Trends in Pediatric Acute Otitis Media Burden During the First COVID-19 Year.

OBJECTIVE: To study the changes in acute otitis media (AOM) pediatric emergency department (PED) visits and pediatric admission before and during the first coronavirus disease 2019 (COVID-19) year. STUDY DESIGN: Retrospective case review. SETTING: Secondary care center. PATIENTS: Children younger than 18 years with all-cause and AOM-related PED visits and pediatric admissions for 3 years (March 1, 2018-January 28, 2021) were identified. Children were categorized according to age (0-2, 2-6, and 6-18 yr) and their date of presentation: pre-COVID-19 (yearly average of visits/admissions during the 2 prepandemic years: March 1, 2018-February 28, 2019 and March 1, 2019-February 29, 2020) or COVID-19 year (visits/admissions between March 1, 2020-February 28, 2021). INTERVENTION: Pre- and post-COVID-19 emergence, alternating lockdowns, kindergarten and school closures, and increased hygiene measures. MAIN OUTCOME MEASURE: Post- versus pre-COVID-19 AOM PED visit and pediatric admission incidence rate ratios (IRRs), using a generalized estimating equation model with a negative binomial regression calculation, while controlling for monthly fluctuations. RESULTS: Annual AOM visits/admissions during the pre-COVID-19 and COVID-19 years were 517 and 192 and 256 and 94, respectively (p < 0.05 for both). For children aged 0 to 2 years, AOM visits/admissions significantly decreased during the first COVID-19 year, compared with the pre-COVID years (ß = -1.11 [IRR, 0.33; 95% confidence interval [CI], 0.26-0.42; p < 0.005] and ß = -1.12 [IRR, 0.33; 95% CI, 0.25-0.42; p < 0.005]). Relatively to all-cause of children aged 0 to 2 years, AOM visits/admissions decreased during the first COVID-19 year versus the pre-COVID-19 years (ß = -2.14 [IRR, 0.12; 95% CI, 0.08-0.17; p < 0.005] and ß = -1.36 [IRR, 0.26; 95% CI, 0.23-0.29; p < 0.005]) and had monthly fluctuations coinciding with the lockdown/relaxation measures. For children aged 2 to 6 years, the reduction in AOM admissions was significant (ß = -1.70, IRR, 0.18; 95% CI, 0.09-0.37; p < 0.005). No significant differences were observed for children aged 6 to 18 years because of the small sample size. CONCLUSION: Pediatric AOM burden substantially decreased during the first COVID-19 year.

Treatment failure in pediatric acute otitis media: How do you define?

INTRODUCTION: Reaching the point of treatment failure in the management of pediatric acute otitis media (AOM) is decision-changing, and is often associated with switching to a broader coverage antibiotic with/without middle ear surgical drainage. Yet, still there is no consensus on the definition of what is treatment failure, which may lead to confusion for clinical decision-making purposes. We sought to review the heterogeneity of treatment failure definitions in AOM. METHODS: We searched for relevant English language manuscripts using the following key-words: ['otitis media' (OM) or (AOM)] AND ['treatment failure' or 'failure' or 'response failure' or 'response'] AND 'human' in various electronic databases from 1/1/2005 through 10/31/2020. RESULTS: In the 60 retrieved papers, treatment failure was considered only when antibiotics had been prescribed beforehand, but not when watchful waiting had been adopted. We categorized the manuscripts into 5 major treatment failure definition subgroups, which occasionally overlapped: unimprovement or worsening of symptoms or signs of failure in otoscopy (n = 36), specialist(s) referral or hospital admission (n = 12), changing or adding antibiotic treatment (n = 22), failure to eradicate causative bacteria (n = 7) and failure as perceived by parents (n = 4). CONCLUSIONS: We suggest a broader definition of AOM treatment failure including physical examination findings and degree of initial treatment response, which will enable an unbiased, uniform comparison of treatments for pediatric AOM.

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.

Adult Otogenic Meningitis in the Pneumococcal Conjugated Vaccines Era.

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 otitis media, PCVs did not change the epidemiology and bacteriology of OgM.

Pediatric nasal tip abscesses.

Nasal tip abscesses in children are uncommon. We report on 7 children/teenagers who presented with an advanced nasal tip abscess that required intravenous antibiotics and surgical drainage, despite adequate pre-admission antibiotic therapy with amoxicillin/clavulanic acid or cephalosporins. Cultures were positive for Staphylococcus aureus, that was clindamycin-resistant but TMP/SMX sensitive.

Combined Single-Step Procedure for Correction of Silent Sinus Syndrome.

