Prophylactic antibiotics in septoplasty with intranasal septal splints: A comparative analysis.

OBJECTIVES: Postoperative antibiotic therapy is a common practice following septoplasty with intra-septal splints placement (ISS), even though there is a lack of evidence to support it. We sought to investigate the role of antibiotic therapy in septal surgeries with the placement of ISS. DESIGN: A retrospective comparative study was conducted using the electronic charts of adult patients who underwent septoplasty with the placement of ISS with or without turbinate reduction. Nasal cultures were taken routinely during surgery as part of the department's protocol for monitoring infectious diseases. The ISS were also routinely examined for the presence of bacteria after their removal on the eighth day following surgery. SETTING: A large otolaryngology department in a tertiary medical center. PARTICIPANTS: Adult patients who underwent septoplasty in our institution. MAIN OUTCOME MEASURES: We analyzed all post-operative infections to search for risk factors in the cohort. RESULTS: Post-operative infection rates following septoplasty with ISS were low at 6%, which is consistent with previously published rates. Infection rates were significantly higher in patients who were not treated with antibiotics (OR = 8.2, 95%CI: 1.63-41.1; p = .01, φ = 0.04). Diabetes was associated with an increased risk of postoperative infection regardless of prophylactic antibiotic therapy (OR = 5.2, 95%CI: 1.15-23.5; p = .032, φ = .04). The detection of Klebsiella pneumonia before surgery was associated with an increased rate of postoperative infection (OR = 16.6, 95%CI: 3.02-91.54; p = .001, φ = 0.12). CONCLUSIONS: Patients undergoing septoplasty with the placement of ISS are at increased risk of gram-negative bacterial colonisation, and development of postoperative nasal infection. A single preoperative dose of IV antibiotic therapy should be considered a potential prophylactic option for septoplasty with ISS.

Zinc chloride is effective as an antibiotic in biofilm prevention following septoplasty.

Biofilm-state bacterial infections associated with inserted medical devices constitute a massive health and financial problem worldwide. Although bacteria exhibit significantly lower susceptibility to antibiotics in the biofilm state, the most common treatment approach still relies on antibiotics, exacerbating the phenomenon of antibiotic-resistant bacteria. In this study, we aimed to assess whether ZnCl2 coating of intranasal silicone splints (ISSs) can reduce the biofilm infections associated with the insertion of these devices and prevent the overuse of antibiotics while minimizing waste, pollution and costs. We tested the ability of ZnCl2 to prevent biofilm formation on ISS both in vitro and in vivo by using the microtiter dish biofilm formation assay, crystal violet staining, and electron and confocal microscopy. We found a significant decrease in biofilm formation between the treatment group and the growth control when ZnCl2-coated splints were placed in patients' nasal flora. According to these results, infections associated with ISS insertion may be prevented by using ZnCl2 coating, thereby obviating the overuse and abuse of antibiotics.

Thyroid-split tracheostomy: short- and long-term outcomes.

Objective: Compare long-term outcomes of thyroid-split and standard thyroid-retraction tracheostomy in a large cohort. Methods: The healthcare database of a university-affiliated hospital was searched for past patients over 18 years of age from all of the hospital's wards on whom an ear, nose, and throat specialist performed a tracheostomy in the operating room between 2010 and 2020. Clinical data were extracted from the hospital and outpatient medical records. Life-threatening and non-life-threatening intra-operative and early and late post-operative adverse events in patients who underwent split-thyroid tracheostomy were compared with those who underwent standard tracheostomy. Results: There was no significant difference in intra-operative and early post-operative complications, hospitalisation length, or early reoperation and death rates between the 140 (28%) thyroid-split tracheostomy patients and the 354 (72%) standard tracheostomy patients, although the thyroid-split group had more non-decannulated patients and a longer operative time. Conclusions: Thyroid-split tracheostomy is safe and feasible. Compared to the standard procedure, it provides better exposure and a similar rate of complications, although its de-cannulation success rate is lower.

Retrospective analysis of the role of intra-operative parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism: a single center experience over 2 decades.

