died. The other patients recovered and have since been followed-up as out-patients. CONCLUSION LST may be difficult to diagnose due to previous antibiotic treatment and to the overlap of clinical findings with other entities such as meningitis. Despite the value of modern imaging techniques in the investigation of the disease, a high index of suspicion based on the clinical picture is warranted. Our results are consistent with those of other recent studies, who found that mortality of LST has dropped below 10%.

Magnetic Eye Tracking: A New Approach Employing a Planar Transmitter

A new scleral search coil (SSC) tracking approach employing a planar transmitter has been developed theoretically and tested experimentally. A thin and flat transmitter is much more convenient in installation, operation, and maintenance than the conventional large cubic one. A planar transmitter also increases the mobility of SSC systems, simplifies their accommodation in a limited clinical space, enables bedside testing, and causes no visual distractions and no discomfort to the users. Moreover, it allows tracking not only the SSC orientation, but also its location, which is very important for many medical and scientific applications. The suggested approach provides the speed and precision that are required in SSC applications. The experimental results show that it can be used for the diagnosis of vestibular disorders. The tracking precision is in good agreement with its theoretical estimation.

Bilateral benign paroxysmal positional vertigo following a tooth implantation

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo and may occur following recent head trauma. Bilateral involvement in BPPV is considered rare and has received little attention in the medical literature. We describe an unusual case of bilateral BPPV in a middle-aged woman that presented during a dental implantation, performed with the use of osteotomes. We discuss the diagnostic and therapeutic challenge of this entity.

Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis

We present the case of a 5-year-old boy with otogenic lateral sinus thrombosis that developed after acute mastoiditis, with no prior ear disease. He was treated with myringotomy and antibiotics alone, with no surgical intervention. This approach was followed owing to his good general condition, the prompt response to the antimicrobial treatment, and no evidence of suppurative disease. Sinus recanalization was evident on the follow-up computed tomography 4 months later. We believe that in selected cases of otogenic lateral sinus thrombosis, secondary to an acute ear infection with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld.

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.

The use of standardized orbital ultrasound in the diagnosis of sinus induced infections of the orbit in children: a preliminary report.

Infections of the orbit in children usually present as a complication of sinusitis and may result in blindness or even death. Orbital cellulitis (OC) and subperiosteal abscess (SPA) represent different pathologies within the spectrum of orbital infections. The differentiation between OC and SPA is important, since it implies two different therapeutic modalities. While SPA is usually treated by incision and drainage and parenteral antibiotics, OC may be treated with antibiotics alone. Contrast enhanced CT scan is commonly used in the diagnosis of orbital infections, but does not always prove accurate in differentiating between these two conditions. MRI is superior to CT in the resolution of soft tissue pathology and may be more precise in such situations, but is less available imaging tool outside North America and Europe. There have been a few reports in the early 1980s on the use of standardized orbital ultrasound (SOU) in these two conditions. We have used SOU in seven children with sinus induced orbital infections--four with SPA and three with OC. We reviewed our experience in these patients and compared the imaging characteristics of OC and SPA on SOU with those of conventional imaging modalities, used in orbital infections. In four of the cases, CT scan was inconclusive, while SUO was diagnostic. In this preliminary report, we conclude that SOU may be useful in the diagnosis of orbital infections.

Nonattendance of adult otolaryngology patients for scheduled appointments.

BACKGROUND Nonattendance for appointments is an impediment to otolaryngology patient care worldwide. In a previous study of children attending an otolaryngology clinic, we observed that attendance was determined by the waiting time for an appointment and the timing of the appointment within the day. However, the factors that affect nonattendance in adults have not been well studied. OBJECTIVE We aimed to investigate factors associated with nonattendance in adults visiting an otolaryngology clinic. METHODS Nonattendance was observed for a period of one year in adult patients visiting an ambulatory otolaryngology clinic. The following parameters were also noted: age, gender, treating physician, waiting time and timing of the appointment. The chi-square test was used to analyse differences between categorical variables. The t-test was used to analyse differences between continuous variables. Logistic regression was used for multivariate analyses. RESULTS The study assessed 8071 visits to the otolaryngology clinic. The overall proportion of nonattendance was 27.7 per cent. A multivariate logistic regression model demonstrated that nonattendance was significantly associated with the following factors: female gender, younger age, long waiting time for an appointment, timing of the appointment within the day and the treating physician. CONCLUSION In adult otolaryngology patients, nonattendance was associated with patient-related factors and healthcare systems related factors alike. It is suggested that managed overbooking could be carefully introduced into otolaryngology patient scheduling.

Bell's palsy during pregnancy: is it associated with adverse perinatal outcome?

To determine whether an association exists between Bells palsy during pregnancy and adverse perinatal outcomes.

Health provider determinants of nonattendance in pediatric otolaryngology patients.

Introduction: Nonattendance for otolaryngology appointments disrupts the management of medical care and leads to ineffective use of resources. The determinants of nonattendance in pediatric otolaryngology patients have not been well documented.

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.