Roee Landsberg

Conservative management of acute mastoiditis in children

OBJECTIVE To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy. DESIGN A retrospective chart review. SETTING Tertiary-care, university affiliated childrens hospital. PATIENTS One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002. INTERVENTIONS All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call. MAIN OUTCOME MEASURES Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions. RESULTS Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR. CONCLUSIONS These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

Antral computerized tomography pre‐operative evaluation: relationship between mucosal thickening and maxillary sinus function

OBJECTIVES to assess the correlation between maxillary sinus inferior mucosal thickening and sinus outflow obstruction. MATERIAL AND METHODS the study included 280 computerized tomography (CT) scans (560 maxillary sinuses). CT aimed to assess sinusitis; trauma to the face and intubated patients were excluded. Mucosal thickening was graded as < 5 mm (1), < 10 mm (2), < 15 mm (3), < 20 mm (4) and > 20 mm (5), and classified by appearance as normal, rounded, circumferential, irregular, or complete. Maxillary sinus outflow was classified as patent or obstructed. RESULTS mucosal thickening was found in 36.1% of the maxillary sinuses, graded as 31.2% (1), 34.2% (2), 12.9% (3), 5.4% (4) and 16.3% (5), and classified as rounded (11.8%), irregular (10.4%), circumferential (8.8%) and complete (5.2%). Sinus outflow was obstructed in 15% of the scans. Mucosal thickening of < 5 mm (11.1%), < 10 mm (36.2%) and > 10 mm (74.3%) was associated with sinus obstruction (P<0.0001). Rounded (6.1%), circumferential (55.2%), irregular (38.8%) and complete (100%) mucosal appearances were associated with sinus obstruction (P<0.001). When statistically combined, a substantial risk for sinus obstruction was observed with irregular mucosal appearance of > 5 mm (56.5% for grade 2 up to 82.6% for grades 3-5) and circumferential appearance (21.4% for grade 1 up to 100% for grades 3-5). A low risk for obstruction was found with the rounded appearance (mean 6.1%). CONCLUSIONS irregular (> 5 mm), circumferential and complete mucosal appearance are associated with an increased risk for sinus outflow obstruction and an ENT consultation is recommended. A rounded mucosal appearance of any grade is associated with a low risk for sinus obstruction. Routine CT scans, including the maxillary sinus ostium, are recommended.

Quality of life in patients older than 75 years following major head and neck surgery.

This study was designed to evaluate the quality of life (QOL) of patients older than 75 years undergoing major head and neck surgery.

Systemic corticosteroids for allergic fungal rhinosinusitis and chronic rhinosinusitis with nasal polyposis : A comparative study

Objectives To compare the effect of preoperative high-dose systemic corticosteroids on the radiographic and endoscopic appearance of allergic fungal rhinosinusitis (AFRS) and chronic rhinosinusitis with nasal polyposis (CRSwNP). Study Design and Setting Eight AFRS and 10 CRSwNP patients underwent computed tomographic (CT) scans and then received preoperative 1 mg/kg prednisone for 10 days. CT scans were repeated 1 day before surgery and compared with pretreatment scans (Lund-MacKay radiologic scoring system). The endoscopic appearance was recorded intraoperatively. Results The score dropped from 16 (66.4%) to 4.75 in the AFRS group and from 18.4 (23%) to 14.1 in the CRSwNP group (P = 0.0064). Intraoperatively, most sinus mucosal surfaces appeared normal in the AFRS patients but were markedly edematous in the CRSwNP patients. Conclusion Radiographic response of AFRS to systemic corticosteroids is significantly greater compared with CRSwNP. This finding is supported by endoscopic observation.

Elective paratracheal neck dissection for lateral metastases from papillary carcinoma of the thyroid: is it indicated?

Therapeutic paratracheal neck dissection for patients with papillary carcinoma of the thyroid is standard treatment. Its use as an elective procedure is controversial.

Laser-induced hyperthermia for treatment of granulation tissue growth in rats

Objective: We aimed to develop a new technique for treatment of granulation tissue (GT) growth using local hyperthermia. Methods: A temperature-controlled diode laser system was developed for induction of mild hyperthermia in real time. GT was generated by harvesting the skin over the gluteal fascia in rats. Histopathological analysis was used to estimate the effect of hyperthermia on the tissue. Results: In untreated rats, GT was detected within 3 days and reached maximal thickness after 12 days. Hyperthermia at 43°C and above significantly decreased GT thickness (n = 8 per group). Hyperthermia at 48°C for 3 minutes was the most efficient parameter for treatment of GT (51% reduction), with minimal (5%) muscle necrosis. Conclusions: Hyperthermia can significantly inhibit GT growth, with minimal damage to surrounding structures. Our findings suggest a possible role for hyperthermia as a therapeutic model against GT. Further research and long-term studies are needed to explore the utility of laser-induced hyperthermia for inhibition of GT growth.

