Pediatric Epistaxis-Effectiveness of Conservative Management

OBJECTIVES

Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management.

METHODS

This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018.

RESULTS

Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population.

CONCLUSIONS

Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

Risk Factors for Severe Clinical Course in Epistaxis Patients

Purpose: Epistaxis is a common medical emergency that may require admission to the emergency department (ED) and treatment by an otolaryngologist. Currently, there are no widely accepted indications for hospitalization, and the decision is based on personal experience. Methods: A retrospective study of 1171 medical records of patients with epistaxis treated at our tertiary medical center ED from 2013 to 2018 with no age limit. The presence of recurrent epistaxis, a posterior source of bleeding, the need for hospitalization, the need for blood transfusion, or surgical intervention defined severe clinical course. Results: The 1171 admissions included 230 recurrent admissions for a total of 941 patients (60% males) who were treated by an otolaryngologist. The average age was 57.6 in the adult population (>15) and 6.6 in the pediatric population (≤15). Of all patients, 39% had hypertension; 39% took antiplatelet/anticoagulation therapy; 63% came during winter-a significant risk factor; 34 (2.9%) had reduced hemoglobin levels of >1gr%, but only 7 received a blood transfusion; 131 (11%) were hospitalized, and 21 (1.8%) required surgical control of the bleeding. Age (OR 1.02; CI 1.01-1.023), male sex (OR 2.07; CI 1.59-2.69), hypertension (OR 1.76; CI 1.27-2.45), and antiplatelet/anticoagulation therapy (OR 2.53; CI 1.93-3.33, OR 1.65; CI 1.11-2.44, respectively), were significantly correlated with severe clinical course. Conclusion: Epistaxis is significantly more common and severe in older male patients with hypertension or antiplatelet/anticoagulation therapy. However, few need a blood transfusion or surgical intervention. In borderline cases with no definitive indication for hospitalization, we suggest adopting these factors as indications for hospitalization due to their marked influence on the clinical course. Routine coagulation tests are indicated in patients treated with warfarin or combined antiplatelet + anticoagulation therapy.

[ESTABLISHING A NEW TEAM FOR ENDOSCOPIC ENDONASAL SKULL BASE SURGERY: THE LEARNING CURVE FROM BASIC TO ADVANCED COMPLEXITY LEVEL]

INTRODUCTION

Establishing a new team for endoscopic endonasal skull base surgeries (EES) requires a period of adjustment. Our team was established 4 years ago and consists of surgeons with previous experience. Our objective was to examine the learning curve associated with the establishment of such a team.

METHODS

All patients who underwent EES between January 2017 and October 2020 were reviewed. The first 40 patients were defined as the 'early group' and the last 40 as the 'late group'. Data was retrieved from electronic medical records and surgical videos. Study groups were compared in terms of the level of surgical complexity, (II to V according to EES complexity level scale; level I cases were excluded), surgical outcome and complication rate.

RESULTS

'Early group' cases and 'late group' cases were operated on in 25 and 11 months, respectively. Complexity level II surgeries, which mainly included pituitary adenomas, were the most common in both groups (77.5% and 60%, respectively); of these, functional adenomas and reoperations were more common in the 'late group'. The rate of advanced complexity surgeries (III - V) was higher in the 'late group' (40% vs. 22.5%); level V surgeries were performed only in the 'late group'. No significant differences were observed in terms of surgical outcomes or complications; postoperative cerebrospinal fluid (CSF) leaks were less common in the 'late group' (2.5% vs. 7.5%).

CONCLUSIONS

Our findings indicate that the establishment of a new EES team, even if it includes experienced skull base surgeons, is associated with a learning curve, which requires about 40 cases.

Introduction of Steroid Absorbed Spongostan in Endoscopic Dacryocystorhinostomy Improves Success Rates

BACKGROUND

Endoscopic Dacryocystorhinostomy (DCR) has become an acceptable alternative to the open approach, with considerable data demonstrating comparable success rates and advantages such as avoiding skin incisions. Drug-eluting bio-absorbable materials are relatively new innovation in sinus surgery, the usefulness of such materials in Endoscopic DCR is yet to be described.

