Are Hounsfield Unit Measurements of Bony Absorption Changes in Cholesteatoma Helpful?

Abstract Introduction High-resolution computed tomography (HRCT) scans of the temporal bone are used to assess the bony erosion of the middle-ear structures whenever cholesteatoma is suspected. Objective To study the differences in HRCT Hounsfield unit (HU) index measurements of middle-ear bony structures between an ears with and without cholesteatoma. Methods A retrospective study of 59 patients who underwent surgery due to unilateral cholesteatoma. The HRCT HU index of the scutum, of three middle-ear ossicles, of the lateral semicircular canal (LSCC), and of the fallopian canal was measured in both ears. A comparison was made between the cholesteatoma and the non-cholesteatomatous ear (control). All measurements were conducted by an otolaryngologist. To assess the interobserver bias, 10% of the samples were randomly and independently assessed by another otolaryngologist and a neuroradiologist who were blinded. Results The average HU index was lower in the ear with cholesteatoma when compared with the non-cholesteatomatous ear. While the differences were statistically significant regarding the measurements of the scutum (516.02 ± 311.693 versus 855.64 ± 389.999; p = 0.001), the malleus (1049.44 ± 481.765 versus 1413.47 ± 313.376; p = 0.01), and the incus (498.03 ± 264.184 versus 714.25 ± 405.631; p = 0.001), the differences in the measurements of the LSCC (1042.34 ± 301.066 versus 1154.53 ± 359.609; p = 0.69) and of the fallopian canal (467.19 ± 221.556 versus 543.51 ± 263.573; p = 0.108) were not significantly different between both groups. The stapes was immeasurable in both groups due to its small size. Conclusion Hounsfield unit index measurements are a useful tool that may aid in the diagnosis of early-stage cholesteatoma.

Adult Otogenic Meningitis in the Pneumococcal Conjugated Vaccines Era

Abstract Introduction Streptococcus pneumoniae is a major pathogen of otogenic meningitis (OgM), the most commonly reported intra-cranial complication of otitis media (OM). Objectives To study the changes in adult OgM patients in the pneumococcal conjugated vaccines (PCVs) era. Methods Retrospective cohort of adults presenting with concurrent OM and meningitis in a secondary medical care center between 2005 and 2015. Data collected included demographics, OM-related symptoms, cerebrospinal fluid (CSF) and ear culture results, pre- and during hospitalization antibiotic treatment, imaging findings, and complications. We compared the pre-PCV years (2005-2009) with the post-PCV years (2010-2015). Outcomes were 1) incidence of all-cause adult OgM from the total meningitis cases; 2) impact of PCVs on the clinical presentation of OgM and bacteriology. Results Otogenic meningitis was diagnosed in 26 out of 45 (58%) cases of all-cause meningitis admissions. Of those, 10 (38%) were male, with a mean age of 62.4 years old. Ear-related signs and symptoms were documented in 70% of the patients, and OgM was diagnosed following imaging studies in 6 out of 26 (23%) patients. All of the patients received intravenous antibiotic therapy, and 7 (27%) patients required surgical interventions: 6 required myringotomy and 1 required mastoidectomy. There were 12 (46%) patients in the pre-PCV years and 14 (56%) in the post-PCV years. The positive pneumococcal CSF and ear culture rates remained high and unchanged (~ 75%). There were no significant changes in the clinical presentation or mortality rates. Conclusion Micro-otoscopy should be included in the routine work-up of any suspected adult meningitis, because OgM is underdiagnosed. Unlike their impact on pediatric otitismedia, PCVs did not change the epidemiology and bacteriology of OgM.

