Gadi Fishman

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.

The effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the Test of Variables of Attention (TOVA) in children with obstructive sleep apnea syndrome

OBJECTIVE: To evaluate children with obstructive sleep apnea syndrome (OSAS) for features of attention deficit disorder (ADD) using an objective test of inattention and impulsivity: Test of Variables of Attention (TOVA) and then to determine whether tonsillectomy and adenoidectomy (T+A) results in an improvement in TOVA scores. STUDY DESIGN AND SETTING: This study was a prospective interventional comparative trial in a tertiary care childrens hospital. Nineteen children ages 5 to 14 years with OSAS, and otherwise healthy, with a clinical indication for T+A. Preoperative and 2 months postoperative OSA-18, CBCL questionnaires, and TOVA scores were evaluated. RESULTS: The preoperative TOVA scores were in the abnormal range in 12/19 (63%) of the children. The mean preoperative TOVA score was −2.9 (± 3.1). The mean postoperative TOVA score was −0.4 (±2.8). The improvement in the TOVA scores was significant (P < 0.0001, t-test). CONCLUSION: This preliminary data suggests that treatment of OSAS with T+A results in significant improvement in objective parameters of inattention and impulsivity. SIGNIFICANCE: These findings may be important in understanding the impact of OSAS and therapeutic interventions on behavioral problems in children.

Conservative management of acute mastoiditis in children

OBJECTIVE To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy. DESIGN A retrospective chart review. SETTING Tertiary-care, university affiliated childrens hospital. PATIENTS One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002. INTERVENTIONS All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call. MAIN OUTCOME MEASURES Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions. RESULTS Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR. CONCLUSIONS These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: Inter-observer correlation and comparison with awake endoscopy

OBJECTIVE Evaluate the inter-observer correlation of sleep endoscopy findings in children with persistent obstructive sleep apnea (OSA) with awake office fiber-optic endoscopy. METHOD DESIGN retrospective case series; blinded review. SETTING tertiary care childrens hospital. PATIENTS Children with persistent obstructive sleep apnea. INTERVENTIONS Both awake and drug induced sleep endoscopy were performed. Endoscopy video recordings were mixed at random on a DVD. Two pediatric otolaryngologists and two pediatric pulmonologists independently scored each recording using an upper airway endoscopy scoring survey. MAIN OUTCOME MEASURES reviewers scored the following parameters: each structures contribution (nose, nasopharynx, lateral pharyngeal walls, tongue base, supraglottis) to the obstruction, the main site in which the obstruction occurs, the severity of OSA (mild, moderate, severe), the level of confidence of endoscopy findings (poor, fair, good). RESULTS When reviewing sleep endoscopy recordings for the upper airway obstruction site, the highest correlation among the four observers was found for the nasopharynx and the supraglottis (Kappa score: 0.6 and 0.5, respectively). Compared to awake endoscopy, sleep endoscopy demonstrated more cases of airway obstruction caused by collapse of lateral pharyngeal walls and base of tongue (McNemar test for symmetry, P value<0.05). Level of confidence among the four observers was higher in older children and lower in children with severe OSA. CONCLUSIONS Sleep endoscopy is a consistently reliable tool for identifying the site of obstruction in children with persistent OSA. Though anesthetic induced sleep is not a perfect model for real sleep, the technique demonstrably guides further therapy better than awake endoscopy.

Fat graft myringoplasty: results of a long-term follow-up.

OBJECTIVE To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. DESIGN Prospective case series study. MAIN OUTCOME MEASURES Patients with chronic tympanic membrane perforations were considered candidates for fat graft myringoplasty. Excluded were patients with purulent discharge, suspected ossicular disease, suspected cholesteatoma, or a perforation diameter greater than 6.5 mm. Fat was harvested from the ear lobule or subcutaneous tissue just posterior-inferior to the lobule. RESULTS The study population comprised 27 adults and 11 children. Twenty-eight perforations were small (73.7%) and 10 were large (26.3%). Altogether, 31 of 38 perforations were successfully repaired (81.6%), including 22 of 28 small perforations (78.6%) and 9 of 10 large perforations (90%). Assessment by age showed that 23 of 27 perforations of the adults (85.2%) and 8 of 11 perforations of the children (72.7%) successfully closed (p = .648). Follow-up ranged from 25 to 53 months (mean 40.6 +/- 8.3 months). No recurrence of the perforation during the follow-up period was recorded if the initial results were successful. The speech reception threshold improved significantly (18.5 +/- 7.7 dB vs 23.5 +/- 8 dB; p = .043). No significant sensorineural hearing loss occurred. CONCLUSIONS Fat graft myringoplasty is a reliable technique for the closure of small- and medium-sized perforations. The grafting results showed excellent long-term durability. Given the simplicity of the technique, its short duration, and the favourable hearing results, fat graft myringoplasty should be considered the procedure of choice in patients with suitable perforations and when not otherwise contraindicated.