METHODS

A retrospective analysis of 253 endoscopic DCR procedures performed by a single surgical team from September 2011 to June 2020 was performed. At the end of 2013, a surgical modification took place with the introduction of steroid-eluting Spongostan to the intranasal surgical bed. As a result, 2 cohorts were compared before and after the modification. The first cohort consisted of 55 patients, and the second consisted of 187 patients, respectively. Patient demographics, clinical features, complications and outcomes were examined.

RESULTS

A total of 242 procedures were evaluated after exclusion. In the first cohort of 55 patients (48 adults and 7 children), the overall and adult functional success rates were 83.6% and 83.3%, respectively. In the second cohort of 187 patients (167 adults and 20 children), where steroid-eluting Spongostan was used, the overall and adult functional success rates were 92.5% and 93.4%, respectively. These differences were statistically significant.

CONCLUSION

This is a unique study presenting a single surgical team's experience over a 9-year period where a novel technique involving drug-eluted bio-absorbable material (Spongostan) was introduced midway through, creating 2 cohorts to compare. Success rates were significantly higher after applying steroid eluted Spongostan to our endoscopic DCR technique.

Masquerading solitary plasmacytoma; an eyelid lump in disguise

Solitary plasmacytoma is a rare orbital lesion, most commonly appearing in patients with multiple myeloma. We report a case of a 75-year-old woman who presented with a left upper eyelid lesion, initially misdiagnosed and treated as a chalazion. Histopathological testing revealed plasmacytoma originating from the frontal sinus. This case demonstrates a rare presentation for this malignancy.

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.

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.

Bipolar tonsillotomy: A novel and effective tonsillotomy technique

OBJECTIVE

To present, for the first time, tonsil size reduction using reusable bipolar forceps electrocautery (RBFE), as a treatment for pediatric OSAS and to assess the safety and efficacy of the procedure.

METHODS

A prospective interventional design study was performed. Thirty children aged 2-15 years with OSAS (AHI>5) diagnosed by means of polysomnography were included. All children were treated with adenoidectomy and RBFE tonsillotomy without dissection. Re-polysomnography was performed after 1 year. The size of the tonsils was blindly assessed by two ENT specialists and the parents were asked to fill out 'Pediatric Sleep Questionnaires' (PSQ), before surgery, and one month and one year after surgery.

RESULTS

There were no complications during or after surgery. There were no events involving postoperative bleeding or dehydration. The surgery mean time, including adenoidectomy, was 20.6min. The AHI was 10.9 before surgery and decreased to 1.8 after surgery (p<0.001), minimum saturation (SaO2 min) increased from 86.1% to 93.2% (p<0.001). The size of the tonsils decreased from a mean of +3.3 before surgery to +1.3 and +1.4 one month and one year after surgery, respectively. The mean of the PSQ scores went down from 23.6 to 5.5 and to 6.2 one month and one year after surgery, respectively.

CONCLUSION

We demonstrated that simple cauterization of the tonsils using a RBFE device with an adenoidectomy is a safe and effective treatment to decrease tonsil size in OSAS. In addition, the method is inexpensive, rapid and does not cause bleeding, which may be particularly interesting in the presence of coagulation problems.

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.

Hearing Loss in Patients with Inflammatory Bowel Disease

Objectives:

Inflammatory bowel disease (IBD) has many characteristics of autoimmune diseases. Sensorineural hearing loss has been reported in many autoimmune diseases. Little is known about hearing loss in patients with IBD.

Methods:

A prospective blinded comparative study was conducted over a 3-year period. IBD patients and controls underwent a complete otolaryngology examination and audiometry test.

Results:

A total of 105 participants (76 patients and 29 controls) took part in this study. A total of 59 (77%) had Crohn’s disease (CD) and 17 (23%) had ulcerative colitis (UC). Mean age was 36 years, 51% were males and 40% of the patients were presently hospitalized due to IBD exacerbation. Sixteen of 76 (21%) of the IBD patients complained of hearing loss since first IBD diagnosis and 13% had current hearing disabilities. Audiometric examination revealed that any hearing loss (mild to severe) was found in 23 (30%) of the IBD population, compared with 3 (10%) of the control group ( P < .05). Sensorineural was the hearing deficiency type in 93% of them. Out of 46 patients, whose extraintestinal manifestation (EIM) status was clearly documented, 43% (n = 20) had EIMs. Hearing loss was present in 5 out of 20 (25%) of these patients, compared with 0 out of 23 who did not have EIMs ( P < .01). IBD phenotype, current hospitalization, and disease type were not different between these groups.

