Evaluation of surface disinfection methods to inactivate the beta coronavirus Murine Hepatitis Virus.

The list of EPA-approved disinfectants for coronavirus features many products for use on hard, non-porous materials. There are significantly fewer products registered for use on porous materials. Further, many common, high-touch surfaces fall in between non-porous materials such as glass and porous materials such as soft fabrics. The objective of this study was to assess the efficacy of selected commercially available disinfectant products against coronaviruses on common, high-touch surfaces. Four disinfectants (Clorox Total 360, Bleach solution, Vital Oxide, and Peroxide Multi-Surface Cleaner) were evaluated against Murine Hepatitis Virus A59 (MHV) as a surrogate coronavirus for SARS-CoV-2. MHV in cell culture medium was inoculated onto four materials: stainless steel, latex-painted drywall tape, Styrene Butadiene rubber (rubber), and bus seat fabric. Immediately (T0) or 2-hr (T2) post-inoculation, disinfectants were applied by trigger-pull or electrostatic sprayer and either held for recommended contact times (Spray only) or immediately wiped (Spray and Wipe). Recovered infectious MHV was quantified by median tissue culture infectious dose assay. Bleach solution, Clorox Total 360, and Vital Oxide were all effective (>3-log10 reduction or complete kill of infectious virus) with both the Spray Only and Spray and Wipe methods on stainless steel, rubber, and painted drywall tape when used at recommended contact times at both T0 and T2 hr. Multi-Surface Cleaner unexpectedly showed limited efficacy against MHV on stainless steel within the recommended contact time; however, it showed increased (2.3 times greater efficacy) when used in the Spray and Wipe method compared to Spray Only. The only products to achieve a 3-log10 reduction on fabric were Vital Oxide and Clorox Total 360; however, the efficacy of Vital Oxide against MHV on fabric was reduced to below 3-log10 when applied by an electrostatic sprayer compared to a trigger-pull sprayer. This study highlights the importance of considering the material, product, and application method when developing a disinfection strategy for coronaviruses on high-touch surfaces.

Outcome After Fenestrated and Branched Repair of Aortic Aneurysms-Device Failures Predict Reintervention Rates.

BACKGROUND: Previous reports have indicated endovascular repair to be safe and effective in the treatment of complex aortic aneurysms. The endovascular technology evolves rapidly, and continuous evaluation of F/B-EVAR results is critical to detect failing techniques. Our aim was to analyze the outcome after endovascular repair of complex abdominal aortic and thoracoabdominal aneurysms. METHODS: Single-center, retrospective cohort study, of all F/B-EVAR from August 2009 to December 2018. Primary outcomes were branch instability and freedom from reinterventions at 2 years. Secondary outcomes were major adverse events and all-cause mortality at 30 and 90 days. RESULTS: A total of 72 consecutive patients were included, 55 with a complex abdominal aortic aneurysm (AAA) and 17 with a thoracoabdominal aortic aneurysm (TAAA). Two patients were operated on for rupture. A total of 219 vessels were stented through fenestrations (n = 163) or branches (n = 56). Median follow-up was 24 months (IQR 4-24). Fractured bridging stent graft was the most common cause for reintervention, n = 6. All fractures were in vessels stented with first generation BeGrafts, (6/41 BeGraft vs 0/61 other stents, P < 0.01). Freedom from reinterventions at 2 years was 75% and 35%, in the complex AAA and TAAA groups, respectively (P = 0.04) and excluding BeGrafts 79% (cAAA) and 66% (TAAA). The most common major adverse event was spinal cord ischemia (SCI), in total 8.3% with either transient (2.8%) or permanent (5.6%) deficit. Elective mortality at 30 days was 1.4% (1/70) and at 90 days was 2.9% (2/70). CONCLUSIONS: The rate of branch instability and reintervention was high, with a clear relation to fractured first-generation BeGrafts. Mortality and major adverse event rates were low. Long-term close surveillance of bridging stent graft performance is crucial, and the endovascular community should strive to find ways to report failing materials at an early stage to avoid potentially serious complications.

