Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines.

Currently there is no agreement on the treatment of patients who develop a peritonsillar abscess (PTA). This lack of consensus results in highly variable and possibly expensive therapeutic regimens that may not provide optimum quality patient care at reasonable cost. The present study evaluates surgical, medical, diagnostic, and cost factors that affect the management of PTA based on the following: 1. a cohort study of 123 patients with PTA treated using needle aspiration as the initial surgical drainage; 2. a national survey of the PTA management practices of otolaryngologists; and 3. meta-analyses of various components of the treatment regimen for PTA. In the cohort study, patients diagnosed with PTA were treated by both otolaryngologists and emergency medicine specialists with needle aspiration as the primary surgical modality resulting in a 96% acute resolution rate for PTA. In the national survey, questionnaires were sent to 2000 randomly selected members of the American Academy of Otolaryngology-Head and Neck Surgery regarding their management of PTA. The return rate was 73%. Ninety-six percent of the physicians who returned survey forms treated an average of seven PTAs per year using either needle aspiration, incision and drainage, or abscess tonsillectomy to drain the abscess initially. The incidence of PTA in the United States and Puerto Rico among patients 5 to 59 years of age treated by survey practitioners is 30.1 per 100,000 person years, accounting for approximately 45,000 cases per year. Four meta-analyses were completed to quantify the success rate of needle aspiration in the treatment of PTA (94%), the recurrence rate of PTA (10% to 15%), the rate at which penicillin-resistant microorganisms are found in patients with PTA (0% to 56%), and the rate of prior oropharyngeal infections associated with PTA (11% to 56%). The recurrence rate for PTA in the United States is 10%, which is significantly different from the recurrence rate of 15% reported from the rest of the world (P < .002). A clinical intervention for PTA is proposed based on the clinical series, the national survey data, and the meta-analyses. These clinical guidelines recommend that needle aspiration be used as the initial surgical drainage procedure for all patients with a PTA other than those who have indications for abscess tonsillectomy. Patients should be treated in an outpatient setting, should receive penicillin if they are not allergic to it, and should receive adequate pain medication. The evidence does not suggest that there is any benefit in examining the abscess contents for microorganisms. Approximately 30% of patients with PTA can be expected to exhibit relative indications for a tonsillectomy.(ABSTRACT TRUNCATED AT 400 WORDS)

Short-stay outpatient tonsillectomy.

OBJECTIVE: To determine the risk of complications after discharge in outpatient adenotonsillectomy after a short (< 6 hours) period of postoperative observation. DESIGN: Retrospective chart review. SETTING: Outpatient surgery center at a university hospital. PATIENTS: All patients 18 years of age or less who were scheduled for adenotonsillectomy or tonsillectomy from January 1988 through December 1991. Two hundred fifty-five patient records were reviewed. Twenty-two patients were excluded from the study because of various complicating medical conditions that required planned overnight hospitalization leaving a study population of 233 patients. MAIN OUTCOME MEASURES: (1) Rate and type of complications; (2) duration of postoperative observation. RESULTS: Complication rates of bleeding, emesis, dehydration, and readmission were compared with rates deemed acceptable in the literature (< or = 10%). Power analysis demonstrated that the patient number was sufficient to establish a 95% confidence interval for a complication rate of 0% to 10%. The mean duration of postoperative observation was 136 +/- 48 minutes. Complications included bleeding, emesis, dehydration, and nonscheduled admissions. The total complication rate was 9% (95% confidence interval, 5.5% to 12.7%). The rate of primary bleeding was 1.4%, and all primary bleeding occurred within 75 minutes of arrival in the recovery room; no primary bleeding occurred after discharge from day surgery. This complication rate is comparable with rates previously described in the literature for patients who were observed for a 6- to 12-hour period. CONCLUSION: The findings in this study suggest that short periods of observation are safe for outpatient pediatric patients undergoing adenotonsillectomy after discharge criteria are met.