A Targeted Endoscopic Approach to Chronic Isolated Frontal Sinusitis

OBJECTIVES: Chronic isolated frontal sinusitis occurs infrequently. In this condition, most of the ethmoid cells are well aerated and the frontal sinus is involved secondary to anatomical obstruction or inflammatory changes confined to the frontal recess. The purpose of this study was to evaluate a targeted endoscopic technique where standard anterior ethmoidectomy is unnecessary in the treatment of chronic isolated frontal sinusitis. STUDY DESIGN AND SETTING: This retrospective study was conducted in a large university-affiliated hospital and included 11 patients with chronic isolated frontal sinusitis who underwent endoscopic sinus surgery limited to the frontal sinus outflow. The ethmoid bulla was untouched in all cases. Follow-up continued for 19 to 40 months (mean 28.6 months). RESULTS: Frontal sinus outflow patency was verified in 9 patients (81.8%). Nine patients, including one with an apparent nonpatent frontal ostium, reported improvement. Two patients—one of whom had a patent frontal ostium—reported no improvement. There were no complications. CONCLUSION: Chronic isolated frontal sinusitis can be effectively treated in selected cases by a targeted endoscopic procedure, limited to reestablishment of frontal sinus outflow. EBM rating: C-4

Surgical approaches to juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascularized, locally aggressive benign tumor, occurring almost exclusively in young men. The tumor is assumed to originate in the sphenopalatine foramen area. Tumor invasion to the nasal cavity, paranasal sinuses, orbit, pterygomaxillary fossa, infratemporal fossa, cheek, cavernous sinus, and anterior or middle cranial fossa may occur. Blood supply to the tumor most commonly arises from the internal maxillary artery. A variety of surgical techniques to the facial skeleton and the skull base are now well established; this is mainly the result of improved preoperative imaging assessment, technical advances in tumor resection and reconstruction, improved postoperative care, and the cooperation of multidisciplinary teams. In children and adolescents with JNA, we have used the combined midfacial degloving/transmaxillary approach and the facial translocation technique. The preoperative evaluation, surgical technique, advantages, and limitations of these approaches will be detailed.

Aspirin challenge in patients with chronic rhinosinusitis with polyps correlates with local and systemic inflammatory markers.

Background Acetylsalicylic acid (ASA; aspirin) is a well-known inducer of pseudoallergic response in patients with chronic rhinosinusitis with polyps (CRSwPs). The mechanism that leads to this response remains unclear. This study was designed to measure and compare the local and systemic inflammatory response to aspirin challenge in patients with CRSwPs who develop either a nasobronchial response (NBR) or a nasal response (NR), and compare it with nonresponders (non-Rs). Methods The three groups underwent nasal wash before ASA challenge, and inflammatory mediators were measured in the nasal wash as well as in serum. Results A total of 25 CRSwP patients were enrolled. The NBR patients (n = 13) had a significantly longer mean disease duration and a higher mean serum leukotriene E4 (LTE4) level than the NR (n = 6) and non-R (n = 6) patients (39.2 ± 9.7 months, 21 ± 8.8 months, and 22.8 ± 11.2 months, respectively, and 4221 ± 1205 pg/mL, 1430 ± 605 pg/mL, and 857 ± 461 pg/mL, respectively). The NBR and NR patients had a larger mean number of nasal eosinophils than the non-R group (52.8 ± 28.8 cells/μL, 47 ± 21.3 cells/μL, and 19.3 ± 13.4 cells/μL, respectively). The tryptase, albumin, nasal LTE4, and prostaglandin E2 levels were not significantly different between the three groups in any examined combination. Conclusion The nasal eosinophil and serum LTE4 levels correlate with aspirin sensitivity.

The Sensitivity of Preoperative Scanning in Regional Recurrence of Papillary Thyroid Cancer

BACKGROUND: The treatment of patients with regionally recurrent papillary carcinoma of the thyroid is a matter of controversy. Radioactive nodal picking was proposed as an alternative to neck dissection in these patients. METHODS: We analyzed neck dissection specimens in 20 patients with PTC and compared the results to preoperative total-body scan (TBS) following a therapeutic dose of I131 and ultra-sonographic findings. RESULTS: Eighteen patients underwent paratracheal neck dissection and 10 patients had a lateral neck dissection. Preoperative TBS detected the correct number of positive nodes in only 1 patient (5%) and the correct number of patients with positive nodes in 6/20 (30%) of the patients. US detected 32/98 positive nodes (36%) and 20/20 (100%) of the patients. Prediction of the number of positive nodes for both TBS and US was low (5% and 10%, respectively). CONCLUSIONS: Preoperative TBS and/or US cannot satisfactorily predict metastatic lymph node involvement and cannot safely delineate limited surgery to replace formal neck dissection in patients with regionally recurrent PTC.