Robert D. Engle

Impact of 13-valent pneumococcal conjugate vaccine on otitis media bacteriology☆

OBJECTIVES To determine the microbiology of otitis media (OM) since the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in February 2010. METHODS Middle ear effusion from a pediatric Otolaryngology population undergoing pressure equalization tube (PET) placement was obtained and sent for aerobic culture and antibiotic susceptibility testing between August 2012 and April 2013. Vaccination records were obtained and statistical analysis was completed. RESULTS During the 8-month period, 236 ears were evaluated, and of those 39 ears were found to have positive cultures. The single nonvaccine Streptococcus pneumoniae (serotype 16) isolate was obtained from a PCV7-only vaccinated patient and was penicillin susceptible. The three most common isolates were Staphylococcus coagulase negative (57%), Haemophilus influenzae (17%), and Moraxella catarrhalis (7%). CONCLUSIONS This study is the first to assess the bacteriology of OM in a pediatric population undergoing PET placement in the immediate post-PCV13 era. Our study is limited by sample size; however, the lack of S. pneumoniae cultures indicates that PCV13 has had a significant impact on pneumococcal infections during these initial years following licensure.

Split-calvarial osteopericranial flap for reconstruction following endoscopic anterior resection of cranial base

To conceive and critically evaluate an adaptation of the split calvarial osteopericranial flap for reconstruction following endoscopic endonasal resection of the anterior skull base.

Endoscopic Midfacial Rejuvenation

Early facial rejuvenation focused largely on the upper and lower thirds of the face. More recently, improvements in understanding of midfacial aging and anatomy have paralleled the development of endoscopic and minimally invasive surgical techniques. The midface is now understood to include both the lower lid subunit and the cheek down to the nasolabial fold. Many surgical techniques for midface rejuvenation have been used, including skin tightening with direct excision, skin-muscle flaps, isolated fat pad transposition, and subperiosteal lifting. The methods of endoscopic subperiosteal midface lifting and endoscopic malar fat pad lifting are discussed.

Transnasal endoscopic medial maxillary sinus wall transposition with preservation of structures

To evaluate the increase in access to the maxillary sinus (MS) with transnasal endoscopic medial maxillary sinus wall transposition (TEMMT), while preserving major structures of the nasal cavity.

Total Nasal Reconstruction using a Split Calvarial Osteopericranial Flap

Background: Complete oncologic resection of invasive skin or anterior septal cancers can result in total or near-total rhinectomy. These defects pose a unique challenge in reconstruction, balancing an adequate aesthetic with a functional nasal airway while simultaneously resisting the forces of scar contracture. Case Presentation 56-year-old male underwent successful complete nasal reconstruction following total rhinectomy for recurrent basal cell carcinoma. Partial resection of the right cheek subunit was also necessary to achieve negative margins. A split calvarial osteopericranial flap was used for dorsal nasal support and inner lining, while conchal cartilage provided batten grafts and a paramedian forehead flap provided external coverage. A cheek advancement flap was performed to address the cheek defect. High quality images depict the design and execution of this reconstruction. At 3-month follow-up the patient had good aesthetic and functional results. He has patent nasal airways and no sinus symptoms. Conclusions: This reconstruction provides vascularized tissue with the structural integrity to resist scar contracture and an acceptable functional and aesthetic result. It is a good alternative to costal cartilage grafting, alloplastic reconstruction materials or a nasal prosthesis in the appropriately motivated patient.

Feasibility Study for Transnasal Endoscopic Repair of Orbital Floor Fracture With Alloplastic Implant

Objective: Fractures of the orbital floor are common yet repaired by various techniques, including open periorbital, transantral endoscopic, and endoscopic endonasal approaches. To date, endoscopic endonasal repair of an orbital floor fracture using an alloplastic implant has not been described. We aim to determine the technique and limitations of completely endoscopic endonasal orbital floor repair using an alloplastic implant. Study Design: Cadaveric anatomic study and retrospective case series. Methods: Cadaveric study of 12 sides with endoscopic sinonasal dissection followed by the creation and repair of an isolated orbital floor fracture using an alloplastic implant. Four representative patient cases are presented in which the techniques developed in the cadaveric study were employed. Patients were selected for this technique based on the results of the cadaveric study. Results: Cadaveric study demonstrated feasibility of access and repair for fractures that did not extend lateral to the infraorbital canal or anterior to the nasolacrimal duct. In all cadaveric sides and in all 4 patient cases, successful alloplastic orbital floor reconstruction was achieved. Conclusion: This method of repair is feasible for selected patients and may be considered in cases of favorable fracture anatomy with or without concomitant indication for an ipsilateral sinus procedure.

Epidemiology of OM Pathogens of Those Undergoing Tympanostomy Tube Placement in the Era of PCV13

Objectives: Determine the microbiology of otitis media (OM) since the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in March 2010. Methods: The population included pediatric patients undergoing tympanostomy tube placement between August 2012 and June 2013. Middle ear effusion was sent for aerobic culture and antibiotic susceptibility testing. Statistical analysis will be performed to compare those who received PCV13 and those who only received the PCV7 vaccine. Preliminary data from August 2012 to December 2012 included 72 ears, of which 21 had fluid. Seven of these 21 ears cultured Staphylococcus aureus, Haemophilus influenza, and Pseudomonas aeruginosa. Three patients with positive cultures of Staphylococcus or Haemophilus were vaccinated with at least one dose of PCV13, and 2 patients that cultured Staphylococcus or Pseudomonas had the PCV7 vaccine. All of the cultures were susceptible to a quinolone. Results: Two cultures of Staphylococcus and Haemophilus were resistant to Bactrim. The impact of PCV13 on the molecular epidemiology of OM will be profound, as two of the most common pneumococcal isolates from nasopharyngeal secretions in the post-PCV7 era, serotypes 19A and 6A, are included in PCV13. This study is the first to assess the OM microbiology in a pediatric population vaccinated with PCV13. Our study is currently limited by sample size; however, this has increased, as colonization is higher in fall and winter. Conclusions: This initial lack of Streptococcus cultures indicates that PCV13 is likely to have a significant impact on antibiotic resistance and rate of pneumococcal disease during the initial years following licensure.