Silent sinus syndrome (SSS) is a rare condition characterized by enophthalmos and hypoglobus that is generally not related to trauma or surgery. We present a 30-year-old man who noticed facial asymmetry during the previous month and was referred to our oculoplastic clinic. His examination revealed right hypoglobus and a 2-mm right enophthalmos. The diagnosis of right SSS was confirmed by orbital and paranasal computed tomography scan. The patient had no otolaryngological symptoms and visual acuity was normal bilaterally. He was treated surgically in a combined approach by a team of oculoplastic and otorhinolaryngology surgeons. Functional endoscopic sinus surgery included uncinectomy, maxillary antrostomy, and orbitotomy, with insertion of an orbital implant. This case demonstrates that a single-step surgery for correction of enophthalmos secondary to SSS is a viable option, leading to quick rehabilitation and excellent aesthetic results.

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)

Fish Bone Foreign Body: The Role of Imaging.

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, non-contrast 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.

Tinnitus Perspectives among Israeli Ear, Nose and Throat Physicians: A Nationwide Survey.

OBJECTIVES: To study the compliance of ear, nose, and throat (ENT) physicians to the American Association Otolaryngology-Head - Neck Surgery (AAO-HNS) clinical practice guidelines (CPG) for tinnitus and to identify the disparity of both diagnosis and management options in the absence of a local protocol for the management of adult tinnitus. MATERIALS AND METHODS: A voluntary and anonymous questionnaire was emailed in a Google spread-out sheet format to all practicing ENT physicians across the country (n=370). Overall, 126 ENT physicians responded to the questionnaire (34% of the physicians to whom the questionnaire was sent). RESULTS: Medical history focuses on tinnitus characteristics and otological signs, and symptoms are often queried (80%-98%). Physicians routinely perform an otoscopic examination, whereas other relevant possible physical findings, such as temporomandibular joint disorders or neck trauma, are less frequently examined. Treating physicians have the most frequent recourse to sound therapy and cognitive behavioral therapy in accordance with AAO-HNS CPG. CONCLUSION: The publication of the AAO-HNS CPG for tinnitus is important, permitting a common approach for the diagnosis and management of primary tinnitus (PT). A diagnosis and management scheme that takes into consideration both the AAO-HNS CPG for tinnitus as well as physician diagnosis and management paradigms is suggested.

30-Day Morbidity and Mortality Rates in Elderly Subjects Following Surgical Tracheostomy.

BACKGROUND: Tracheostomy is considered to be effective in the respiratory support of mechanically ventilated patients. We studied a single-center experience of surgical tracheostomy in mechanically ventilated patients to describe the demographics, risk factors, and outcomes of early (≤ 14 d after ventilation) versus late surgical tracheostomy (≥ 15 d after ventilation). METHODS: In this retrospective study, we collected demographic data, medical history, timing of surgical tracheostomy in relation to ventilation day, blood test results, preoperative surgical assessment (subjective impression of neck length, difficulty in neck extension, presence of a goiter), intraoperative complications (bleeding > 100 mL, difficulties in cannula insertion), and postoperative morbidities (bleeding, wound infection, fever, inadvertent de-cannulation, and 30-d postoperative mortality rate) of subjects who underwent surgical tracheostomy in a secondary medical center during 2010-2015. Morbidity and mortality rates were compared between the early versus late surgical tracheostomy groups. RESULTS: Three hundred eleven subjects underwent surgical tracheostomy and met the eligibility criteria. Most of subjects were elderly, with a mean age of 82 y (range 62.5-88 y). There were 22 (7%) subjects in the early surgical tracheostomy group and 289 (93%) subjects in the late surgical tracheostomy group. Late surgical tracheostomy subjects were significantly older compared to early surgical tracheostomy subjects (median age 82 y vs 74 y, P = .001). With regard to intraoperative complications, no appreciable differences were observed between the groups. Timing of surgical tracheostomy was not associated with greater morbidity rates, nor was timing associated with higher postoperative complication rates. Those who survived 30 d were younger than those who died (median 81 vs 83 years, hazard ratio = 1.03). CONCLUSION: In elderly subjects, late surgical tracheostomy was not associated with increased 30-d morbidity or mortality rates. Comorbid conditions and subject age had a greater association with 30-d mortality rate than surgical tracheostomy timing.

Adult acute rhinosinusitis guidelines worldwide: similarities and disparities.

