Dov Ophir

Acute mastoiditis — the antibiotic era: a multicenter study☆

OBJECTIVESnTo evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients who develop acute otitis media are treated with antibiotics.nnnMETHODSnA multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis.nnnSETTINGnNine secondary or tertiary academic or non-academic referral centers.nnnRESULTSnPrior to the diagnosis of acute mastoiditis, 121 of the patients (54.3%) had been receiving oral antibiotic treatment for acute otitis media for periods ranging from 1 to 21 days (mean 5.3 days). Samples for bacterial culture were obtained from 152 patients. Cultures were negative in 60 patients. The organisms isolated in the 92 positive cultures were: Streptococcus pneumoniae (15 patients), Streptococcus pyogenes (14 patients), Staphylococcus aureus (13 patients), Staphylococcus coagulase negative (three patients), Pseudomonas aeruginosa (eight patients), Haemophilus influenzae (four patients), Proteus mirabilis (two patients), Escherichia coli (two patients), Klebsiella pneumoniae (one patient), Enterobacter (one patient), Acinetobacter (one patient), anaerobic gram-negative bacilli (one patient), and fungi (two patients). Ten patients had mixed flora. Sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy).nnnCONCLUSIONSnAntibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis. Early myringotomy for acute otitis media seems to decrease the incidence of complications. The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. Intracranial complications in acute mastoiditis are not rare. Because of the diversity of causative organisms in acute mastoiditis and the growing resistance of bacteria to the various antibiotics, all means to obtain a sample for culture prior to antibiotic treatment, including general anesthesia.

Prognostic factors for local control of early glottic cancer : The Rabin Medical Center retrospective study on 207 patients

PURPOSEnDifferent radiation therapy schedules and devices have been used over the last 20 years at Rabin Medical Center in patients with early glottic cancer. The aim of the present retrospective analysis was to identify the subgroup of patients at high risk of failure of radiation treatment.nnnMATERIALS AND METHODSnBetween 1974 and 1994, 207 patients with squamous cell carcinoma of the glottis, 182 Stage T1 and 25 Stage T2, underwent definitive radiation therapy. During this period, treatment was administered with different radiation devices (60Co or 6-MV X ray), using different dose/fraction protocols (1.8 or 2 Gy per day, 5 or 6 fractions per week), total doses (42-77.4 Gy), overall radiation times, and delays. These treatment variables, in addition to certain patient and tumor characteristics, were correlated with local control at a median follow-up of 57 months (range 18-265 months).nnnRESULTSnThe 5-year local control rates for T1 and T2 tumors were 88% and 73%, respectively. Univariate analysis showed that smoking, diabetes mellitus, anterior commissure involvement, T stage, and extension of tumor to one third or more of the vocal cord were highly significantly correlated with decreased local control. None of the treatment variables, including dosage at which complete tumor regression was noted, were found to be predictive. By multivariate analysis, only anterior commissure involvement was found to be highly significant (risk ratio 1.9, 95% CI 1.2-3.0, p = 0.027), and T stage was borderline significant (risk ratio 1.6, 95% CI 1.0-2.5, p = 0.054).nnnCONCLUSIONnThis study suggests that only two tumor characteristics are predictive of local failure of early glottic cancer: anterior commissure involvement and T stage. Treatment variables apparently do not influence local control.

The Rising Incidence of Adult Acute Epiglottitis and Epiglottic Abscess

OBJECTIVEnTo examine preliminary observations that the incidence of adult acute epiglottitis has risen between 1986 and 2000.nnnMATERIALS AND METHODSnDemographics, annual and seasonal occurrences, clinical presentation, diagnostic procedures, treatment, airway management, and complications of 116 consecutive adult patients with laryngoscopically confirmed acute epiglottitis are presented.nnnRESULTSnThe mean annual incidence of acute epiglottitis per 100,000 adults significantly increased from 0.88 (from 1986-1990) to 2.1 (from 1991-1995) and to 3.1 (from 1996-2000) (P <.001). This rise seems to be unrelated to Haemophilus influenzae type b infection but related to miscellaneous pathogenic bacteria. During these periods, the number of epiglottic abscesses increased concomitantly with the rise in the incidence of acute epiglottitis (from 4/14 episodes [29%], to 8/38 [21%], and to 16/66 [24%], respectively), showing a relatively constant ratio between both phenomena (P =.843). Twenty-five patients (21%) underwent airway intervention, 16 because of objective respiratory distress and 9 because of imminent respiratory obstruction. Stepwise logistic regression showed that drooling, diabetes mellitus, rapid onset of symptoms, and abscess formation were associated with airway obstruction. Diverse origins for the epiglottic abscess, either from coalescent epiglottic infection or from mucopyocele of the tongue base, are suggested.nnnCONCLUSIONSnA rise in the incidence of acute epiglottitis and a concomitant rise in the number of epiglottic abscesses were established. Although the course of acute epiglottitis is often benign and can be safely treated with a conservative management approach, delayed airway obstruction may develop from a few hours to days after admission.