PURPOSE: Role of intra-operative parathyroid hormone (IOPTH) monitoring during parathyroidectomy for primary hyperparathyroidism (PHPT) has long been debated. Our main goal was to investigate the cure rates of parathyroidectomy for primary hyperparathyroidism with and without IOPTH monitoring. Our secondary goal was to investigate if operating room time can be saved when IOPTH monitoring is not used. METHODS: A retrospective analysis of patients who underwent parathyroidectomy for PHPT due to a single adenoma between 2004 and 2019 was performed. Cure rates and operating room time were compared. RESULTS: 423 patients were included. IOPTH was used in 248 patients (59%). Four patients were not cured, two from each group, with no significant difference between the groups (98.8% vs. 99.1%, p = 0.725). Surgery time was significantly longer in the IOPTH group, p < 0.001. CONCLUSIONS: There is no advantage for using IOPTH during parathyroidectomy in suitable clinical settings. The procedure may be safely performed without IOPTH while achieving non-inferior success rates and reducing operative time.

Implementation of a Novel Protocol for Preventing Venous Thromboembolism in Otolaryngology Patients.

OBJECTIVE: Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality. The Caprini risk assessment model (CRAM) is a validated tool for estimating the risk for postoperative VTE. Previous studies demonstrated a low risk of VTE among otorhinolaryngology-head and neck surgery (ORL-HNS). Hence, our objective was to modify the CRAM-based protocol to be applicable for otolaryngology patients and assess protocol efficacy and safety. STUDY DESIGN: Observational pilot study conducted on ORL-HNS patients undergoing surgery. SETTING: University-affiliated tertiary care center. METHODS: We constructed a modified protocol based on the CRAM and previous reports in the ORL-HNS literature using a reduced postoperative anticoagulation regimen. Primary end point was symptomatic VTE up to 3 months after surgery. Main secondary outcome was postoperative bleeding. RESULTS: A total of 508 patients were enrolled. Of them, 48% underwent head and neck surgery, 18% direct laryngoscopy and transoral robotic surgery, 15% endoscopic sinus surgery, and 11% otology surgery. Adherence to the protocol was 79%. Mean follow-up time was 115 days (range, 30-448 days). Only 1 patient developed deep vein thrombosis, and none developed pulmonary embolism. Two patients had major bleeding not related to the use of anticoagulation. CONCLUSIONS: Our novel CRAM-based protocol appears to be efficacious and safe for VTE prevention in otolaryngology. A larger-scale study is required to validate these findings. LEVEL OF EVIDENCE: Level 2b.

The value of tracheostomy of critically ill COVID-19 patients - A multicentral study.

PURPOSE: Tracheostomy is an aerosol-generating procedure, thus performing it during the COVID-19 pandemic arises considerations such as the most appropriate timing and the patients to whom it is suitable. Medical teams lack sufficient data to assist determining whether or not to conduct tracheostomy, its short- and long-term implications are not fully understood. This study aims to shed light on the critically ill COVID-19 patients that require tracheostomy, and to investigate its value. METHODS: A retrospective multicentral case-control study of 157 hospitalized critically ill COVID-19 patients, among whom 30 patients went through tracheostomy and consisted of our study group. RESULTS: The mean age was similar between study and control groups (68.9 ± 12.7 years vs 70.5 ± 15.8 years, p = 0.57), as well as comorbidity prevalence (56.7% vs 67.7%, p = 0.25). Patients in the study group were hospitalized for longer duration until defined critically ill (5 ± 4.3 vs 3 ± 3.9 days; p = 0.01), until admitted to the intensive care unit (6 ± 6.6 vs 2.5 ± 3.7 days respectively; p = 0.005), and until discharged (24 ± 9.7 vs 10.7 ± 9.1 days, p < 0.001). Mortality rate was lower in the study group (30% vs 59.8%, p = 0.003). Kaplan Meier survival analysis revealed a statistically significant difference in survival time between groups (Log rank chi-sq = 20.91, p < 0.001) with mean survival time of 41 ± 3.1 days vs 21 ± 2.2 days. Survival was significantly longer in the study group (OR = 0.37, p = 0.004). CONCLUSION: Tracheostomy allows for more prolonged survival for gradually deteriorating critically ill COVID-19 patients. This should be integrated into the medical teams' considerations when debating whether or not to conduct tracheostomy.

Safety of Endoscopic Sinus Surgery in the Elderly-Are Octogenarian Patients at a Higher Risk?