Near Infrared Spectroscopy as a Predictor for Shunt Requirement During Carotid Endarterectomy.

OBJECTIVE/BACKGROUND: Near infrared spectroscopy (NIRS) continuously monitors regional cerebral oxygenation (rSO2) in the frontal lobes. This method may be used in patients during carotid endarterectomy to indicate the need for shunting. The aim of the study was to evaluate the value of NIRS in determining the need for selective shunting during CEA. A secondary aim was to compare NIRS with stump pressure. METHODS: Between January 2013 and October 2016, 185 patients from two vascular units, undergoing CEA under local anaesthesia were prospectively included. All patients gave informed consent to participate; there were no exclusion criteria. A Foresight® oximeter was used for rSO2 measurement, which was compared with stump pressure. Receiver operating characteristic curve analysis was used to identify optimal cutoff points, and sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Twenty patients (10.8%) developed neurological symptoms during clamping. Mean stump pressure was lower in the group that developed neurological symptoms than in the group who did not (34 ± 19 mmHg vs. 55 ± 17 mmHg [p < . 01]). Corresponding NIRS results for the decrease in rSO2 on the ipsilateral side was 15 ± 7% versus 4 ± 6% (p < .01). Using stump pressure ≤50 mmHg as cutoff value for predicting symptoms, the sensitivity was 85% (95% confidence interval [CI] 64-95) and specificity 54% (95% CI 46-61). With a relative decrease in NIRS saturation (ΔrSO2) of 9%, sensitivity was 95% (95% CI 76-99), and specificity 81% (95% CI 74-86) to predict ischaemic symptoms during carotid clamping. Neurological deterioration during carotid clamping was detected in one patient with a relative decrease in rSO2 of <9% compared with three patients with a stump pressure >50 mmHg. CONCLUSION: NIRS allows continuous non-invasive monitoring of cerebral oxygenation during CEA, with high sensitivity and acceptable specificity in predicting cerebral ischaemia and the need for shunting, which makes it an attractive alternative to stump pressure.

Peri-procedural Risk with Urgent Carotid Artery Stenting: A Population based Swedvasc Study.

OBJECTIVES: Current European Society for Vascular Surgery guidelines recommend that patients with a symptomatic carotid stenosis should be operated on within 14 days of onset of symptoms. Recent reports indicate that carotid endarterectomy (CEA) within 2 days of a neurological event may be associated with a higher peri-procedural risk of stroke. Whether urgent carotid artery stenting (CAS) carries a similar high risk is unclear. The aim of this study was to analyze if urgent CAS increases the peri-procedural risks. METHODS: Retrospective analysis of all CAS registered in Swedvasc, a validated nationwide registry, between January 1, 2005, and March 20, 2014. Only symptomatic patients treated for a stenosis of the internal carotid artery were included. Patients were categorized according to time from index event to surgery; 0-2 days, 3-7 days, 8-14 days, and 15-180 days. Primary outcome was 30 day combined stroke and death rate. RESULTS: 323 patients underwent CAS for symptomatic carotid artery stenosis. The demographic and clinical data were similar in the groups. No procedure related complications or deaths were observed in the urgent CAS group. The 30 day combined stroke and death rate did not differ significantly between the groups; zero of 13 (0%; 95% CI 0-26.6) in the group treated 0-2 days versus four of 85 (4.7%; 95% CI 1.5-11.9), at 3-7 days, five of 80 (6.3%; 95% CI 2.4-14.1) at 8-14 days, and six of 145 (4.1%; 95% CI 1.7-8.9) for the patients treated at 15-180 days (p = .757). Stroke and death were not more frequent for patients treated within 1 week compared with after 1 week: 4 out of 98 (4.1%; 95% CI 1.3-9.0) versus 11/225 (4.9%; 95% CI 2.7-8.6) (p = .751). CONCLUSIONS: In this national registry study, CAS performed within 1 week of the onset of a neurologic event was not associated with an additional risk of a peri-operative complication compared with those treated subsequently.