Fish Bone Foreign Body: The Role of Imaging

Abstract Introduction Fish bone foreign body (FFB) impaction in the upper aerodigestive tract is a common cause for emergency department referral. Its management varies in both diagnosis and treatment paradigms. Fish bone foreign bodies are more commonly found in the oropharynx in cases of patients < 40 years old, and in the esophagus in cases of patients > 40 years old. Symptoms are typically non-indicative for the location of the FFB, with the exception of foreign body sensation at/superior to the cervical esophagus. A lack of findings during the physical examination is routinely followed by imaging, with computed tomography (CT) being the preferred modality. In practice, many patients undergo unnecessary imaging studies, including CT scans. Objectives To identify patients with suspected fish bone impaction who do not require CT imaging and can be safely discharged. Data Synthesis We have searched the PubMed database for the following medical subject headings (MeSH) terms: fish bone, fish foreign body AND oropharynx, hypopharynx, esophagus, flexible esophagoscopy, and rigid esophagoscopy. Our search in the English language yielded 32 papers. Case reports were included, since they highlighted rare and serious complications. Conclusion In patients > 40 years old suspected of fish bone impaction, noncontrast CT is recommended and should be urgently performed, even in the presence of ambiguous symptoms. However, in patients < 40 years old presenting within 24 hours from ingestion, imaging has little diagnostic value due to the low probability of esophageal fish bones. For this specific subgroup, in the absence of clinical findings, discharge without imaging studies may be considered safe. (AU)

The Impact of Tobacco Smoking Upon Chronic/ Recurrent Tonsillitis and Post Tonsillectomy Bleeding

Abstract Introduction Smoking has many adverse effects on the oral and pharyngeal mucosa. Outcomes may be developing tonsillar infections and predisposing for post tonsillectomy bleeding (PTB). Objective The objective of our study was to determine whether smokers have more chronic/recurrent tonsillitis indicating for tonsillectomy or develop more PTB episodes. Methods We conducted a retrospective study on two groups of adults (age ≥18 years). Cohort 1: Smoking among patients who underwent tonsillectomy for recurrent/ chronic tonsillitis. Cohort 2: Smoking among patients requiring control of PTB that were operated primarily for recurrent/chronic tonsillitis. Cohort 1 served as a populationreference for the second. We retrieved the data from medical records. Results Cohort 1: 206 adults aged 18-50 years (mean 26 ± 7.6). 28% (57 patients) were smokers, versus 24% and 20% in the general population (in the years 2000 and 2010; p = 0.5, p = 0.18, respectively). Cohort 2: 114 adults aged 18-73 years (mean 26 ± 7.6). 43% were smokers, double the incidence in the general population (p = 0.004, p = 0.0004, in 2000 and 2010, respectively), and 1.5 times cohort 1 (p = 0.02). Smoking rates among bleeders on post-operative days 8-10 and later than day 10 were 53% and 60% (p = 0.0005 and p < 0.0001, respectively). Five of ten patients presenting a second PTB were smokers. Timing of re-bleedings was similar to their first PTB and dated similarly as first PTB of the entire group, mean 5.6 days (SD ± 3.2). Conclusion Smokers may encounter more chronic/recurrent tonsillitis episodes, indicating tonsillectomy and significantly are more prone for PTB. Smoking cessation may perhaps diminish recurrent/chronic tonsillitis.Whether pre-operative abstinence or its length would reduce PTB incidence is yet to be determined.

Is Primary Hyperparathyroidism a Risk Factor for Papillary Thyroid Cancer? An Exemplar Study and Literature Review

Introduction Primary hyperparathyroidism (PHPT) is associated with several cancer types, including papillary thyroid carcinoma (PTC). Objective To explore further the relation between PHPT and PTC. Methods By considering patients with PHPT as extra-suspicious for PTC, we studied an exemplar group of patients with PHPT with a small (1 cm) thyroid nodule, which was negative in preoperative cytologic examination. During parathyroidectomy, a frozen section biopsy of the thyroid nodule confirmed PTC, as did the final surgical specimen, revealing that the preoperative cytology was false-negative. Additionally, relevant reports retrieved from the English literature addressing thyroid cancer and hyperparathyroidism were reviewed and processed. Results Four patients with PHPT were studied. Three had a multifocal thyroid disease, and three had neck lymph node metastasis. Processing previous report data supported an association between PHPT and PTC. Although thyroid nodularity among patients with PHPTwas similar to the general population, PTC incidence was higher. This was true also for patients with secondary hyperparathyroidism. Conclusions This study emphasized that PHPT should be considered as a noteworthy risk factor for PTC. Fine needle aspiration of a thyroid nodule is the most valuable diagnostic procedure for thyroid cancer. Yet, false-negative results were reported in up to 10% of cases, especially in small, subcentimeter nodules. In line with our data and the literature, patients with PHPT should have both a detailed ultrasound addressing the thyroid and cytology of any thyroid nodule, including small subcentimeter lesions. Moreover, surgical flexibility, allowing intraoperative thyroid nodule sampling, should be considered even for "innocent" nodules. .