Nili Segal

Acute Otitis Media Caused by Streptococcus pyogenes in Children

BACKGROUNDnStreptococcus pyogenes, or group A beta -hemolytic Streptococcus (GAS), is an important causative agent of bacterial pharyngotonsillititis and skin, soft-tissue, and invasive infections. Although it is also an important pathogen in acute otitis media (AOM), its exact role has not been determined.nnnMETHODSnPatients aged 0-18 years with AOM, from whom a specimen of middle-ear fluid was obtained and cultured during 1999-2003, were enrolled. Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and GAS were considered pathogens. Information collected included demographic characteristics, clinical history, and signs and symptoms.nnnRESULTSnGAS otitis was observed in 350 (3.1%) of 11,311 episodes (of which 117 were also culture-positive for other pathogens). The other 10,961 episodes involved H. influenzae only (n = 2507), S. pneumoniae only (n = 2131), dual infection with H. influenzae and S. pneumoniae (n = 1290), M. catarrhalis only (n = 129), and other combinations of pathogens (n = 271). Increased age and Jewish ethnicity were independent, significant, positive risk factors for GAS AOM, and fall season was a negative risk factor. Episodes of GAS infection were less frequently bilateral, febrile, and accompanied by other systemic findings than were other episodes of other types of infection. Most patients with GAS AOM presented with acute drainage from the ears. A lower proportion of cases of AOM were due to GAS in children with recurrent AOM and in patients recently treated with antibiotics, compared with patients with AOM who did not have these factors. The risk for mastoiditis was highest among patients with GAS AOM, compared with patients infected with other pathogens: 11.6 episodes per 1000 episodes of GAS AOM, compared with 2.2, 0.3, and 0 episodes of mastoiditis per 1000 episodes of AOM due to S. pneumoniae, H. influenzae, and M. catarrhalis, respectively.nnnCONCLUSIONnCompared with AOM caused by pathogens other than GAS, GAS AOM is characterized by older age and higher local aggressiveness manifested by lower rates of fever and respiratory symptoms and higher rates of tympanic perforation and mastoiditis.

Peritonsillar abscess in children in the southern district of Israel.

OBJECTIVEnPeritonsillar abscess is the most common deep neck infection and still provides a challenge to care givers in terms of diagnosis and treatment in the pediatric population. This study reviews our experience over the years 2004-2007 at the Soroka University Medical Center in the southern district of Israel in treating children with peritonsillar abscess. We compared our results with data regarding peritonsillar abscess in adults.nnnMETHODSnWe performed a retrospective chart review of 126 children diagnosed and proved to have a peritonsillar abscess. Data regarding: age, sex, ethnicity, number of patients per year, seasonality, prior history of tonsillar infection, prior antibiotic treatment, length of hospitalization, surgical treatment, bacterial results and in hospital antibiotic treatment was collected from the medical charts of the patients.nnnRESULTSnThe average age of children with peritonsillar abscess was 12.8 years. 92 patients (73%) were above 10 years of age. We did not find an increase in the number of children with peritonsillar abscess per year over the time period of the study. The number of patients with peritonsillar abscess was significantly higher in the autumn and spring, 79 (62.6%) patients did not have prior history of tonsillar infections and 64 (67.4%) children were treated with antibiotics prior to the diagnosis of an abscess. In 95 (75.4%) patients the drainage method was needle aspiration, in 30 (28.3%) patients incision and drainage was performed and only one patient underwent bilateral quinsy tonsillectomy (0.8%). The bacterial culture was negative in 37 (36.7%) patients. In 29 patients (45% of positive cultures) the causative organism was Streptococcus group A. Mixed culture was present in 10 (15.6%) patients, nine cultures (14%) were positive for anaerobes, alone or in combination with other pathogens. Eighty-one patients (64.2%) were treated with amoxicillin-clavulanate potassium, 24 (19%) received cefuroxime and 17 (13.5%) were treated with cefuroxime+ metronidazole. The average hospital stay was 3 days.nnnCONCLUSIONnPeritonsillar abscess, a potentially life threatening infection, is similar in presentation and bacteriology in the pediatric and the adult population. Based on our review we conclude that peritonsillar abscess in children can be effectively treated by the same methods used in the adult population.

A prospective randomized double-blind trial of fibrin glue for reducing pain and bleeding after tonsillectomy.

