Gabriel Rosen

Acute mastoiditis — the antibiotic era: a multicenter study☆

OBJECTIVES To 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. METHODS A multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis. SETTING Nine secondary or tertiary academic or non-academic referral centers. RESULTS Prior 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). CONCLUSIONS Antibiotic 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.

A comparison of partial inferior turbinectomy and cryosurgery for hypertrophic inferior turbinates

A variety of surgical procedures are performed for treatment of hypertrophic inferior turbinates, but there is no completely effective therapy. We evaluated subjectively and objectively 52 patients who underwent one of two procedures: partial inferior turbinectomy (PIT) or cryosurgery of the inferior turbinates (CS). The results of PIT showed good functional results in 77 per cent of cases for long-term effectiveness. The results of CS showed that effectiveness was reduced from a 62 per cent success rate after one year to 35 per cent later, but CS was a simple procedure which was performed on an outpatient basis with no post-operative morbidity.

Comparison of the incidence of cholesteatoma surgery before and after using ventilation tubes for secretory otitis media

Inserting ventilation tubes has become, probably, the most common surgical operation performed on children in the free world. In our study, we attempted to examine whether the widely used procedure of inserting ventilation tubes in children with secretory otitis media is indeed justified in the long term. For this purpose, we have studied the influence of the procedure on the formation of cholesteatoma by comparing the incidence of cholesteatoma surgery before and after using ventilation tubes in our department. The data were divided into two periods. The first period included the number of operations in the 10 years (1961-1970) before ventilation tubes were used as a routine treatment for secretory otitis media in our department. The second period included the number of operations in the last 10 years (1989-1998) following the usage of ventilation tubes over 30 years. We found that the number of cholesteatoma operations has decreased, from 413 operations in the 10 years before ventilation tubes were used to 228 operations over the last 10 years. The number of operations per 10000 of the entire population has decreased from 20 operations to 6.6 operations after using ventilation tubes (P=0.0000001). We have shown that the incidence of surgery for cholesteatoma has been declining. Having analyzed the options that might cause this decline, we believe that using ventilation tubes in secretory otitis media might help to reduce the incidence of cholesteatoma surgery in the long term.

Isolated extramedullary plasmacytoma of the true vocal fold.

We report a rare case of isolated extramedullary plasmacytoma (EMP) of the right true vocal fold in a 38-year-old male with a one-year history of hoarseness. Immunohistochemical staining of plasma cells in the tumour, showed over 90 per cent of them to be positive for kappa light chains. After two attempts at local surgical excision and recurrence within 10 months, the tumour was irradiated. Only seven reported cases of isolated EMP of the true vocal fold are reported in the literature. The therapeutic options are discussed.

Basement membrane material (hyaline globules) in synovial sarcoma : A case report with description of a potential diagnostic pitfall

BACKGROUND Synovial sarcoma (SS), a malignant mesenchymal tumor, has a biphasic growth pattern characteristically. Histologically and cytologically the tumor can pose diagnostic difficulty when the epithelial component is predominant. CASE REPORT A 22-year-old female presented with a rapidly enlarging mass on the lower left side of the neck. Fine needle aspiration of the tumor yielded abundant, discohesive round-oval cells mingled with amorphous hyaline material, raising a suspicion of medullary carcinoma of the thyroid. In addition, air-dried, Giemsa-stained smears demonstrated rosettelike structures with central magenta globular material, mimicking adenoid cystic carcinoma. However, histologic examination of the excised tumor, including immunohistochemical and ultrastructural studies, proved it to be a typical SS with copious basement membrane accumulations. CONCLUSION The cytologic appearance of SS can be confusing. However, a false diagnosis may be avoided if adequate needle sampling is ensured and clinical correlation considered.

Duration of antibacterial effectiveness of gentamicin ear drops in external otitis

The recommendation of Anderson and Steele, for the use of ear drops four times a day, has not been changed since 1948. In order to re-evaluate the frequency of using ear drops, we examined the duration of the effectiveness of the antibacterial activity of gentamicin ear drops in external otitis. Seventeen patients (25 ears) with external otitis were studied. We took 18 samples from each ear at 0, 1, 2, 3, 6, 8, 10, 12 and 14 hours and measured the concentration of gentamicin on the wick and in the ear canal. We found that the concentration of gentamicin began to decrease only after 12 hours and a more significant decrease was detected after 14 hours of treatment. We have shown that the antibiotic used on the wick is effective for 12 hours. In conclusion, we recommend using ear drops twice a day on a wick as routine therapy for external otitis.

Rhabdomyosarcoma of the trachea.

A 12-year-old girl was admitted on two occasions to our department because of severe dyspnoea, necessitating emergency tracheostomy. On the second admission, a lateral neck X-ray demonstrated a globular tumour which was found to be an embryonal rhabdomyosarcoma. The patient received post-operative radiation therapy followed by two years of continued chemotherapy. She is now five years post diagnosis and requiring no further therapy for about three years and her condition remains in remission.

Hemifacial spasm associated with external carotid artery compression of the facial nerve

We report a unique case of hemifacial spasm due to compression of the facial nerve by the main trunk of the external carotid artery within the parotid space. Decompression of the facial nerve as well as partial section of the proximal trunk of the nerve, caused the hemifacial spasm to disappear. Our case gives support to the theory that hemifacial spasm can be caused by pressure on the facial nerve along all its course and not only in its intra-cranial portion.

Comparison of the proteins of middle ear effusion with human mast cell proteins.

In order to clarify the role of mast cells in the aetiology of secretory otitis media (SOM), we compared the protein components of middle ear effusion (MEE) with human mast cells using acrylamide gradient gel electrophoresis and electrofocusing methods. This first direct comparison between the proteins of MEE and human mast cells has been made possible by a method developed in our laboratory for cultivation of human mast cells in tissue culture. On electrophoresis, we found that out of 12 bands of MEE proteins that were different from the serum, seven (58 per cent) had a similar electrophoretic migration rate (Rx) to mast cells. On electrofocusing, three of the four bands of MEE had a similar Rx to the mast cells. We have shown that proteins of mast cells and MEE had similar Rxs. Therefore, our study supports previous studies which suggests that mast cells play an important role in the aetiology of SOM.