Human lung cancer cell lines express cell membrane complement inhibitory proteins and are extremely resistant to complement-mediated lysis; a comparison with normal human respiratory epithelium in vitro, and an insight into mechanism(s) of resistance

Human lung cancer expresses cell membrane complement inhibitory proteins (CIP). We investigated whether human lung cancer cell lines also express cell‐membrane CIP molecules and whether the biology of CIP molecules in these cell lines differs from that of CIP in normal human respiratory epithelium in culture. The cell lines ChaGo K‐1 and NCI‐H596 were compared with normal human nasal epithelium in primary cultures in respect to the level of cell membrane CIP expression of membrane cofactor protein (MCP; CD46), decay‐accelerating factor (DAF; CD55) and CD59, in respect to the level of cell resistance to complement‐mediated lysis, and in respect to the contribution of cell membrane CIP to cell resistance against complement‐mediated lysis. We found, using flow cytometry, that both human lung cancer cell lines expressed MCP, DAF and CD59, as did normal nasal epithelial cells. However, normal cells showed a large subpopulation of low DAF‐expressing cells (60% of all cells) and a smaller subpopulation of high DAF‐expressing cells (40%), while the lung cancer cell lines showed only one cell population, of high DAF expression. In addition, both lung cancer cell lines expressed higher MCP levels, and NCI‐H596 cells showed higher levels of CD59. Cell resistance to complement‐mediated lysis of both lung cancer cell lines was much higher than that of normal cells. Fifty percent normal human serum, under the same concentrations of complement activators, induced lysis of less than a mean of 10% of lung cancer cells, while lysing up to a mean of 50% of nasal epithelial cells. Lung cancer cell resistance to complement was due to its ability to prevent significant activation of complement upon its cell membrane, as manifested by a failure of complement activators to increase cell membrane deposition of C3‐related fragments. The exact mechanism for this resistance remains obscure. Unexpectedly, neutralizing antibodies, anti‐MCP and anti‐DAF were entirely ineffective and anti‐CD59 was only slightly effective (18% mean cell lysis) in increasing the susceptibility of the lung cancer cell lines to complement, while the same antibodies were very effective in facilitating complement‐mediated lysis of the normal nasal epithelial cells (50% mean cell lysis with CD59 MoAb). On the other hand, detachment of DAF and CD59 by phosphatidylinositol‐specific phospholipase C (PIPLC) from the lung cancer cell lines abrogated their resistance to lysis. We suggest that the biology of cell membrane CIP molecules in human lung cancer cell lines is different from that of CIP in normal respiratory epithelial cells. Human lung cancer cell lines are able to prevent significant complement activation upon its cell membrane and are therefore especially resistant to complement‐mediated lysis. Complement resistance may serve this common and highly lethal human cancer as an escape mechanism from the bodys immunosurveillance and prevent effective immunotherapy with tumour‐specific MoAbs.

Polypoid Mucosa With Eosinophilia and Glandular Hyperplasia in Chronic Sinusitis: A Histopathological and Immunohistochemical Study

Objective To evaluate the histopathological and immunohistochemical characteristics of chronic sinusitis, with reference to the extent of sinus involvement.

The normal inferior turbinate: histomorphometric analysis and clinical implications.

Objective To study the histological and morphometric features of the normal inferior turbinate.

Adult vallecular cyst: Thirteen-year experience

OBJECTIVE: To assess the characteristics of adult vallecular cyst. STUDY DESIGN AND SETTINGS: A retrospective chart review from a university affiliated hospital. SUBJECTS AND METHODS: Clinical manifestations and airway management of 38 consecutive adult patients with vallecular cyst admitted between 1992 and 2004 were studied. RESULTS: Two distinct groups were identified: infected (n = 24) and noninfected (n = 14). Twenty-two (91.7%) patients of the former group had acute epiglottitis with an abrupt onset culminating in abscess formation in 19 (79.2%) and airway compromise in 9 (37.5%) compared with none in the noninfected group (P = 0.006). In 4 (18.2%) of 22 patients, the origin of the infected vallecular cyst was evident only after symptoms subsided. Three patients had recurrent acute epiglottitis. The noninfected group had a relatively prolonged mild clinical course. CONCLUSIONS: Two types of vallecular cysts were characterized. Abscess formation was the hallmark of adult infected vallecular cyst. SIGNIFICANCE: To improve patient care, endoscopic follow-up is advocated. In patients with recurrent episodes of acute epiglottitis, imaging is recommended.

Subjective comparison of Nd:YAG, diode, and CO2 lasers for endoscopically guided inferior turbinate reduction surgery.

Lasers using different wavelengths and delivery systems have been used to reduce the inferior turbinate mass when hypertrophic inferior turbinates obstruct the nasal airway. Different laser systems produce different laser-tissue interactions. This study presents a comparison between three laser systems: CO2, Nd:YAG, and Diode lasers for inferior turbinate reduction surgery, all performed under endoscopic control. A total of 46 patients were randomized into three treatment groups and followed for more than 1 year. Subjective and objective data were collected. Subjective impressions of improved nasal airway was achieved in 41% (Diode), 47% (Nd: YAG) and 57% (CO2) and was not statistically significant. There was more postoperative bleeding in the CO2 laser group, with 3 patients requiring tamponade. The CO2 laser procedure also took longer to perform. These results failed to show a significant difference between the different lasers for inferior turbinate reduction. Overall, the results were not impressive.

Speech-aid prostheses for neurogenic velopharyngeal incompetence ☆ ☆☆

STATEMENT OF PROBLEMnWhen surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses.nnnPURPOSEnThis study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence.nnnMETHODSnSeven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations.nnnRESULTSnEffective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses.nnnCONCLUSIONnWire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance.

Familial multicentric paragangliomas in a child.

A 12-year-old girl presented with bilateral carotid-body paragangliomas and a unilateral jugular paraganglioma. The tumours were surgically removed. This is a rare combination of tumours in any patient and previously unreported in a child of this age. Her father died of a cerebellar astrocytoma and her mother underwent surgical removal of a large mediastinal paraganglioma. The association of astrocytoma with familial paragangliomas has never been documented. The literature on the epidemiology and inheritance pattern of familial paragangliomas is reviewed. The need for thorough pre-operative evaluation of the patient and close follow-up of family members is stressed.