Coexistent thyroid cancer and pregnancy.

OBJECTIVE: A study was performed to determine the appropriate time for the initiation of therapy for thyroid carcinoma first diagnosed during pregnancy. DATA SOURCES: Material on thyroid cancer cases was obtained from the New Mexico Tumor Registry, Albuquerque, a computerized population-based registry for the state of New Mexico, and the Indian reservation facilities in New Mexico and Arizona (a Surveillance, Epidemiology, and End Results Registry funded by the National Cancer Institute, Bethesda, Md) for the period 1970 to 1991. STUDY SELECTION: All cases of thyroid cancer, except medullary and anaplastic, in patients aged 18 to 46 years were evaluated. Subgroups were established for (1) all women who were noted to be pregnant at the time of their initial diagnosis and (2) all women with thyroid cancer in the 18- to 46-year-old age group. DATA EXTRACTION: The information was extracted by a certified tumor registrar for age, sex, thyroid cancer, specific type of thyroid cancer, period, race, year of diagnosis, accession date, last date seen, tumor status, treatment, and patient status. DATA SYNTHESIS: There have been no deaths in the pregnant group with a follow-up ranging from 0.5 to 20 years. There was no statistically significant difference in observed survival rates between the pregnant group and 465 women, aged 18 to 46 years, with comparable thyroid cancers or in the death rates of women aged 18 to 67 years in the general population. CONCLUSIONS: Surgical treatment for patients with well-differentiated thyroid cancer diagnosed during pregnancy can be delayed until after parturition.

Fine needle aspiration of inverted Schneiderian papilloma. A case report.

The cytologic and histopathologic findings in an inverted Schneiderian papilloma of the paranasal sinuses are described. This uncommon neoplasm of the sinonasal region is characterized by a significant recurrence rate and an association with squamous cell carcinoma in 7-13% of patients. Fine needle aspiration of inverting papillomas may allow rapid identification of the lesion when a tissue biopsy is impractical.

Vasodepressor syncope from neck cancer with associated C-6 dermatome neuralgia.

An unusual case of neck cancer with associated C-6 dermatome neuralgia causing vasodepressor syncope episodes is discussed. Pacemaker therapy proved not to be required. When evaluating syncope with bradycardia, it is important to search for underlying causes and to ascertain whether or not pacemaker therapy is indicated.

Otolaryngology/Head and neck surgery: needle aspiration of peritonsillar abscesses.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in otolaryngology/head and neck surgery. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in otolaryngology/head and neck surgery that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Otolaryngology/Head and Neck Surgery of the California Medical Association and the summaries were prepared under its direction.

Needle aspiration of nonperitonsillar head and neck abscesses. A six-year experience.

Twenty-five patients with various head and neck abscesses have been managed with needle aspiration as the initial surgical modality over a six-year period. Twenty (83%) of 24 patients' abscesses resolved without formal surgical intervention. Patient 25 in the series whose abscess, though initially resolving, reaccumulated within two weeks requiring an incision and drainage. Recurrent cancer was then diagnosed. Eight of ten large-volume abscesses (over 10 mL) were controlled with needle aspiration. Fourteen patients required multiple aspirations, five of whom had indwelling catheters placed to facilitate abscess decompression. These data confirm that needle aspiration is an effective means of controlling nonperitonsillar abscesses of the head and neck.

Management of nonperitonsillar abscesses of the head and neck with needle aspiration.

Ten patients in a three-year period with various abscesses of the head and neck (nonperitonsillar) were treated with needle aspiration as the primary surgical modality. Eight were successfully managed with antibiotics and needle aspiration alone. Two required incision and drainage. Three patients had large volume abscesses (greater than 10 cc). Two of these resolved with multiple needle aspirations. These data suggest that certain nonperitonsillar abscesses of the head and neck may be successfully managed with needle aspiration and antibiotics.

Functional hearing loss presenting as sudden hearing loss: a case report.

