Moshe Puterman

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.

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.

Bilateral consecutive blindness due to sphenoid sinus mucocele with unilateral partial recovery

BACKGROUND We present an interventional case report of a rare occurrence of sphenoid sinus mucocele causing bilateral consecutive blindness with unilateral partial recovery after endoscopic surgery. METHODS A 64-year-old woman with known sphenoid sinus mucocele and right blindness was referred because of an acute drop of vision to hand motion in her only-seeing left eye over 5 days. Imaging revealed a large mucocele enlarging the sphenoid sinus, eroding the base of the skull, protruding into the cranial cavity, and compressing the left optic nerve. RESULTS Urgent endoscopic sphenoidotomy was performed. Several hours after the procedure, visual acuity was partially recovered in the left eye. INTERPRETATION Sphenoid sinus mucoceles can cause bilateral blindness. A high index of suspicion and urgent imaging studies are necessary. Because visual recovery depends on prompt diagnosis and surgical intervention, a close collaboration between otolaryngologists and ophthalmologists is crucial.

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.

Endoscopic, assisted, modified turbinoplasty with mucosal flap

A variety of surgical methods have been developed to reduce the volume of the inferior turbinates, in order to create a more patent nasal airway. We describe a technique used in our department since February 2002 for all patients undergoing inferior turbinectomy. We resect with endoscopic assistance the lateral mucosa and bony inferior turbinate. This technique can reduce a large volume of the turbinate while preserving the mucosal continuity and the submucosa by covering the raw surface with a mucosal flap. We believe our method minimises post-operative side effects and complications such as dryness, infection, bleeding and pain.

Circulating cytokines in patients undergoing tonsillectomy with fibrin glue

OBJECTIVE Fibrin glue is used as a haemostatic agent or as a sealant. The aim of this study is to objectively evaluate the efficacy of the use of fibrin glue Quixil - a human surgical sealer - in tonsillectomy, for the reduction of post-operative inflammatory response. STUDY DESIGN A prospective randomized single-blind study. METHODS The study was performed on 40 consecutive patients undergoing adenotonsillectomy (T&A). Patients were randomly assigned to one of two sub-groups: a study group and a control group. The tonsillar beds of patients in the study group were coated with fibrin glue (Quixil, OMRIX biopharmaceuticals) at the end of the operation; the patients in the control group were treated for hemostasis without the use of fibrin glue. Complete blood counts and circulating pro-inflammatory cytokines (assayed by specific immunoassay - ELISA) were assessed in samples drawn pre- and 16 h post-tonsillectomy. RESULTS Forty patients (aged 5.8 ± 2.4 years) were consecutively enrolled; 45% (18) of the patients were treated with fibrin glue, 55% (22) were not. Compared to controls, Quixil-treated patients demonstrated a reduction in post-tonsillectomy circulating leukocytes (29.2% vs. 45.4%, p<0.05), neutrophiles (28.3% vs. 42.1%, p<0.05), IL-6 (+1% vs. +42%, p<0.05), and TNF-alpha (+8% vs. +26%, p<0.05. CONCLUSIONS Intra-operative fibrin glue therapy is associated with decreased immediate inflammatory response following T&A. Further studies are warranted to assess long-term outcome. LEVEL OF EVIDENCE 1B.

Rates of tympanic membrane closure in double-tympanocentesis studies.

Background: Data on the outcome of tympanic membrane (TM) closure after tympanocentesis in acute otitis media (AOM) patients is limited. Objectives: To analyze the dynamics of TM perforation closure after 1 or 2 tympanocentesis procedures performed at diagnosis and during AOM treatment. Patients and Methods: Study population included 113 children enrolled in 4 double-tympanocentesis studies. Only the files of patients whose first and second examination were performed by the same 2 otorhinolaryngologists were analyzed. Middle ear fluid (MEF) was cultured on day 1 and days 4–6, the latter only in initially culture-positive patients. Patients were also examined on days 11–14 and followed until days 22–28. Results: Ninety-three (82%) patients underwent tympanocentesis on days 4–6; 103 (91%) and 95 (84%) were evaluable on days 11–14 and 22–28, respectively. One hundred seventy-three ears underwent tympanocentesis on day 1 and 139 on days 4–6. Ninety-seven (86%) patients had positive MEF cultures. One hundred fifty-three (88%) tympanocentesis procedures performed at enrollment were closed on days 4–6. No differences were recorded in the closure rates as function of patient age, previous AOM history, MEF culture positivity, pathogens isolated at enrollment, and pathogen eradication on days 4–6. The 20 eardrums still open on days 4–6 were closed on days 11–14. Eleven (9%) of the evaluable ears tapped on days 4–6 were not closed on days 11–14 and 9 of 10 were closed on days 22–28. Conclusions: TM perforation closed in most cases within a few days regardless of patient and disease characteristics, and 2 consecutive tympanocentesis procedures performed at short-time intervals are associated with good TM closure rates.

A severe form of sjogren's syndrome

Sjogrens syndrome is an autoimmune disease characterized by exocrine gland destruction and manifested by parotid, submandibular and lacrimal gland infection. We report a case with recurrent severe parotid gland infections. The sialographic and CT findings are presented.

Vallecular papilloma simulating chronic pulmonary disease

Presented here is a case of chronic persistent cough, in a patient in whom squamous papilloma of the base of tongue was found. The cough disappeared completely after removal of the tumour.