Low post-operative mortality after surgery on patients with screening-detected abdominal aortic aneurysms: a Swedvasc registry study.

OBJECTIVES: Screening for abdominal aortic aneurysms (AAAs) substantially reduces aneurysm-related mortality in men and is increasing worldwide. This cohort study compares post-operative mortality and complications in men with screening-detected vs. non-screening-detected AAAs. METHODS: Data were extracted from the Swedish National Registry for Vascular Surgery (Swedvasc) for all screening-detected men treated for AAA (n = 350) and age-matched controls treated for non-screening-detected AAA (n = 350). RESULTS: There were no differences in baseline characteristics besides age, which was lower in the screening-detected group than in the non-screening-detected group (median 66 vs. 68, p < .001). Open repair was used more frequently than endovascular aortic repair (EVAR) in patients with screening-detected AAAs than in non-screening-detected controls (56% vs. 45% p = .005). No differences in major post-operative complications at 30 days were observed between the groups. In patients treated with open repair there were no differences in 30-day, 90-day or 1-year mortality in screening-detected patients compared to non-screening-detected controls (1.0% vs. 3.2% p = .25, 2.1% vs. 4.5% p = .23, 4.1% vs. 5.8% p = .61). None of the patients treated with EVAR in either group died within 30 days. The 90-day mortality after EVAR was lower in patients with screening-detected AAA than in those with non-screening-detected AAAs (0.0% vs. 3.1%, p = .04). No difference in the 1-year mortality was detected in the EVAR-patients between the two groups (1.4% vs. 4.7%, p = .12). CONCLUSIONS: The contemporary post-operative mortality after AAA surgery was low in this national audit of patients with screening-detected AAAs and age-matched controls. Patients with screening-detected AAAs have the same frequency of complications at 30 days as patients with non-screening-detected AAA. This study gives further support to national screening programs for the detection of AAA in men.

Quality of life, shoulder range of motion, and spinal accessory nerve status in 5-year survivors of head and neck cancer.

OBJECTIVE: To determine the association of neck dissection and radiation treatment for head and neck cancer (HNC) with subsequent shoulder range of motion (ROM) and quality of life (QOL) in 5-year survivors. DESIGN: A cross-sectional convenience sample. SETTING: Otolaryngology clinics at tertiary care hospital and Veterans Affairs medical center. PATIENTS: Five-year, disease-free survivors of HNC. METHODS: Demographic and cancer treatment information was collected, including type of neck dissection (none, spinal accessory "nerve sparing," and "nerve sacrificing") and radiation. QOL questionnaires were administered, and shoulder ROM was measured. MAIN OUTCOME MEASUREMENTS: University of Washington Quality of Life (UWQOL), Functional Assessment of Cancer Therapy (FACT) Head and Neck, and Performance Status Scale for Head and Neck. Shoulder ROM measurements included abduction, adduction, flexion, extension, internal and external rotation. RESULTS: One hundred and five survivors completed QOL surveys; 85 survivors underwent additional shoulder ROM evaluations. The nerve sacrifice group exhibited significantly poorer scores for UWQOL measures of disfigurement, level of activity, recreation and/or entertainment, speech and shoulder disability, and willingness to eat in public, FACT functional well-being, and FACT Head and Neck (P < .05). Shoulder ROM for flexion and abduction was poorest in the nerve sacrifice group (P < .05). Radiation was associated with significantly worse UWQOL swallowing (P < .05), but no other differences were found for QOL or ROM measurements. Decreased QOL scores were associated with decreased shoulder flexion and abduction (P < .05). Survivors with decreased shoulder abduction had significantly (P < .05) worse scores in disfigurement, recreation and/or entertainment, employment, shoulder disability, and FACT emotional well-being. CONCLUSIONS: Sparing the spinal accessory nerve during neck dissection is associated with significantly less long-term shoulder disability in 5-year survivors of HNC. QOL measures demonstrated the highest level of function in the no dissection group, an intermediate level of functioning with nerve sparing, and poorest function when the nerve is sacrificed. Decreased shoulder flexion and abduction is associated with reduced QOL in long-term survivors of HNC.