BACKGROUND: Surgeons are often faced with concerns regarding the risks versus benefits of endoscopic sinus surgery (ESS) in elderly patients. OBJECTIVE: To analyze the risk for complications of ESS in the elderly (age ≥70 years) compared to younger patients, with emphasis on octogenarians. METHODS: Retrospective review of medical charts of adult patients who underwent ESS at a tertiary referral center during the years 2014 to 2018. RESULTS: We compared 128 elderly patients with 276 matched younger patients. In the elderly group mean age was 76 years (range, 70-91 years ). Thirty-one elderly patients were 80 years or older. Surgical complications in the elderly patients were 3.9%. Minor complications were 2.3% and major complications were 1.7%. The surgical complications rate was similar in the younger group (8%, P value: .127). Medical complications were observed in 2.3% comparing to 0.7% in younger patients. Interestingly, age, revision surgery, extent and duration of surgery, and modality of anesthesia were not identified as risk factors. Only ischemic heart disease (IHD) was identified as a risk factor for complications in a multivariate analysis in elderly patients. Comparison of elderly patients younger than 80 years with octogenarians revealed no difference in complication rate between these groups. CONCLUSIONS: Overall, ESS was found to be a safe procedure in elderly patients compared to younger patients. Octogenarian patients should not be denied upfront surgery. IHD is a risk factor for complications in elderly patients.

Intranasal Septal Splints: Prophylactic Antibiotics and Nasal Microbiology.

OBJECTIVES: Intranasal septal splints are often used in nasal septal surgeries. Routine use of postoperative antibiotics is an accepted practice, although data regarding its efficacy in preventing postsurgical complications are limited. This study aimed to examine bacterial colonization on septal splints following prophylactic antibiotic therapy and the association with postoperative infections. METHODS: Fifty-five patients underwent septoplasty by a single surgeon between March 2015 and April 2016. All had intranasal septal splints and were given antibiotic prophylaxis for 7 days until removal of splints. Nasal cultures were taken before surgery, and septal splints were examined for bacterial colonization following their removal. RESULTS: Thirty-six patients (65%) had positive nasal culture prior to surgery. The most common isolates were Staphylococcus aureus (30%) and Enterobacteriaceae species (66%). All these patients had postoperative bacterial colonization on septal splints. In 15 patients with negative preoperative cultures, bacteria were isolated postoperatively. An increased resistance profile was documented postoperatively in 9 patients (16%), including two with multidrug resistance. In two of these patients preoperative wild-type strains acquired antibiotic resistance postoperatively. No adverse drug reactions to antibiotics were reported. CONCLUSIONS: Increased bacterial growth and emergence of resistant strains were observed on intranasal septal splints despite prophylactic antibiotic treatment. Nonetheless, this did not translate into clinical infection. Thus, considering antibiotics overuse and increasing bacterial resistance, further research is needed to determine the role of antibiotic prophylaxis in the setting of intranasal splints.

Antibiotic prophylaxis in clean head and neck surgery: A prospective randomised controlled trial.

OBJECTIVE: Antibiotic prophylaxis is not indicated for clean head and neck surgery. However, its role in revision cases is not known. The objective was to prospectively test whether antibiotics are useful in this patient group. DESIGN: This was a prospective, double-blind, randomised, placebo-controlled study. SETTING: A single-centre study in a tertiary care centre. PARTICIPANTS: The patients were selected from a referred sample of adult patients (>18 years old) who were planned to undergo revision clean head and neck surgery and who had no preoperative indication for prophylactic antibiotics (eg previous radiation therapy, tracheostomy, active infection, immunosuppression). A total of 59 patients were approached for the study. After exclusion, 53 were available for final analysis. INTERVENTION: The intervention group received a single-dose cefazolin, while the control group received placebo. MAIN OUTCOMES: The primary end-point was the combined rate of surgical wound infection, bacteremia and sepsis. The secondary end-points were length of hospital stay and drug-induced adverse reactions. RESULTS: A total of 53 patients were randomised to 2 groups: 31 to antibiotics group and 22 to control group. There was no difference between the groups in baseline characteristics. The primary end-point occurred in both groups at the same rate. There was no difference in secondary end-point rate, as well. CONCLUSION: Prophylactic antibiotics appear to have no benefit in revision, clean head and neck surgery. Further studies in larger populations and other settings are needed. (ClinicalTrials.gov number NCT01980082, clinicaltrials.gov/ct2/show/NCT01980082).