Iman Naseri

Nationwide Trends in Pediatric Staphylococcus aureus Head and Neck Infections

OBJECTIVES To evaluate the epidemiologic manifestations of pediatric Staphylococcus aureus head and neck infections nationwide and to identify possible trends in the antibiotic drug susceptibility of S aureus during a 6-year period. DESIGN Retrospective review of microbiologic data from a peer-reviewed national database. SETTING More than 300 hospitals nationwide. PATIENTS All pediatric patients with head and neck infections involving S aureus. MAIN OUTCOME MEASURES Anatomic sites were divided into oropharynx/neck, sinonasal, and otologic infection categories. Demographic and antimicrobial drug susceptibility patterns were reviewed. RESULTS A total of 21,009 pediatric head and neck S aureus infections that occurred between January 2001 and December 31, 2006 were gathered from the database. Predominance was observed in the oropharyngeal/neck category (60.3%). For all sites, the mean patient age was 6.7 years (range, 0-18 years), with a 51.7% male predominance. There was a high occurrence in the North East Central region of the United States. Overall, methicillin-resistant S aureus was seen in 21.6% of all patient isolates (n = 4534), with rates of 11.8%, 12.5%, 18.1%, 27.2%, 25.5%, and 28.1% for 2001 through 2006, respectively. This represents a 16.3% increase in methicillin-resistant S aureus during these 6 years for all pediatric head and neck S aureus infections. CONCLUSIONS There is an alarming nationwide increase in the prevalence of pediatric methicillin-resistant S aureus head and neck infections. Disparities in the treatment of various head and neck infections nationwide may contribute to the regional differences in the prevalence of such infections. Judicious use of antibiotic agents and increased effectiveness in diagnosis and treatment are warranted to reduce further antimicrobial drug resistance in pediatric head and neck infections.

The increased risk of community-acquired methicillin-resistant Staphylococcus aureus neck abscesses in young children.

To analyze the microbiological origins of deep neck space infections requiring surgical intervention in a pediatric population.

Proximal pharyngeal reflux correlates with increasing severity of lingual tonsil hypertrophy

Objective To determine if degree of lingual tonsil hypertrophy(LTH) correlates with pharyngeal reflux. Design Prospective. Methods Patients with flexible laryngoscopic evidence of LTH were included. Degree of LTH was graded mild, moderate, or severe by two otolaryngologists blinded to pH study results. Threesensor pH study results were correlated to LTH grade. Results Nineteen patients were included (five with mild LTH, eight with moderate LTH, and six with severe LTH). Nasopharyngeal reflux (NPR) events <pH4 were found in four of six severe LTH patients but no mild or moderate LTH patients (P = 0.006). All severe LTH patients had NPR events <pH5, compared with only 4 of 11 mild or moderate LTH patients (P = 0.017). Atthe UES, 4 of 6 severe LTH patients had pathologic reflux, compared with 4 of 13 mild or moderate (P = 0.025). Interobserver reliability calculated by Cohens kappa was excellent (0.92). Conclusions Our study shows a continuum of increasing pharyngeal reflux with higher LTH severity. Severe LTH may be a reliable physical sign of pharyngeal reflux, especially NPR.

High-Volume Tracheostomies in the Critically Ill Population: Analysis of Technique and Indications

Objectives: Analyze the frequency of and techniques used in performing tracheostomies. Understand the prevailing contraindications used in the decision between open versus percutaneous method. Evaluate outcomes among the 2 modes of tracheostomy procedures. Methods: Case-series review of all patients who underwent a tracheostomy spanning 4 years within a tertiary metropolitan hospital. Clinical and demographic data were used to compare the 2 groups of patients with respect to average age, hospital stay, related emergency department (ED) visits, and other complications. Results: A total of 1333 tracheostomies were performed on 1302 patients. This included 452 (34%) open versus 881 (66%) via the percutaneous dilatational technique (PDT). There was no difference in short-term complications between the 2 groups. The primary long-term complication, tracheal stenosis, occurred most commonly in the PDT group. The contraindications practiced in decision for open versus PDT are not uniform among the various services performing tracheostomies. Approximately 26% of all discharged patients presented to the ED with respiratory or tracheostomy-related complaint within 90 days of discharge. Conclusions: We present the largest tracheostomy case-series containing a majority performed via the percutaneous technique. Tracheal stenosis is the most common long-term complication seen primarily among PDT group, indicating that factors such technique may lead to such outcomes. Institutional adoption of absolute contraindications may be necessary to avoid long-term complications. The development of an institutional common pathway for care and follow-up may help avoid related ED visits.