Reasons for non-participation in population-based abdominal aortic aneurysm screening.

BACKGROUND: A population-based screening programme for abdominal aortic aneurysm (AAA) started in 2010 in Stockholm County, Sweden. This present study used individual data from Sweden's extensive healthcare registries to identify the reasons for non-participation in the AAA screening programme. METHODS: All 65-year-old men in Stockholm are invited to screening for AAA; this study included all men invited from July 2010 to July 2012. Participants and non-participants were compared for socioeconomic factors, travel distance to the examination centre and healthcare use. The influence of these factors on participation was analysed using univariable and multivariable logistic regression models. RESULTS: The participation rate for AAA screening was 77·6 per cent (18 876 of 24 319 men invited). The prevalence of AAA (aortic diameter more than 2·9 cm) among participants was 1·4 per cent. The most important reasons for non-participation in the multivariable regression analyses were: recent immigration (within 5 years) (odds ratio (OR) 3·25, 95 per cent confidence interval 1·94 to 5·47), low income (OR 2·76, 2·46 to 3·10), marital status single or divorced (OR 2·23, 2·08 to 2·39), low level of education (OR 1·28, 1·16 to 1·40) and long travel distance (OR 1·23, 1·10 to 1·37). Non-participants had a higher incidence of stroke (4·5 versus 2·8 per cent; P < 0·001) and chronic pulmonary disease (2·9 versus 1·3 per cent; P < 0·001). Daily smoking was more common in residential areas where the participation rate for AAA screening was low. CONCLUSION: Efforts to improve participation in AAA screening should target the groups with low income, a low level of education and immigrants. The higher morbidity in the non-participant group, together with a higher rate of smoking, make it probable that this group also has a high risk of AAA.

Outcome after 7 years of carotid artery stenting and endarterectomy in Sweden - single centre and national results.

OBJECTIVES: The aim was internal vascular centre quality-control measures to compare single-centre results with the national perspective, as well as analysing the Swedish results from carotid artery stenting (CAS) and comparing a relatively high-volume single centre with the Swedish Vascular Registry (Swedvasc) data. The second aim was to compare CAS and carotid artery endarterectomy (CEA) outcomes for the same 7-year period. DESIGN: Retrospective review of a single high-volume centre (Södersjukhuset (SÖS)) (approximately 30 CAS year(-1) approximately 90 CEA year(-1)) versus Swedvasc National data. MATERIALS AND METHODS: All consecutive selective patients treated with CAS at SÖS for a stenosis of the internal carotid artery (n = 208) or CEA (n = 552) between 2004 and 2011 were compared with all patients in Swedvasc registered for CAS (n = 258) and CEA (n = 6474). Primary outcome was 30-day frequency of stroke or death. Secondary outcome was stroke/death/acute myocardial infarction (AMI). RESULTS: The 30-day frequency of any stroke or death after CAS at SÖS compared to the national data was 2.9% and 7.4%, respectively (P = 0.04). The 30-day AMI/stroke/death frequency was 3.4% and 9.5%, respectively (P = 0.01). After CEA during the same time period, the Swedvasc national data had a 4.4% frequency of 30-day stroke and death and 5.8% for AMI/stroke/death. CONCLUSIONS: CAS is not as safe as CEA from a national perspective but our results indicate that a single centre can achieve acceptable results with CAS.

Disappointment and drop-out rate after being allocated to control group in a smoking cessation trial.

