Mordechai Kraus

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%.

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.

Beneficial effects of caloric vestibular stimulation on denial of illness and manic delusions in schizoaffective disorder: a case report.

INTRODUCTION Preliminary data suggests that caloric vestibular nerve stimulation (CVS) single session application of cold water to the left ear induces a clinically significant, short-lived beneficial effect on specific types of illness denial (i.e., anosognosia) and delusions (i.e., somatic type). METHODS We recently studied the effect of left versus right ear ice water (4°C) CVS on delusions and insight of illness in a patient with manic episode due to schizoaffective disorder. The patient was evaluated at baseline, immediately after the CVS, and then at 20 minutes, 60 minutes, and 24 hours. The method was first applied to one ear and 4 days later to the other. To assess whether the effect is specific to mania we employed the same procedure in two other patients with schizophrenia who also demonstrated delusions and impaired insight. RESULTS All three patients showed a difference favoring left versus right ear CVS that was maintained for 20 minutes, and diminished over a 60 minute period. EEG analyses showed a numerically non-significant increase in bilateral frontal and central alpha EEG band activation (more pronounced in the right hemisphere) with left but not right ear CVS 5 minutes after the CVS, and that diminished after 20 minutes. DISCUSSION The results suggest that left versus right CVS may have a short lived beneficial effect on manic delusions and insight of illness that seem to appear in other types of psychoses (i.e., schizophrenia). CONCLUSION These preliminary results suggest that single session CVS may have short lived beneficial effects in mania and perhaps in other types of psychoses. Further research is mandatory.

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.

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.

Relation between Peritonsillar Infection and Acute Tonsillitis: Myth or Reality?

Objective. To investigate the relationship between tonsillar and peritonsillar infections. Study Design. Retrospective population-based study and a retrospective case series review. Settings. Tertiary academic medical facility. Subjects and Methods. All individuals hospitalized with peritonsillar abscess (PTA) or peritonsillar cellulitis (PTC) during 2004-2008 were reviewed. Patient age, gender, diagnosis of PTA or PTC, recurrence, and date of presentation were recorded. In addition, a database of patients diagnosed in the community with acute tonsillitis (AT) was reviewed for the same time period. The weekly number of patients with AT was recorded, and a comparison between incidence of tonsillar infections and peritonsillar infection was performed. Results. A total of 685 patients were hospitalized with either PTA (467) or PTC (218). Incidence of both upper respiratory infections and AT peaked in January and February of every year with a nadir in August. In contrast, PTA and PTC showed a consistent rate of infection throughout the year. Likewise, assessment based on weekly intervals showed that peaks of PTA and PTC did not follow those of acute tonsillitis with a 1 to 2 weekly lag as would be expected if peritonsillar infection is a complication of AT. Rather, an association between peritonsillar infection and tonsillitis was found within the same week (P = .04). Conclusion. Higher rates of occurrence of PTA or PTC following AT outbreaks were not found. These results lend further support to the theory that peritonsillar infection is associated not only with complications of AT but may occur from infection of Weber glands or other unknown causes.

Candida parotitis with abscess formation

This report describes the case of an elderly, diabetic man who developed acute suppurative parotitis with abscess formation. The causative agent of parotid abscess was Candida albicans, which is an unusual cause of salivary gland pathology. The parotid gland is the salivary gland most commonly affected by inflammation. Acute parotitis occurs most often in elderly patients who are debilitated by systemic disease or are in a state of dehydration following major surgical procedures. Despite the high prevalence of oral candida carriage, there have been few previous reports of candida sialoadenitis in the literature. This is due to the toxicity of saliva to fungi under normal conditions. The diagnosis of candidiasis in our patient was made by culturing the purulent discharge from Stensens duct and by culture of the pus obtained at surgical drainage of the abscess. After incision and drainage, the patient was treated with intravenous and then oral fluconazole for a total of 4 weeks with complete resolution of his condition. This case is interesting in light of recent and ongoing investigations of salivary proteins as potential new antifungal agents.

Central nervous system complications secondary to oto-rhinologic infections. An analysis of 39 pediatric cases

Fifty-eight central nervous system complications were noted in 39 pediatric patients with a primary oto-rhinological infection. The ages ranged from 1 to 15 years. Eleven patients (25%) had more than one complication. 12.8% of the cases died. Leptomeningitis was the most common intracranial complication (54%) Lateral sinus thrombosis (LST) occurring in 10 patients (26%) was accompanied with other intracranial abnormalities in 80% of cases. Brain abscess as an initial or concomitant complication was associated with the highest mortality rates (40%). In two of these fatal cases multiple brain abscesses were detected. The low incidence of intracranial infections secondary to oto-rhinologic infections and the masking effect of antibiotics present difficulties in the early recognition of the CNS complication. Despite the value of the modern imaging techniques in the investigation of the CNS complication, the clinical oto-rhinologic examination is of paramount importance in detecting the original infection in the pneumatic spaces of the upper respiratory tract. Additionally, bone scans were found of value in demonstrating the osteitic process of these cases.

Burkitt's lymphoma of the tonsil

A case of Burkitts lymphoma involving the tonsil in a 10-year-old Bedouin boy, is presented. The biological behaviour and the clinical presentation of this unusual neoplasm are discussed and the English language literature is reviewed. The diagnosis was made by histological examination, electron microscopy and confirmed by immunohistochemistry. The patient showed an excellent symptomatic response to surgery and chemotherapy.

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.