BACKGROUND: Acute rhinosinusitis (ARS) is a common respiratory infection that poses a major public healthcare burden with respect to antibiotic consumption and related morbidity. Position statements and national ARS guidelines have been published worldwide, aiming to define diagnostic criteria and outline treatment options. Our objective was to analyze the similarities and disparities between such guidelines. METHODS: We conducted an electronic database search for ARS guidelines using relevant keywords between January 1, 1989, through December 31, 2017. Overall, 25 guidelines from 39 countries were retrieved: 8 from 8 developed countries, and 17 from 31 developing countries. Representative guidelines from developing and developed countries from America, Europe, Africa, Asia, and Oceania were evaluated. We compared the bibliographic data, diagnostic criteria, and treatment recommendations of selected guidelines. RESULTS: In most developed countries, otorhinolaryngological societies published ARS guidelines, whereas the Ministry of Health formulated the guidelines or adopted generic guidelines prepared by an international organization in developing countries. Many similarities in the diagnostic criteria were found, such as purulent nasal discharge and nasal obstruction sensation. In contrast, maxillary culture as a diagnostic tool was mentioned in developed countries, while it was generally ignored in developing countries. The watchful waiting (WW) policy and abstaining from immediate antibiotics was unanimously adopted in developed countries, which was only partly embraced in developing countries. The recommended universal first-line antibiotic therapy is amoxicillin, with or without clavulanic acid, whereas options for second-line and third-line antibiotic therapies varied. CONCLUSION: ARS guidelines from different countries have many similarities. Specific recommendations are tailored to local epidemiology and healthcare accessibility.

Acute bacterial meningitis caused by acute otitis media in adults: A series of 12 patients.

We conducted a retrospective chart review to characterize the outcomes of 12 patients-9 men and 3 women, aged 21 to 79 years (mean: 49)-who had been treated at our tertiary care center for acute bacterial meningitis caused by acute otitis media (ABMAO). Fever was the most common presenting sign/symptom, observed in 8 patients, followed by otalgia, neck stiffness, headache, and confusion. An opaque and bulging tympanic membrane was observed in 8 patients. Cultures were positive for Streptococcus pneumoniae in the cerebrospinal fluid, ear, and blood in 7, 5, and 3 patients, respectively. Immediate treatment included tympanocentesis, with aspirates sent for bacteriologic cultures. Seven patients (58.3%) underwent surgery; 5 were operated on early, and 2 underwent surgery at a later stage because of a suspected defect in the mastoid bone. A cortical mastoidectomy was performed in 6 of the 7 surgical patients; the remaining patient underwent a canal-wall-down procedure. Ten patients experienced a full recovery, 1 died, and 1 had a poor neurologic outcome (vegetative state); both of the latter 2 patients were older than 60 years. We conclude that early diagnosis, administration of antibiotics, and myringotomy are crucial for control of ABMAO. A cortical mastoidectomy with ventilation tube insertion can be reserved for patients who do not respond, which is common.

Orbital complications associated with paranasal sinus infections - A 10-year experience in Israel.

OBJECTIVE: Orbital involvement is the most common complication of sinus infections. The epidemiology of the disease is continuously changing in the antibiotic era. MATERIALS AND METHODS: Data on patients who were hospitalized due to acute sinusitis and orbital complications were retrospectively collected and analyzed from four medical centers in Israel during the years 2002-2012. RESULTS: 288 patients were included in the study, the average age was 14.4 years, 180 were males, and 220 were children. No significant annual increase in the number of patients was noted. The lowest number of patients was found during the summer 19.4%. A linear direct correlation was found between older age and prolonged hospital stay. Children were presented with a significantly higher Chandler score than adults. No patient had cavernous sinus thrombosis. 101 (35%) patients received antibiotics before hospital admission. Their average hospital stay was similar to those who were not treated prior to admission. 106 patients (39.8%) had fever. A direct correlation was found between older age and the presence of fever. 102 (35.4%) patients had leukocytosis. The difference in white blood cell count between patients younger than two years of age to the other groups was statistically significant. Forty four (15.3%) patients underwent surgical intervention. A direct correlation was found between leukocytosis and older age to surgery. CONCLUSIONS: Periorbital cellulitis occurs mainly in children and males and is less frequent in the summer. Children tend to have worse orbital involvement with lower temperatures than adults. Older age and leukocytosis are associated with surgical intervention.

Deep neck infections in cervical injection drug users.