BACKGROUND: If a patient agrees to take part in a randomised trial it is reasonable to presume that the patient would prefer to be allocated into the intervention. This study's aim was to investigate how patients react after they have been randomised into control group. METHODS: Nested study within two randomised trials. Telephone interviews with a structured questionnaire. The participants were invited after they had been randomised into the control group in two smoking cessation trials. The main outcome measures were reaction to control group allocation and drop-out rates. RESULTS: Twenty-seven out of 30 possible interviews were successfully completed. Fourteen persons expressed that they were disappointed of being allocated to the control group. Five persons said that they had not understood the consent information and three of these were very disappointed. Surprisingly these three persons said that they had not expected a randomization. A woman expressed that she "felt as if I was being swindled". There were in total 9/117 (7.7%) lost to follow-up in the control group and there were 4/105 (3.8%) losses to follow-up in the intervention group (P=0.26). Active withdrawal of consent was slightly higher among the control group, five in the control group (4.3%) and no active withdrawals in the intervention group (P=0.06). CONCLUSIONS: Disappointment was common after allocation to the control group. This is a probable explanation of the higher drop-out rate in the control group. The consent information is of highest importance since those who were very disappointed claimed they did not receive understandable information.

The efficacy of a smoking cessation programme in patients undergoing elective surgery: a randomised clinical trial.

It is known that smokers constitute an important risk group of patients undergoing surgery. It is unknown how smoking cessation intervention initiated 4 weeks prior to elective surgery affects the probability of permanent cessation. We randomly assigned 117 patients, scheduled to undergo elective orthopaedic and general surgery, to smoking cessation intervention and control group. The intervention group underwent a programme initiated, on average, 4 weeks prior to surgery with weekly meetings or telephone counselling and were provided with free nicotine replacement therapy (NRT). The control group received standard care. As a result, 20/55 (36%) patients the intervention group vs 1/62 (2%) in the control group became completely abstinent throughout the peri-operative period (p < 0.001). After 1 year, those in the intervention group was most likely to be abstinent (18/55 (33%) vs 9/62 (15%) of the controls (p = 0.03). Level of nicotine dependence and obesity seemed to be a predictor of long-term abstinence (p = 0.02).

Impact of body mass index and tobacco smoking on outcome after open appendicectomy.

BACKGROUND: The effect of body mass index (BMI) and smoking on the risk of perforated appendix and postoperative complications in patients undergoing open appendicectomy for acute appendicitis was studied. METHODS: Record linkage was used to identify 6676 male construction workers who underwent open appendicectomy for acute appendicitis between 1971 and 2004. Multivariable binomial logistic regression analyses were performed. RESULTS: After adjustment for age, calendar period and BMI, smoking was significantly associated with an increased risk of perforated appendicitis (PA) (P = 0.004). The relative risk was 1.29 (95 per cent confidence interval 1.11 to 1.50) among current smokers with more than 10 pack-years of tobacco use. In patients with non-perforated appendicitis (NPA), the relative risk of overall postoperative complications was significantly associated with BMI (P < 0.001), and was 2.60 (1.71 to 3.95) in obese patients and 1.51 (1.03 to 2.22) in current smokers with more than 10 pack-years of tobacco use. In patients with PA, overweight, obesity and smoking status were not associated with an increased risk of overall postoperative complications. CONCLUSION: Perforation due to acute appendicitis was associated with current tobacco smoking. A BMI of 27.5 kg/m(2) or more and current smoking were associated with overall postoperative complications in patients with NPA.

Ibuprofen therapy and nasal polyposis in cystic fibrosis patients.

