Uri Peleg

Stratification for Malignant External Otitis

OBJECTIVE: To propose a CT-based method for early identification of severe cases of malignant external otitis (MEO) by correlating between initial CT findings and clinical course. STUDY DESIGN AND SETTING: Eighteen MEO patients who underwent CT on admission were included in this retrospective study conducted at a tertiary center. The number and extent of anatomical areas involved according to CT were compared to clinical course severity. RESULTS: The patients were categorized into two groups according to clinical course. There were 13 patients in the “nonsevere” group and 5 in the “severe.” In six out of eight CT anatomical areas the “severe” group had significantly higher scores (P < 0.05 to P < 0.0005). The average number of areas involved in the “nonsevere” group was 2.9 and in the “severe” 5.4 (P < 0.0005). CONCLUSION: We found a clear correlation between clinical course and initial CT findings in MEO patients. Based on these findings it may be possible to predict clinical course severity according to initial CT.

Acute mastoiditis in children: is computed tomography always necessary?

Objectives Acute mastoiditis (AM) is the most common intratemporal complication of acute otitis media in children. In the past decade, reports have indicated a rise in the incidence of AM in the pediatric population. A parallel rise in the use of computed tomography (CT) imaging has occurred. The rise in the use of CT scanning in the pediatric population, entraining with it a rise in pediatric brain irradiation, has led us to question the necessity of using CT for pediatric patients with AM. Methods We reviewed the medical files of pediatric patients who had AM in the years 2005 through 2007. Results Fifty patients were identified. The gender distribution was equal, and the ages ranged from 4 months to 12 years. Of the 46 patients who were admitted to our institution “de novo,” only 2 underwent CT scanning on admission, and 4 other patients had CT performed during hospitalization. The majority of patients (92%) with AM did not have a CT scan performed and were treated conservatively with no complications. Conclusions In most pediatric patients, CT does not seem to be indispensable in the diagnosis of AM. Conservative therapy and close follow-up seem to suffice for most.

Shifting trends: mastoiditis from a surgical to a medical disease.

OBJECTIVE The aim of this study is to review the outcome of pediatric patients suffering from acute mastoiditis treated conservatively and to correlate this to the evolution of our understanding of the shift in which mastoiditis has been transformed from a surgical to a medial disease. METHODS We performed a retrospective review patient files hospitalized in our tertiary-care center between 2005-2008. We examined the data concerning the infection which included: presenting signs/symptoms, prior otologic history, treatment (including both surgical and conservative) prior to hospitalization and during hospitalization, computed tomography (CT), hospital duration, complications and overall outcome. This data was analyzed and compared between different patients who underwent different treatment strategies. RESULTS Fifty-one patients were included in this retrospective review. Initially, forty-nine patients admitted to our hospital were treated conservatively. This treatment included intra-venous antibiotics, myringtomy and if needed subperiosteal abscess incision and drainage. Only 2 patients underwent CT scanning on admission. Further on, during hospitalization 4 additional patients underwent CT scanning due to continued fever or progression of local disease. All four CT scans showed no intra-cerebral complications, and so all continued with conservative treatment. CONCLUSION Most cases of acute mastoidits may be treated with a conservative therapy regime. This regime, in our opinion, should include three branches: the first intravenous antibiotic therapy using a broad spectrum antibiotic. The second is myringotomy and the third branch is incision and drainage of subperiosteal abscess when needed.

Gradenigo's syndrome: Is fusobacterium different? Two cases and review of the literature

Gradenigos syndrome is a rare but life threatening complication of acute otitis media (AOM), which includes a classic triad of otitis media, deep facial pain and ipsilateral abducens nerve paralysis. The incidence of Fusobacterium necrophorum infections has increased in recent years. We describe two cases of Gradenigos syndrome caused by F. necrophorum. Additional four cases were identified in a review of the literature. Gradenigos syndrome as well as other neurologic complications should be considered in cases of complicated acute otitis media. F. necrophorum should be empirically treated while awaiting culture results.

Is Needle Aspiration for Peritonsillar Abscess Still as Good as We Think? A Long-term Follow-up:

Objective: The aim was to study the therapeutic management, recurrence, and need for tonsillectomy in patients who underwent needle aspiration for peritonsillar abscess (PTA). Methods: A prospective observational design study was performed. Patients hospitalized in Shaare Zedek Medical Center between the years 2004 and 2007 with a diagnosis of PTA who underwent needle aspiration obtaining pus were included. A minimum 5-year follow-up was required for all patients. Recurrences, complications, the need for a repeated surgical procedure, length of hospital admission, and tonsillectomy were the primary end points. Results: The study included 117 patients. One hundred four patients (88.9%) improved after 1 needle aspiration without any other intervention, whereas 13 patients (11.1%) required an additional procedure. Broad spectrum antibiotics showed a statistical advantage over penicillin only, regarding need for recurrent procedure (14.7% vs 4.7%, P = .02). No short- or long-term complications were documented. Seventeen patients (14.5%) had any recurrence. Primary recurrent tonsillitis, female sex, and younger age were predictive risk factors for recurrent events of PTA (32% vs 10%, P < .01). A total of 18 patients (15.4%) eventually underwent tonsillectomy. Conclusion: Needle aspiration is an effective first line procedure for patients with PTA. Tonsillectomy is not necessary in most cases. In our study, young age, female sex, and recurrent tonsillitis are negative prognostic factors for recurrence. These patients should be managed accordingly. Broad spectrum antibiotics may offer additional advantages when compared to penicillin only.