A case of functional hearing loss presenting as sudden sensorineural hearing loss in the only hearing ear of a musician is presented. Pure-tone audiometric evaluation showed good intratest and intertest consistency. The pitfalls of diagnosis, ultimately made by brain stem evoked response audiometry, are discussed in light of the literature on sudden and functional hearing loss. Psychiatric evaluation revealed features consistent with hysterical conversion. It is argued that it is important to establish the exact etiologic agent of functional hearing loss despite the difficulty of diagnosis so that the patient may receive appropriate treatment.

Permucosal needle drainage of peritonsillar abscesses. A five-year experience.

Forty-one patients with proved peritonsillar abscesses were treated during a five-year period with needle aspiration as the sole initial surgical treatment. Ninety percent (37/41) of the patients' abscesses resolved without further invasive therapy. All but two of the patients were treated as outpatients. Fifty percent (21/41) of the patients were treated by nonotolaryngologists. These data indicate that outpatient needle aspiration is the simplest, most cost-effective therapy for peritonsillar abscess.

Peritonsillar abscess: needle aspiration.

Needle aspiration and antibiotics (usually penicillin) were used as the sole initial treatment of peritonsillar abscess in 29 patients over a 2 1/2-year period. Positive aspirations occurred in 23 patients, 19 (82%) of whom had complete resolution of their abscesses without further initial therapy. The implications of these findings are discussed.

Pi meson radiotherapy for advanced head and neck neoplasms: preliminary results.

Under the auspices of the University of New Mexico Cancer Research and Treatment Center, trials are under way at the Los Alamos Meson Physics Facility to evaluate the effects of pi meson irradiation on locally advanced human tumors. This paper summarizes the preliminary results in patients with locally advanced head and neck tumors treated under Phase 1 and Phase II studies. A total of 26 patients were treated between June 1977 and May 1979 with a minimum follow-up of 9 months and a maximum follow-up of 33 months. Sites of disease included the oropharynx in 10 cases (base of tongue in 7, tonsil in 2, and pharyngoepiglottic fold in 1), the supraglottic larynx in 4, the nasopharynx in 5, the oral cavity in 4, the hypopharynx in 2, and the sublingual salivary gland in 1. Twelve of the 26 patients are alive, and 10 survive with no evidence of disease. Doses employed ranged from a minimum of 1,000 peak pion rad in 7 fractions over 9 days to a maximum of 5,4000 peak pion rad in 51 fractions of 89 days. The minimum dose employed for any patients treated with peak pions alone was 3,000 rad. These data are analyzed according to dose, sit, histology, tumor response, local control, and survival. Results from these cases form the basis of the Phase III randomized trials for advanced squamous-cell carcinomas of the head and neck, which are currently in progress.

Tympanostomy tubes. Infectious complications.

Tympanostomy tube placement for a variety of indications is one of the most commonly performed surgical procedures in the United States. In the voluminous literature on the subject, little attention has been paid to the infectious complications associated with the insertion of tympanostomy tubes. A 4 1/2-year retrospective study of 140 patients to examine this problem revealed that 21.4% had otorrhea at least once during intubation. Five patients had prolonged and complicated problems associated with otorrhea. These problems are examined in detail, and the implications of the otorrhea associated with tympanostomy tubes are discussed.

Electroacoustic assessment of the semipermeable tympanic ventilating tube. A physical model.

The semipermeable membrane ventilating tube has been in use for the past few years. Initial evaluation of this tube indicated that electroacoustic impedance measurements could be used to measure in situ patency. Our clinical experience seemed to question this assumption. A physical model was developed to evaluate the validity of using electroacoustic impedance measurements to test patency of membrane-type ventilating tubes. Our results indicate that volume impedance measurements cannot be used to evaluate patency. Pressure clearance studies validated the efficacy of the membrane tubes but would not appear to be a reliable method for in vivo evaluation of patency.