OBJECTIVE: To assess the effects on nasal polyposis from high-dose ibuprofen therapy used in children with cystic fibrosis (CF) pulmonary disease. DESIGN: Retrospective case series. MAIN OUTCOME MEASURE: Presence or absence of nasal polyps. RESULTS: Twenty-two patients treated with high-dose ibuprofen therapy to benefit pulmonary function were identified from 235 patients with CF. Sinonasal disease was present in 19 patients, of whom 12 had nasal polyposis. All 12 patients had observed absence of nasal polyps at some point during their ibuprofen course. Nasal polyps were present in five patients during ibuprofen therapy, and all resolved with increased ibuprofen doses. Polyps occurred in six of eight patients after ibuprofen therapy ceased. Five of the 12 patients required endoscopic sinus surgery for polyposis. CONCLUSION: High-dose ibuprofen therapy chronically administered at appropriate weight-based dosing is a possible treatment option for children and young adults with CF polyposis. More testing is indicated.

The effect of tobacco consumption and body mass index on complications and hospital stay after inguinal hernia surgery.

BACKGROUND: The extent to which lifestyle factors such as tobacco consumption and obesity affect the outcome after inguinal hernia surgery has been poorly studied. This study was undertaken to assess the effect of smoking, smokeless tobacco consumption and obesity on postoperative complications after inguinal hernia surgery. The second aim was to evaluate the effect of tobacco consumption and obesity on the length of hospital stay. METHODS: A cohort of 12,697 Swedish construction workers with prospectively collected exposure data on tobacco consumption and body mass index (BMI) from 1968 onward were linked to the Swedish inpatient register. Information on inguinal hernia procedures was collected from the inpatient register. Any postoperative complication occurring within 30 days was registered. In addition to this, the length of hospitalization was calculated. The risk of postoperative complications due to tobacco exposure and BMI was estimated using a multiple logistic regression model and the length of hospital stay was estimated in a multiple linear regression model. RESULTS: After adjusting for the other covariates in the multivariate analysis, current smokers had a 34% (OR 1.34, 95% CI 1.04, 1.72) increased risk of postoperative complications compared to never smokers. Use of "Swedish oral moist snuff" (snus) and pack-years of tobacco smoking were not found to be significantly associated with an increased risk of postoperative complications. BMI was found to be significantly associated with an increased risk of postoperative complications (P = 0.04). This effect was mediated by the underweighted group (OR 2.94; 95% CI 1.15, 7.51). In a multivariable model, increased BMI was also found to be significantly associated with an increased mean length of hospital stay (P < 0.001). There was no statistically significant association between smoking or using snus, and the mean length of hospitalization after adjusting for the other covariates in the model. CONCLUSION: Smoking increases the risk of postoperative complications even in minor surgery such as inguinal hernia procedures. Obesity increases hospitalization after inguinal hernia surgery. The Swedish version of oral moist tobacco, snus, does not seem to affect the complication rate after hernia surgery at all.

Ofloxacin otic drops vs neomycin-polymyxin B otic drops as prophylaxis against early postoperative tympanostomy tube otorrhea.

OBJECTIVES: To evaluate the incidence of tympanostomy tube (TT) sequelae, tube otorrhea, and tube obstruction immediately postoperatively in patients receiving TT for otitis media and to compare patients receiving postoperative otic drops with controls. DESIGN: Blinded randomized control trial. SETTING: A tertiary pediatric otolaryngology practice. SUBJECTS: The study population comprised 306 patients undergoing TT placement. INTERVENTIONS: The 306 patients were enrolled into the following 3 groups: (1) those receiving no postoperative otic drop prophylaxis (control group), (2) those receiving ofloxacin otic drops (FLOX group), and (3) those receiving neomycin sulfate-polymyxin B sulfate-hydrocortisone otic drops (COS group). RESULTS: Overall otorrhea rates postoperatively were 14.9% for the control group, 8.1% for the FLOX group, and 5.5% for the COS group. When controlling for disease severity, the rate of otorrhea was significantly higher for the control group than for both the FLOX (P = .04) and COS (P = .01) groups. Nonpatent, plugged, tube rates were added to otorrhea rates for a TT failure analysis postoperatively. The control group demonstrated a significantly greater failure rate (29.9%) than both the FLOX (12.1%) and COS (7.7%) groups. The only differences between the patients in the 2 groups receiving drops were that ofloxacin was more well liked by patients (P = .04) and caused less pain (P = .004). CONCLUSIONS: Nonpatency and otorrhea are the most frequent sequelae immediately following TT placement. Few studies have compared different treatment regimens in a randomized controlled trial. These results demonstrate that otic drops clearly provide benefit postoperatively in preventing TT plugging and otorrhea but primarily in patients who have middle ear fluid at the time of TT placement. In addition, consideration of drop choice should be based on patient tolerance and medication safety profiles.