OBJECTIVES/HYPOTHESIS: To characterize deep neck infections (DNI) in adult intravenous drug users (IDUs) who injected illicit substances to their neck, in comparison to DNI in non-IDUs. STUDY DESIGN: Retrospective, cohort study. METHODS: Data were retrieved from medical charts of adult DNI patients in a secondary hospital during 2000-2013. Clinical, radiologic, and microbial data were extracted and tabulated following categorization into 2 patient groups: IDUs and non-IDUs. RESULTS: Of the 136 patients identified with DNI, 20 (15%) were IDUs; of them 80% were males. IDUs were significantly younger than non-IDUs (mean age, 35 ± 10 vs. 44 ± 16 years, P = .01). All IDUs had multiple comorbidities. IDUs presented for medical examination and hospitalization later in the course of their disease, and the most common involved neck spaces were consistent with areas where cervical injections are commonly performed. Abscess formation was more common in IDUs than non-IDUs (16 [80%] vs. 79 [68%], respectively, P = .04). Despite later presentation of IDUs and their higher rate of comorbidities, laboratory data, microbiology cultures, and disease course were similar to non-IDUs. CONCLUSIONS: Although IDU and non-IDU differ in DNI presentation, both groups had good outcomes. DNI in IDUs frequently evolved into abscesses, and most were found in the anterior triangle deep to sternocleidomastoid (SCM), posterior triangle, and anterior triangle superficial to SCM, in concordance with the injection sites. LEVEL OF EVIDENCE: 4.

The usefulness of preoperative biopsy in unilateral nasal masses.

Unilateral nasal masses are considered suspicious for proliferative diseases. Several tools are routinely used to investigate unilateral lesions such as imaging and nasal biopsy. This study investigated the usefulness of nasal biopsy in predicting the actual nature of unilateral lesions. Preoperative nasal biopsy pathological results were compared with the final pathology obtained during an operation. Forty-six patients with unilateral nasal masses were included in the study group. In 40 patients the final pathology was similar to the preoperative nasal biopsy. In three patients the biopsy specimen was a benign polyp and the final pathology was of an inverted papilloma in two patients and hemangiopericytoma in one patient. In two patients the biopsy specimen was suspicious for an inverted papilloma and the final pathology was a benign polyp. In one patient the biopsy specimen was chordoma and the final pathology was osteosarcoma. The total agreement was 86.9%. The kappa value was 81.2%. Preoperative nasal biopsy is important and useful in evaluating unilateral nasal masses.

[Unilateral choanal atresia: a missed diagnosis].

Bilateral choanal atresia is a congenital anomaly usually diagnosed at birth. In contrast, unilateral atresia causes variable degrees of nasal stuffiness and discharge that might mask the diagnosis and delay the proper treatment. We present five cases of unilateral atresia in which the correct diagnosis was delayed and erroneous treatments were instituted--two adults who had undergone unnecessary septal and turbinate surgery, two older children who were treated medically and one patient who was treated for epiphora. Insufficient awareness of this entity occurring in adults and older children and other possible causes of diagnostic error are discussed. A unilateral mucoid or watery rhinorrhea and obstruction, that lasts from early childhood without evidence of sinusitis and not responding to any medical treatment, should alert the physician to consider unilateral atresia and to perform endoscopic and computed tomography examinations at an early age. Careful interpretation of the computed tomography scan including the axial planes is required.

Pediatric invasive sinonasal Scopulariopsis brevicaulis--a case report and literature review.

OBJECTIVE: Acute invasive fungal sinusitis (AIFS) appears mainly in immunocompromized patients and may be caused by various pathogens. We describe a teenager with invasive sinonasal Scopulariopsis brevicaulis and review all the reports on this rare pathogen. METHODS: A literature search on Scopulariopsis sinonasal invasive infections was performed and clinical data including age, gender, co-morbidities, treatment and prognosis was collected on all the patients. RESULTS: A 17 years old boy with acute myelocytic leukemia and Scopulariopsis brevicaulis sinonasal infection was successfully treated at our department with a combination of extensive surgical debridement and antifungal antibiotics. We found six articled describing six patients with AIFS due to Scopulariopsis species. Four patients were adults and two were children, 3 males and 3 females. Two had an infection with Scopulariopsis acremoium, one with Scopulariopsis candida and for 3 patients no data was given on the specific Scopulariopsis species. All the patients except one were immunocompromized. One patient was treated with antifungal drugs, 2 with surgery and 4 patients received antifungals and were operated. One patient died due to the fungal infection and two patients died due to other causes. CONCLUSIONS: Scopulariopsis AIFS is a life threatening disease affecting mainly immunocompromized patients, both children and adults. No clear treatment regimen has been established yet. We describe the first case of a teenager with Scopulariopsis brevicaulis sinonasal infection treated successfully with a combination of wide local excision and antifungal therapy.