Surgical Management of Spontaneous and Traumatic Anterior Skull Base Meningoceles: Technique and Pitfalls

Objectives: A majority of anterior skull base meningoceles are often managed via the endoscopic endonasal approach (EEA) for the excision and repair of the cerebrospinal fluid (CSF) leak, in addition to the reconstruction of the skull base defect. The aim of the study was evaluation of an institutional case series to identify specific risks and strategies for successful management of anterior skull base meningoceles. Methods: Case series review of all surgical cases involving repair of any anterior skull base meningocele spanning 3 years. Results: A total of 18 patients were managed surgically for repair of meningocele with or without CSF rhinorrhea. All patients had postoperative follow-up to one year. EEA was used in 17 patients, and one had a combined transcranial with endoscopic approach. Four patients had meningoceles with a larger than 1.0-cm bony skull base defect. Large spontaneous meningoceles along the ethmoid were likely to include cerebrovascular structures within their intranasal component. Nasal airway obstruction was the initial presenting symptom in all large spontaneous ethmoid meningoceles, rather than CSF rhinorrhea (present in all large traumatic ones). Conclusions: The endoscopic technique is a safe and effective approach to repair of anterior skull base defects involving both ethmoid and sphenoid regions. Successful repair of lateral sphenoid wall defects depends on gaining sufficient access via incorporating extended approaches, such as trans-pterygopalatine approach. Preoperative angiography may be warranted, especially in spontaneously appearing anterior skull base meningoceles with a bony defect larger than 1.0 cm.

Targeted Multilevel Surgical Management of Obstructive Sleep Apnea: A Case Series of 44 Patients

Objectives: (1) Assess the effectiveness of multilevel surgery in the treatment of obstructive sleep apnea (OSA). (2) Analyze outcomes based on reduction of apnea hypopnea index (AHI) and positive airway treatment pressures. Methods: Case-series review in a tertiary referral center. A total of 44 patients underwent multilevel OSA surgery between November 2009 and September 2013. Depending on the preoperative examination and OSA severity based on sleep study, patients underwent multilevel surgery including nasal, oropharyngeal, transoral robotic, tongue base, hyoid, and/or orthognathic surgery. Follow-up sleep studies at 4 months were obtained and compared with preoperative data. Results: Overall AHI was significantly reduced from a mean of 44.5 to 19.9 (P = .0008), 78.9 to 35.8 (P = .0001) in the severe OSA group, 21.4 to 7.0 (P = .0001) in the moderate group, and 8.7 to 4.5 (P = .0004) in the mild group. AHI reduced from mean of 98.1 to 31.7 (P = .0013) in those who underwent orthognathic surgery and 36.1 to 18.1 (P = .011) in those who had soft tissue procedures without orthognathic surgery. Overall continuous positive airway pressure (CPAP) improved from mean of 10.9 to 4.7 cmH20 (P = .0001). Body mass index was significantly higher in the severe OSA group than the mild and moderate groups. No significant difference was noted in neck circumference between the 3 groups. Conclusions: Targeted multilevel OSA surgery in this cohort was successful in an overall reduction of AHI and CPAP pressures. The maximum improvement in AHI was seen in patients with moderate OSA and in those who had an orthognathic procedure.

Endoscopic Orbital Decompression: When and How?

Objective: 1) Identify acute and chronic indications for orbital and/or optic nerve decompression. 2) Review known techniques for endoscopic orbital decompression. 3) Evaluate the necessity to include inferior orbital wall/orbital floor. 4) Compare and contrast the endoscopic technique in comparison to various open methods. Method: Retrospective review of all patients that underwent endoscopic orbital decompression procedures between 2009 and 2011. Data analysis included review of perioperative clinical findings, operative technical details, radiology data, and outcomes. Results: A total of 15 orbital decompressions were performed. All patients underwent endoscopic medial orbital wall decompression, 2 included the orbital floor. The majority of the patients had allergic fungal sinusitis as their primary diagnosis for surgical indication (n = 7, 47%). Neoplasms (n = 5, 33%) and Graves disease (n = 3, 20%) were the remaining diagnoses. Restricted ocular motility, proptosis, and diplopia were the most common presentations indicating surgery (n = 13, 11 and 8, respectively). Resolution of diplopia was observed in all patients, but delayed in Graves patients (2-3 months). Proptosis improved in 7 patients (64%), without any significant difference among those including orbital floor. Conclusion: The endoscopic technique for orbital decompression is a safe and less invasive alternative to currently used open approaches. Sufficient medial wall decompression may yield sufficient outcomes, precluding the need for including the orbital floor. Further objective outcomes data is needed to compare proptosis among various modes of endoscopic decompression techniques.