OBJECTIVESnVarying 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.nnnSTUDY DESIGNnA prospective randomized double-blind study was performed on 168 consecutive patients undergoing tonsillectomy for obstructive sleep apnea and chronic tonsillitis.nnnMETHODSnPatients 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.nnnRESULTSnNinety-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.nnnCONCLUSIONSnWe 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.

Mucinous sweat gland adenocarcinoma of the eyelid - current knowledge of a rare tumor.

Purpose: To review the medical literature on mucinous sweat gland adenocarcinoma of the eyelid (MSA) and present two new cases. Methods: Details of published case reports and small series (between 1971–2010) were evaluated and summarized including two patients diagnosed and treated at our institution. Data regarding age, gender, ethnicity, precise location, clinical presentation, treatment and follow up of each patient were collected. Results: 25 reports describing 55 patients were found in the medical literature. The mean age was 61.3 years (30–87), 22(59%) were male and 28(80%) were Caucasian. In 23(44.2%) patients the lesion was in the lower lid, in 20(38.5%) in the upper lid, in 3(5.7%) involving both lids and in 6(11.6%) in a canthus. In 12(21.8%) patients a lesion with a benign diagnosis was previously excised from the same location. In 2 of them histological re-examination resulted in a diagnosis of MSA. Intraorbital involvement was found in 2(3.6%) patients. Regional lymph node metastasis was found in 2(4.4%) patients. Surgical excision was the treatment of choice using Mohs’ micrographic-controlled excision technique in recent years. Radiotherapy was applied to 2 patients with clinical resolution in 1. Recurrence of the tumor was reported in 14(30%) patients. Conclusions: MSA is a rare tumor of the eyelid with no clinically distinguishing features. It should be suspected particularly with recurrent eyelid lesions and must be differentiated from metastatic disease. The tumor may extend into the orbit and metastasize regionally. Surgical removal with continued regular follow-up examination is the treatment of choice.

Pediatric invasive sinonasal Scopulariopsis brevicaulis--a case report and literature review.

OBJECTIVEnAcute invasive fungal sinusitis (AIFS) appears mainly in immunocompromized patients and may be caused by various pathogens. We describe a teenager with invasive sinonasal Scopulariopsis brevicaulis and review all the reports on this rare pathogen.nnnMETHODSnA literature search on Scopulariopsis sinonasal invasive infections was performed and clinical data including age, gender, co-morbidities, treatment and prognosis was collected on all the patients.nnnRESULTSnA 17 years old boy with acute myelocytic leukemia and Scopulariopsis brevicaulis sinonasal infection was successfully treated at our department with a combination of extensive surgical debridement and antifungal antibiotics. We found six articled describing six patients with AIFS due to Scopulariopsis species. Four patients were adults and two were children, 3 males and 3 females. Two had an infection with Scopulariopsis acremoium, one with Scopulariopsis candida and for 3 patients no data was given on the specific Scopulariopsis species. All the patients except one were immunocompromized. One patient was treated with antifungal drugs, 2 with surgery and 4 patients received antifungals and were operated. One patient died due to the fungal infection and two patients died due to other causes.nnnCONCLUSIONSnScopulariopsis AIFS is a life threatening disease affecting mainly immunocompromized patients, both children and adults. No clear treatment regimen has been established yet. We describe the first case of a teenager with Scopulariopsis brevicaulis sinonasal infection treated successfully with a combination of wide local excision and antifungal therapy.

Asymmetric Hearing Loss in a Random Population of Patients with Mild to Moderate Sensorineural Hearing Loss

Objectives: We evaluated the correlation of asymmetric hearing loss, in a random population of patients with mild to moderate sensorineural hearing loss, to several clinical factors such as age, sex, handedness, and noise exposure. Methods: We randomly selected, from 8 hearing institutes in Israel, 429 patients with sensorineural hearing loss of at least 30 dB at one frequency and a speech reception threshold not exceeding 30 dB. Patients with middle ear disease or retrocochlear disorders were excluded. The results of audiometric examinations were compared binaurally and in relation to the selected factors. Results: The left ears hearing threshold level was significantly higher than that of the right ear at all frequencies except 1.0 kHz (p < .05). One hundred fifty patients (35%) had asymmetric hearing loss (more than 10 dB difference between ears). In most of the patients (85%) the binaural difference in hearing threshold level, at any frequency, was less than 20 dB. Conclusions: Age, handedness, and sex were not found to be correlated to asymmetric hearing loss. Noise exposure was found to be correlated to asymmetric hearing loss.

