In vitro resistance to bacterial biofilm formation on coated fluoroplastic tympanostomy tubes.

Bacterial biofilm formation has been implicated in persistent posttympanostomy otorrhea and irreversible tube contamination. The use of a tympanostomy tube with a resistance to biofilm formation by the most common organisms associated with persistent infection may decrease the incidence of chronic otorrhea and the need for tube removal. In this investigation, scanning electron microscopy was used to compare a phosphorylcholine-coated fluoroplastic tympanostomy tube to plain fluoroplastic and silver oxide-impregnated fluoroplastic for resistance to biofilm formation after in vitro incubation with Staphylococcus aureus or Pseudomonas aeruginosa. Only a biofilm from Pseudomonas formed on the untreated fluoroplastic tubes, whereas the silver oxide-impregnated tubes developed biofilms from both S aureus and P aeruginosa. In contrast, the coated fluoroplastic tube showed resistance to both staphylococcal and pseudomonal biofilm adhesion. This is the first study to demonstrate the effect of a surface treatment of fluoroplastic as a method to inhibit biofilm formation by both S aureus and P aeruginosa. This reinforces our previous studies showing that surface-adherence properties such as charge or slickness or both may be more beneficial than antibacterial treatments in preventing film adhesion.

In vivo resistance to bacterial biofilm formation on tympanostomy tubes as a function of tube material.

Adherent bacterial biofilms have been implicated in the irreversible contamination of implanted medical devices. We evaluated the resistance of various tympanostomy (pressure equalization [PE]) tube materials to biofilm formation using an in vivo model. PE tubes of silicone, silver oxide-impregnated silicone, fluoroplastic, silver oxide-impregnated fluoroplastic, and ion-bombarded silicone were inserted into the tympanic membranes of 18 Hartley guinea pigs. Staphylococcus aureus was then inoculated into the middle ears. An additional 8 guinea pigs were used as controls; the PE tubes were inserted without middle ear inoculation. All PE tubes were removed on day 10 and analyzed for bacterial contamination using culture, immunofluorescence, and scanning electron microscopy (SEM). All infected ears developed otitis media with otorrhea, but none of the animal control ears drained. Fluorescence imaging of the animal control tubes showed large cellular components consistent with inflammation. The infected tubes showed heavy DNA fluorescence consistent with bacteria and inflammatory cells. All animal control tubes except the ion-bombarded silicone tubes showed adherent inflammatory film on SEM. Also, all tubes placed in infected ears except the ion-bombarded silicone tubes showed adherent bacterial and inflammatory films on SEM. Nonadherent surface properties such as the ion-bombarded silicone may be helpful in preventing chronic PE tube contamination.

In vivo analysis of bacterial biofilm formation on facial plastic bioimplants.

OBJECTIVES: This study examines the formation of biofilm on biomaterials commonly used in facial plastics and reconstruction including titanium, silicone, ion-bombarded silicone (Ultrasil), e-PTFE (Gore-Tex), e-PTFE with silver/chlorhexidine (Gore-Tex Plus), and PHDPE (Medpor). METHODS: These biomaterials were implanted subcutaneously in the dorsum of 11 guinea pigs after contamination with Staphylococcus aureus and examined with scanning electron microscopy after 7 days. Wounds were also inspected for infection and extrusion rates. RESULTS: Results show biofilm formation on titanium, silicone, ion-bombarded silicone, e-PTFE, and PHDPE associated with high rates of extrusion and infection. Implants of e-PTFE with silver/chlorhexidine, on the other hand, appeared resistant to biofilm formation and demonstrated significantly lower rates of extrusion and infection. CONCLUSIONS: Contamination of bioimplants in vivo leads to formation of bacterial biofilm on the surface of the biomaterial, causing infection, pus formation, and extrusion. The authors hypothesize that the antiseptic agents impregnated in the biomaterial form a protective coat of silver, chlorhexidine, and inflammatory cells that inhibits initial bacterial adhesion to the biomaterial surface.

Pre- and postoperative imaging analysis for frontal sinus disease following conservative partial middle turbinate resection.

The prudence of partial or complete middle turbinate resection during endoscopic sinus surgery (ESS) is controversial. The greatest concern regarding partial resection relates to the effect on the frontal recess and the development of frontal sinus disease. The purpose of this study was to radiographically evaluate the frontal sinus in patients who had undergone ESS with partial conservative middle turbinate resection. We reviewed the charts and operative records from 195 consecutive cases of ESS performed by a single surgeon (JFB) over a two-year period. Thirty-three of 117 patients who had undergone ESS with conservative partial middle turbinate resection without frontal recess exploration agreed to return for magnetic resonance imaging (MRI) of their sinuses. The preoperative computed tomography (CT) scans and postoperative MR images were reviewed and graded (1-3) by a single neuroradiologist. Significant frontal sinus disease (grades 2 and 3) was seen in 15 of 52 sides preoperatively (29%), and in 14 sides postoperatively (27%). During the postoperative MRI studies, only six frontal sinus sides demonstrated minimal mucosal thickening (grade 1) which had not been apparent on preoperative CT. This radiographic analysis suggests that conservative partial middle turbinate resection during ESS does not adversely affect the frontal sinus. We believe that the surgical technique employed when resecting the middle turbinate, and the avoidance of unnecessary dissection in the recess are both important factors in preventing the development of frontal sinus disease following ESS.