Percutaneous vs Open Tracheostomy for Critical Care Patients

Objective: 1) Evaluate the indications for performing a tracheostomy across the spectrum of all trauma and pulmonary critical care patients. 2) Understand the existing contraindications used in the decision against performing a percutaneous dilatational tracheostomy. 3) Examine outcomes among the 2 modes of tracheotomy procedures. Method: A retrospective review identifying all patients who underwent open surgical or percutaneous dilatational tracheostomy procedure spanning 3 years (from 2008) within a tertiary hospital. Clinical and demographic data were used to compare the 2 groups of patients with respect to average age, hospital stay, related ER visits, and other complications. Results: A total of 1333 tracheostomies were performed on 1302 patients. This included 452 (34%) open surgical versus 881 (66%) percutaneous dilatational techniques. There was no significant difference in age between the 2 groups (53 years). The average length of hospital stay was 21 days, indifferent among the 2 groups. The majority of the total tracheostomies were performed by the surgical services, in comparison to the pulmonary critical care service, 1080 (81%) versus 253 (19%), respectively. Approximately 26% of all discharged patients had a related ER visit (respiratory or tracheostomy-related) within a year. Conclusion: A majority of tracheostomies at our tertiary care trauma hospital are performed via the percutaneous technique. Both groups have similar short-term safety and complication rates. Our surprisingly high ER return rate suggests possible deficiency in pre-discharge teaching and care arrangements. Prospective studies are needed to determine long-term complications.

P055: Neuropsychiatric Evaluation in Patients w/Skull Base Tumors

OBJECTIVES: 1. Pictorially review 25 cases of Paragangliomas of head and neck, in terms of their clinical presentation, and radiological and surgical findings. METHODS: The study was a retrospective and prospective analysis of 25 cases of Paragangliomas of the head and neck region seen at a medical college hospital. A systematic record of the clinical presentation, radiological investigations (ultrasound, CT Scan, MRI), medical and surgical management with intraoperative findings, and the final outcome was made. RESULTS: Out of the 25 cases of Paragangliomas, 18 cases of Carotid body tumor, 4 cases of Glomus tympanicum, 2 cases of Glomus Jugular, and 1 case of Glomus Vagale were seen. One patient of bilateral Carotid body tumor was also seen. The most common presentation of carotid body tumor was a neck swelling. Glomus Tympanicum and Glomus Jugulare typically presented with tinnitus. Ultrasound could accurately diagnose 12 cases of carotid body tumours, while MRA confirmed the diagnosis in all cases; 17 patients underwent surgery while the rest were conservatively managed. CONCLUSIONS: Paragangliomas are very rare tumors, with a high incidence at high altitude areas. Surgery is indicated in selected cases and mortality due to these tumors is uncommon.

08:54: The Role of Gastric Reflux in Lingual Tonsil Hypertrophy

MMC was associated with improved surgical outcomes for airway obstruction in 15 of 17 articles (7 of 8 human, 8 of 9 animal). Among human studies, random effects modeling revealed that 81.4% (95% CI 72.0%-90.9%, p 0.001) of individual patients had improved outcomes attributed to the use of MMC compared with near 100% subject benefit for animal studies. Human studies tended to have a smaller sample size (mean 17 vs. 27), decreased MMC concentration(1.43 mg/ml vs. 4.06 mg/ml), and decreased duration of application (3.9 vs. 4.1 minutes) than animal studies. CONCLUSIONS: The level of evidence supporting the human use of MMC is fair and consists mainly of small uncontrolled case series. Animal models tended to have superior study design and more aggressive MMC dosing. Further studies addressing MMC dosing are needed before the benefits of MMC can be fully understood.