Lymph Node Metastasis in Cutaneous Head and Neck Squamous Cell Carcinoma.

BACKGROUND Cutaneous squamous cell carcinoma (CSCC), the second most common cancer in whites, may result in nodal metastasis in 4% of patients. In the last decade, sentinel lymph node biopsy (SLNB) became the common practice for treating patients with invasive skin cancers such as melanoma, although its use in patients with CSCC is still under debate. OBJECTIVE To find the rate of cervical lymph node metastasis in the series of patients with CSCC of the head and neck and to identify those who may need SLNB. MATERIALS AND METHODS A retrospective data collection on all patients diagnosed with CSCC of head and neck during the years 1998 to 2005. RESULTS A total of 572 patients with 725 head and neck CSCC were included in the study group. During the follow-up period, 10 (1.3%) patients developed lymph node metastases and no patient developed distant metastases. The probability of lymph node metastasis within 6 years for T1 and T2 tumors was 1.09% and 5.46%, respectively (p = .0387). CONCLUSION Because of the relatively low incidence of cervical lymph node metastases in patients with CSCC of the head and neck, SLNB for clinically N0 patients is not justified.

Randomized study comparing inflammatory response after tonsillectomy versus tonsillotomy.

To determine if there was a difference in the inflammatory reaction after tonsil surgery with “traditional” techniques (tonsillectomy and adenoidectomy or TA) compared to partial intracapsular tonsillectomy and adenoidectomy (PITA). Design: Randomized, double-blind study. Setting: tertiary care academic hospital. Children under the age of 16xa0years with a diagnosis of obstructive sleep disordered breathing were randomly allocated into three study groups: TA with electrocautery (nxa0=xa034), PITA with CO2 laser (nxa0=xa030) and PITA with debrider (nxa0=xa028). All of the children underwent adenoidectomy with a current at the same surgical procedure. Main outcome measure: c-reactive protein level (CRP) was the primary endpoint. In addition, the following were assessed: white blood cells (WBC), neutrophils (NEU), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Pre- and post-procedure measurements were compared between the groups. Parents filled out a questionnaire daily during the first postoperative week assessing pain, swallowing and snoring. CRP levels ascended higher in the PITA groups after surgery (pxa0=xa00.023), WBC and NEU showed the same pattern, IL-6 levels were higher in PITA group and there was no difference in TNF-alpha levels between the two types of procedures. Postoperative pain and postoperative hemorrhage were significantly lower in the PITA groups as compared to the TA group (pxa0=xa00.01 and 0.048). PITA in comparison to TA is associated with lower morbidity; however, the inflammatory response does not differ significantly in the first 24xa0h after surgery. Additional long-term studies assessing efficacy of PITA are warranted. Level of evidence: Level 1, prospective randomized controlled trial.

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.

Delayed diagnosis of intracranial injury due to a dog bite-A case report and review of the literature

OBJECTIVESnDog bite injury of the head and neck is not rare in children although intracranial injury is reported anecdotally. Among the case reports there is a significant number of patients in whom the diagnosis of penetrating cranial injury was delayed. The aim of the study was to describe a patient with a trans mastoid head injury due to a dog bite that was not diagnosed at presentation and review similar cases in the literature.nnnMETHODSnA 13-year-old girl was admitted to the emergency room with severe head, neck and breast lacerations. She was transferred to the operating room for debridement and only then was a trans mastoid fracture diagnosed. We searched for case reports in the literature describing children suffering from dog bites in whom the diagnosis of intracranial injury was delayed.nnnRESULTSnWe found descriptions of five children, 4 after dog bite and one after tiger bite. Four of them were under two years of age and all had scalp lacerations that were treated at presentation. The time period to diagnosing the brain injury was one day to three weeks. The symptoms that led to the diagnosis were fever in 3 patients, meningitis in two, brain abscess in one child and four of them developed neurological signs. All of the children had surgical intervention after diagnosis.nnnCONCLUSIONSnIntracranial injury after dog bite should be suspected in any child with scalp lacerations. Adequate investigations should be performed at presentation with careful attention to this specific type of trauma.