Comparison of caregiver otitis media risk factor knowledge in suburban and urban primary care environments.

OBJECTIVE: There are many risk factors for otitis media. Some of these, such as passive tobacco smoke exposure and childcare arrangements; have the potential to be modified. The purpose of this study is to assess caregiver knowledge deficits about risk factors associated with otitis media and their willingness to modify behaviors associated with those risks. RESEARCH DESIGN AND METHODS: This study is a prospective survey study investigating knowledge deficits of parents or guardians of children ages 6-36 months about the risk factors of otitis media. The patients were consecutively drawn from a suburban and an urban pediatric practice. Any difference in survey results between these two groups was also assessed. Participants completed a survey of 21 questions with content including demographic and OM risk factor data. RESULTS: A total of 401 caregivers completed surveys, with 213 from an urban pediatric practice and 188 from a suburban practice. There was a significant difference in the ethnic distributions of the two populations. The suburban population had a significantly greater family history of ear infections, number of ear infections in the past 12 months, and number of previous ventilation tubes placed. The urban population had a significantly greater number of smokers in the household and decreased knowledge about day care as a risk for OM. The urban population's question responses suggested a greater willingness to change day care arrangements to reduce the risk of otitis media. CONCLUSIONS: Both populations demonstrated knowledge deficits regarding risk factors associated with OM and both populations exhibited willingness to modify behaviors to reduce risk. These findings demonstrate that there are opportunities for improving education regarding OM risk factors and that this education could potentially reduce risk for OM and in turn reduce the incidence of OM in children.

Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience.

INTRODUCTION: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses. METHODS: A retrospective review of CSF leak management was conducted. This study included patients with CSF rhinorrhea managed by the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, from 1992 to 2002. Data collected included site of leak, surgical approach, and any recurrence of leak. RESULTS: Fifty-seven CSF leaks occurred in 53 patients with CSF rhinorrhea originating from the nose or paranasal sinuses. Twenty-eight of the 53 had iatrogenic injuries resulting in CSF rhinorrhea, 16 had leaks from trauma, and 13 developed spontaneous CSF leaks. Ten patients responded to nonoperative management with bed rest with or without lumbar drain placement. Forty-three patients with 47 leaks underwent surgical repair of CSF rhinorrhea, of which 38 resolved after initial repair. Five of these patients developed recurrent CSF leaks at the repair site but resolved with subsequent surgery. Of these, two initially presented with spontaneous CSF leaks, one patient had a gunshot wound with massive skull base injury, and two recurred after repair of an iatrogenic injury. Factors associated with failure included lateral sphenoid leaks and elevated body mass index (BMI). DISCUSSION: Multiple approaches to the management of CSF rhinorrhea can be successful. An endoscopic repair results in resolution of CSF rhinorrhea in the majority of cases. Patients with spontaneous CSF rhinorrhea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases.

Long-term results of Armstrong beveled grommet tympanostomy tubes in children.