Conclusions:

Sensorineural hearing loss may be another EIM of IBD. It is found in 30% of IBD patients, and in up to 43% of patients with other EIMs. Early hearing evaluation should be recommended to IBD patients who have other EIMs.

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.

Treatment and Long-term Follow-up of Peritonsillar Abscess

Objectives:

Study the therapeutic management, recurrence, and need of tonsillectomy in Peritonsillar abscess. Study design: Retrospective study and long term telephone survey. Setting: Otolaryngology Head and Neck Surgery Department at Shaare Zedek Medical Center, Jerusalem, Israel.

Methods:

Review of 117 files of patients diagnosed with peritonsillar abscess who underwent needle aspiration obtaining pus were hospitalized at our department between the years of 2004 to 2007, and were followed at least four years after their discharge date.

Results:

One hundred four patients (89%) improved without any other intervention. Thirteen patients (11%) underwent an additional procedure such as aspiration and/or incision and drainage. After the needle aspiration, the patients were treated with intravenous antibiotic treatment: penicillin or broad spectrum antibiotics, amoxicillin-clavulanate, or a combination of metronidazole and cefuroxime. There was no clinical distinction between the various groups. A hundred and five patients (90%) were followed up by telephone call, obtaining the following information: 88 patients (84%) had no recurrence. The remaining 17 suffered recurrence; most of them, 9 patients, had only one. 18 patients underwent tonsillectomy; 13 due to recurrent peritonsillar abscess and 5 due to recurrent tonsillitis.

Conclusions:

1) Needle aspiration is an effective treatment for peritonsillar abscess. 2) The supplementary antibiotic treatment with penicillin was satisfactory, and no advantage was found to the broad-spectrum antibiotic treatment. 3) A sweeping recommendation for tonsillectomy is not required after a single episode. Surgery should be recommended only after two or more episodes of peritonsillar abscess.

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.

Neurologic manifestations of Fusobacterium infections in children

Fusobacterium necrophorum causes various clinical syndromes, ranging from otitis media to life-threatening Lemierre's syndrome. The purpose of this study was to review our experience with pediatric Fusobacterium infections. The medical records of all children aged 0 to 18 years who were diagnosed between 1999 and 2011 with Fusobacterium infection were reviewed. Fusobacterium was isolated from clinical samples of 27 children: blood cultures (n = 16), abscesses (n = 8), joint fluids (n = 2), and cerebrospinal fluid (n = 1). The median age at admission was 3.5 years (range, 7 months to 17 years). Eight children (30 %) had seizures at presentation. Ten children (37 %) underwent lumbar puncture. Fifteen children (56 %) underwent brain imaging, and in seven of these children, a thrombus was identified either in a sinus vein or in an internal jugular vein. The most common source of infection was otogenic in 19 (70 %) of the children. Six of the children presented in 2011. All patients recovered.

CONCLUSIONS

Neurologic manifestations are common at presentation of children with Fusobacterium infections. In young children, the most common source of infection is otogenic. Thrombotic complications are common, and imaging should be considered in all children with Fusobacterium infections arising from the head or neck region. There was a recent increase in the isolation of this bacterium, either because of better culturing techniques and increased awareness to this entity or a true increase in infections due to this organism.

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.

Salicylate ototoxicity and its implications for cochlear microphonic potential generation

Salicylic acid causes a reversible sensori-neural hearing loss. Its ototoxicity is probably related to its effect on prestin, the motor protein of the outer hair cells. In order to gain further insight into the mechanism and implications of its ototoxicity, auditory nerve brainstem evoked responses, compound action potentials of the auditory nerve, distortion product otoacoustic emissions, and cochlear microphonic potentials (CM) and vestibular evoked potentials were recorded before and after systemic salicylate administration. These responses were depressed, except for the CM and the vestibular evoked potential. This result and additional considerations provide evidence that the extracellularly recorded CM does not represent the summation of intracellular outer hair cell receptor potentials. It is possible that the CM reflects an early stage of mechano-electrical transduction by the outer hair cells, before the activation of the cochlear amplifier and the later stages of transduction.