Harmonic Scalpel Assisted Superficial Parotidectomy

Objective: The Harmonic Scalpel (HS) has been recently widely used to perform a variety of surgical procedures. We reviewed our experience with the use of HS in superficial parotidectomy to determine the safety and efficacy of this procedure, with regard to operative time, postoperative facial nerve function, and drainage output. Study Design: Nonrandomized retrospective review. Materials and Methods: The medical records of all patients who underwent superficial parotidectomy for benign pathology at Shaare Zedek Medical Center from January 2006 to July 2009 were retrospectively reviewed. Patients with prior facial nerve weakness or prior parotid surgery or who had undergone concurrent neck dissection or total parotidectomy were excluded. Results: Fifty-eight patients were reviewed; 26 patients underwent HS parotidectomy and 32 patients underwent conventional (cold knife) parotidectomy (control group). Harmonic Scalpel assisted parotidectomy was associated with significantly decreased length of surgery from 163.12 ± 21.8 minutes for controls to 137.3 ± 18.6 minutes in the HS assisted group (P < .05). The incidence of temporary postoperative facial nerve paresis was significantly reduced from 43% in the controls to 23% in the HS group (P < .05). No permanent facial nerve paralysis was reported. There were differences in the overall postoperative drain output between the HS and control groups, 68 ± 22.3 mL and 73.5 ± 38.2 mL, respectively, but these differences did not achieve significance. Conclusion: This study shows that HS assisted superficial parotidectomy for benign pathology is a safe technique and associated with reduced surgical time and incidence of temporary postoperative facial nerve paresis compared with conventional techniques.

Starplasty tracheostomy: case series and literature review

ObjectivesThe starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center.MethodsA retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012.ResultsAmong the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3–207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred.ConclusionsIn our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.

When Can Acute Supraglottitis Patients Be Discharged from Intensive Care

Objectives: Acute supraglottitis in adults is usually managed by admitting the patient for airway monitoring in the intensive care unit (ICU). However, data are lacking on when patients could be transferred from the ICU to the ward. Our aim is to suggest decision criteria for transferring patients to the regular ward. Methods: A retrospective review of medical records from adult patients admitted for supraglottitis to our center was conducted. The information obtained included airway management, length of stay in the ICU and in the ward, clinical condition of the patients at the time of their transfer from the ICU to the ward, and outcome. Results: Between 2006 and 2012, 38 adult patients were treated in our department for supraglottitis with antibiotics and systemic steroids. All patients were admitted to the ICU for monitoring. Fiberoptic laryngoscopy was performed every 12 hours. 5 patients required intubation at admission. 33 patients were admitted to the ICU for monitoring and did not require further intubation. Average time in the ICU was 27.4 hours. We observed that all patients who had a mild swelling regression did not deteriorate or require re-intubation or re-admission to the ICU. They were all discharged from the regular ward without any complications. Conclusions: Patients without severe airway compromise could undergo monitoring in the ICU without intubation. Since all patients who began to improve did not suffer from deterioration afterwards, we suggest that even mild airway improvement could be considered as a sufficient criterion for safe transfer of patients to the regular ward.

Intratympanic Steroid for Sudden Sensorineural Hearing Loss

Objective: Intratympanic (IT) steroids are increasingly used in the treatment of sudden sensorineural hearing loss (SSNHL). The aim of this study is to investigate the effectiveness of IT administration of dexamethasone treatment for SSNHL. Method: We retrospectively reviewed medical records of SSNHL patients who were treated with IT dexamethasone in our hospital from January 2004 to October 2010. Indications for IT treatment: 1) Failure of systemic therapy; 2) Contraindications for systemic therapy; 3) Patients who presented more than 2 weeks after the onset of hearing loss. Results: A total of 117 patients were reviewed. The mean age of the patients was 51.2 years, ranging from 18 to 81 years. Patients were divided into 2 groups: I) Patients who were treated with IT dexamethasone after the failure of initial systemic treatment: n = 80 (68.3%). II) Patients who were treated only with IT dexamethasone: n = 37 (31.6%). Thirty-nine patients (48%) from group I showed improvement of more than 20 dB in SRT while 14 patients (38%) from group II showed similar improvement. Overall, 87 patients (74.35%) showed some improvement in speech reception threshold (SRT). The presence of vertigo had negative effect on the hearing outcome. Conclusion: This study shows that IT prednisone therapy may be beneficial in the treatment of sudden SNHL. Although the results of this study and other similar ones are convincing, a prospective randomized controlled study is warranted.