Resistance to biofilm formation on otologic implant materials.

New materials and coatings are now being developed to resist permanent bacterial contamination of implanted medical devices. This study exposed several styles of middle ear ventilation tube materials and coatings to high concentrations of Pseudomonas and Staphylococcus. Electron microscopy was then used to evaluate these tubes' resistance to bacterial biofilm formations. Ionized, processed silicone tubes were the only tubes resistant to Pseudomonas adhesion. Tubes that were made of fluoroplastic or that were ionized processed were very resistant to Staphylococcus contamination when compared with untreated silicone or silver oxide-treated silicone. This study suggests that ionized, coated fluoroplastic would be a highly effective tube material in preventing bacterial biofilm contamination of implanted ventilation tubes.

Comparison of CT scan and electron microscopic findings on endoscopically harvested middle turbinates.

CT scans of eight nonsmoking patients with chronic sinusitis and two controls were graded for their disease severity (from 0 to IV) with the classification system proposed by May. Subsequently, endoscopically harvested middle turbinate specimens from these patients (16 diseased turbinates, 4 controls) were evaluated both by scanning and by transmission electron microscopy. As the severity of the disease increased as demonstrated by CT scan, electron microscopy of 5 x 3 x 0.05 mm mucosal specimens demonstrated that the number of ciliated cells decreased whereas the number of goblet and squamous cells increased. As the disease progressed to stages III and IV, scanning and transmission electron microscopy demonstrated areas of squamous metaplasia and areas completely denuded of epithelium. The increased goblet cell population, the loss of cilia and ciliated cells, and the patches of denuded epithelium may account for the recurrent bacterial infections and chronic nasal drainage seen in patients with chronic sinusitis. The extensive mucosal changes that occur in grade III and IV disease are similar to those occurring in cigarette smokers, and it takes years to recover after discontinuation of smoking. Delayed recovery of the mucosal epithelium may account for both the recurrent infections and the slower response to treatment on the part of patients with extensive grade III and IV changes on the CT scan.

Myospherulosis of the upper eyelid as a complication of endoscopic sinus surgery.

Myospherulosis is a chronic inflammatory reaction to the mixture of red blood cells and petroleum based ointments. A literature review does not reveal any cases involving ophthalmic manifestations. We present the first reported case of a patient experiencing recurrent eyelid inflammation from myospherulosis after endoscopic sinus surgery. The pathophysiology and management of myospherulosis are discussed.

Histopathology and CT analysis of partially resected middle turbinates.

Thirty-eight partial middle turbinate resections from 20 patients undergoing endoscopic sinus surgery were evaluated by histopathology of mucosa and bone and by computed tomography (CT) appearance prior to resection. Histopathologic analysis revealed not only mucosal inflammation but also chronic osteitis of the bone in all patients with sinus disease. The preoperative CT was accurate in predicting turbinate osteitis when the scans displayed advanced grades III and IV disease. These findings suggest that in advanced disease, conservative partial middle turbinate resections may be necessary to remove chronically infected bone from the osteomeatal complex. Because it is unsafe to remove all of the middle turbinate, consideration should also be given to long-term antibiotic therapy to treat the osteitis found in advanced disease.

Anastomosis technique for high pharyngogastrostomy.

Pharyngogastric anastomosis, otherwise referred to as the "gastric pull-up" procedure, is the most reliable method of reconstruction after laryngopharyngectomy. We currently use a method of gastric to pharyngeal anastomosis that avoids excess tension, and thus decreases the incidence of fistulas and flap failures. With the stomach fully mobilized, the "pull-up" is brought high into the neck using a plastic bag to facilitate delivery via the posterior mediastinum. A curved, U-shaped incision is then made in the fundus of the tongue anteriorly, allowing the posterior nasopharynx to be reached without tension.

Isolated third-nerve palsy associated with frontal sinus mucocele.

Isolated third-nerve palsies are seen most commonly with aneurysms, vascular disease, trauma, or neoplasms (1-5). Sinus mucoceles have been known to cause orbital symptoms including proptosis and cranial nerve palsies. Rarely, an oculomotor nerve abnormality may be seen in the setting of mucoceles of the paranasal sinuses. We describe an unusual case of an isolated pupil-sparing third-nerve palsy as the presenting sign of a frontal sinus mucocele. Emphasis is placed on the discussion of sinus mucoceles and their relation to orbital symptoms.

Two ear problems you may not need to refer. Otitis externa and bullous myringitis.

Primary care physicians are being forced to broaden the scope of their practice because of the financial restraints placed on them by managed care. Common otologic conditions such as otitis externa and bullous myringitis, which are often referred to otolaryngologists, can be promptly diagnosed and treated by primary care physicians. Referral to a subspecialist is indicated when symptoms persist despite treatment and when the cause of ear pain remains unexplained after thorough evaluation.

Modified double mandibular osteotomy for tumors of the parapharyngeal space.

In 1984, Attia et al described the double mandibular osteotomy as a more direct approach for tumors of the ptergomaxillary and parapharyngeal space. The procedure incorporates the traditional parasymphyseal osteotomy of the mandible with a horizontal osteotomy of the ascending ramus. Several modifications of this technique are described that increase the surgical exposure, while requiring less surgical dissection. The incorporation of rigid fixation with miniplates has improved postoperative recovery by avoiding maxillomandibular fixation and improving oral nutrition.