OBJECTIVE: Many different tympanostomy tubes have been developed with different sizes, shapes, compositions, and coatings. Despite the frequency of ventilation tube placement, very few large studies have examined the outcomes of patients receiving this procedure. An ideal tube would be easy to insert and would extrude at a predictable interval without complications. This study was performed to assess outcome measures and complication rates of the Armstrong beveled grommet tube. DESIGN: A retrospective case series of patients who had Armstrong beveled grommet tympanostomy tubes placed over a 3 year period by two Children's Hospital of Wisconsin pediatric Otolaryngology staff. MAIN OUTCOME MEASURES: Patient age, diagnosis, operative findings, and time to tube extrusion were reviewed. Otorrhea, perforation, and cholesteatoma rates were also assessed. RESULTS: Five hundred seven consecutive patients who had Armstrong tubes placed were reviewed. One thousand ninety-six Armstrong tubes were placed in these patients. Follow-up to extrusion rates were available for 756 tubes. The mean patient age at tube placement was 33.3 months, and the median age was 23 months. Mean and median times to extrusion were 16.5 and 15.5 months. One hundred sixty episodes of otorrhea were noted in 148 patients. Four patients had histories of cholesteatoma, none of which developed in conjunction with Armstrong tubes. Ten (1.32%) perforations that have not resolved over time were noted after Armstrong tube placement. CONCLUSIONS: Armstrong beveled grommet tympanostomy tubes have complication rates comparable with those reported for Armstrong or other short-acting tubes in smaller series.

Office-based lower airway endoscopy in pediatric patients.

BACKGROUND: Office-based evaluation of the lower airway in adults with only topical anesthetics has been well documented. This study was performed to assess the feasibility of performing office-based lower airway endoscopy in a pediatric population. DESIGN: One hundred five consecutive pediatric patients requiring flexible laryngoscopy were studied. All received only a topical anesthetic-decongestant applied nasally. After flexible laryngoscopy, the endoscope was passed below the vocal folds to visualize the subglottis, trachea, and carina. All evaluations were videotaped for later review. SETTING: Academic pediatric otolaryngology practice. MAIN OUTCOME MEASURES: All 105 patients were studied for complications and agreement between office endoscopy and operative endoscopy when necessary (performed in 20 patients). A subset of 24 consecutive patients were studied for ease of performing the lower airway evaluation, rated on a 3-point scale: 1, unable to perform; 2, performed with some difficulty; and 3, performed without difficulty. The ability to view the subglottis, trachea, and carina were also rated on a 3-point scale. RESULTS: There were no complications for any of the procedures. Office endoscopy correlated with operative endoscopy in all cases. In the subset of 24 patients, the mean score for ease of endoscopy was 2.83. The mean scores for visualizing the lower airway were 2.91 for the subglottis, 2.80 for the trachea, and 2.24 for the carina. CONCLUSION: With the use of only topical anesthesia, flexible endoscopy of the lower airway in children can be performed in the office setting and can be used effectively to evaluate abnormalities of the lower airway.

Anterior lingual thyroglossal cyst: antenatal diagnosis, management, and long-term outcome.

OBJECTIVE: To describe the long-term outcome of a large anterior lingual thyroglossal duct cyst, diagnosed antenatally by ultrasound that completely obstructed the oral cavity and had almost completely replaced the anterior two-thirds lingual musculature. METHODS: Longitudinal observation. RESULTS: Anticipated airway obstruction at birth did not occur. Complete cyst removal occurred at day 2 of life with a rim of lingual muscle observed present only on the left side. Complete and safe oral feeding was achieved by day 11 of life. Progressive muscle mass development and function with mild asymmetry was observed during sequential assessments. Vigorous speech therapy was started at age 7 months achieved 80-100% intelligible speech with minimal misarticulations at age 33 months. CONCLUSION: This case demonstrates the remarkable compensatory ability of the tongue to achieve almost normal function with minimal anterior musculature that is critical to deglutition and articulation. Early speech therapy appears key to improving functional outcomes of speech. A strong central nervous system basis for suckle development is suggested by the rapid development of a safe and effective suckle and swallow soon after cyst resection and in spite of in utero tongue fixation.