Long-Term Outcome of Atticotomy for Cholesteatoma in Children

Objective: To evaluate the long-term outcome of atticotomy (AT) surgery for cholesteatoma in children. Study Design: Case series, retrospective chart review. Setting: General otology practice in a teaching hospital. Patients: Fifty-three children aged 5 to 16 years old with cholesteatoma limited to the attic and middle ear who underwent AT between the years 1979 to 1994. Interventions: AT consisting of removal of cholesteatoma confined mainly to the attic. The procedure consists of removal of the lateral attic wall (scutum) and involved ossicles with excision of the cholesteatoma and tympanic membrane grafting with temporalis fascia, leaving a small attical cavity. The mastoid antrum was left intact. Main Outcome Measures: Disease recurrence, middle ear status, hearing results, and the need for further surgery. Results: Mean follow up was 5.1 (±3.6) years. Eleven (21%) children required completion canal wall down tympanomastoidectomy because of residual disease or recurrence. The mean preoperative speech recognition threshold was 39.4 ± 13.4 dB. The mean postoperative speech recognition threshold was 34.5 ± 15.4, an improvement of 6.1 dB compared with the preoperative level. Last follow-up examination revealed a dry ear in all cases but one. Conclusions: In selected cases, AT can be a less invasive option in children with cholesteatoma limited to the attic and middle ear.

Malignant melanoma of the lacrimal sac: A case study

Primary malignant melanoma of the lacrimal sac is extremely rare and is usually diagnosed late, after excision or biopsy of the tumor. Its current management consists of surgical excision, chemotherapy, radiation therapy, and immunotherapy in various combinations. This form of the melanoma is probably not curable. We present a case of malignant melanoma of the lacrimal sac and nasolacrima1 duct that masqueraded as a chronic dacryocystitis.

Improving children's cooperation with tracheotomy care by performing and caring for a tracheotomy in the child's doll-a case analysis.

Described is a 2-year-old child who required a tracheotomy for an obstructing laryngeal tumor. Post-operatively the child responded with extreme anxiety and refused to cooperate with tracheostomy care including suctioning, tie changing and cannula change. A novel approach was attempted. We performed a tracheotomy on the childs favorite doll and taught her to perform all the necessary tracheostomy care on the doll. Once the child became accustomed to treating the doll, it became much easier to care for her tracheostomy and compliance to treatment improved greatly to the point were restraint was no longer required. This model of mock surgery and care of a childs doll may be helpful in treating young children with tracheotomies.

Optical-fiber-coupled inferometric measurement of tympanic membrane temperature: a new diagnostic tool for acute otitis media

A novel infrared (IR) transparent optical fiber coupled to a hand held otoscope and a radiometer was constructed and used to measure the temperatures of the tympanic membrane (TM) and to distinguish between diseased and healthy middle ears. A greater temperature difference between TM readings was found when Acute Otitis Media (AOM) existed in one of the ears examined. This supports the hypothesis that acute inflammation of the middle ear will result in elevated local temperature when measured in such a way that the reading is taken only from the TM without interference of the external canal. The use of an optical fiber enabled temperature measurements of the TM with high spatial resolution eliminating the external ear canal interference. A small patient population was examined and the initial results were statistically significant. In the hands of the primary care physician, this tool would prevent misdiagnosis of AOM preventing indiscriminate use of antibiotics and avoiding complications by early diagnosis.

Improved tympanic thermometer based on a fiber optic infrared radiometer and an otoscope and its use as a new diagnostic tool for acute otitis media

Clinical diagnosis of acute otitis media (AOM) in children is not easy. It was assumed that there is a difference ΔT between the Tympanic Membrane (TM) temperatures in the two ears in unilateral AOM and that an accurate measurement of ΔT may improve the diagnosis accuracy. An IR transmitting fiber, made of AgClBr, was coupled into a hand held otoscope and was used for the non-contact (radiometric) measurements of TT, the TM temperature. Experiments were carried out, first, on a laboratory model that simulated the human ear, including an artificial tympanic membrane and an artificial ear canal. Measurements carried out using commercially available tympanic thermometers shown that the temperature Tc of the ear canal affected the results. Tc did not affect the fiberoptic radiometer, and this device accurately measured the true temperature, TT of the tympanic membrane. A prospective blinded sampling of the TM temperature was then performed on 48 children with suspected AOM. The mean temperature difference between the ears, for children with unilateral AOM was ΔT = (0.68 ± 0.27)°C. For children with bilateral AOM it was ΔT = (0.14±0.10)°C (p<0.001). It was demonstrated that afor unilateral AOM the difference ΔT was proportional to the systemic temperature. In conclusion, the fiberoptic interferometric measurements of the TM can be a useful non-invasive diagnostic tool for AOM, when combined with other data.