Efficiency Analysis of Hemostatic Agents in Drainless Neck Surgery: Cellulose-Based Versus Liquid Fibrin Sealants.

PURPOSE:  Using liquid fibrin sealants has once again questioned the benefit of drain placement in head and neck operations. Cellulose-based hemostats offering different hemostasis mechanisms have scarcely been investigated in drainless neck surgeries. This study aimed to evaluate whether liquid fibrin sealant offers any advantage over cellulose-based hemostats in various head and neck surgeries. METHODS: A prospective trial of patients who underwent various neck surgeries between 2020 and 2022. Baseline characteristics and postoperative outcomes were compared between the drain-placed and the drainless groups, with the latter sub-categorized into three groups: fibrin sealant, cellulose-based hemostats, and a combination of both. RESULTS: A total of 119 patients were included (63 thyroidectomies, 40 parathyroidectomies, and 16 sialoadenectomies). Fifty eight had a drain placed and 61 had no drain. In the drainless group, 23 patients received cellulose-based absorbable hemostats (SURGICEL®/ FIBRILLAR™); 18 patients had fibrin sealants (EVICEL®/TachoSil®/TISSEEL); in 16, a combination of both was used; and in four patients, no hemostatic agent was used. Three (5%) of the 61 drainless patients developed a seroma compared to one (2%) seroma in the drain-placed patients. No advantage was demonstrated using a combination of FIBRILLAR™ with a fibrin sealant nor for any used separately. Drain placement delayed patient discharge by at least one day compared to the group without a drain (p < 0.001). CONCLUSION: Drain placement offered a minor advantage in the postoperative course reducing rates of seroma formation, while delaying patient discharge by at least one day. There was no advantage in using a specific hemostatic agent over the other.

Comparative analysis of approaches to the Wharton's duct during surgery of the submandibular gland: A retrospective case-control study.

INTRODUCTION: We investigated complications and recurrence rates after surgical techniques for sialolith removal with intact and resected Wharton's duct of the submandibular gland. METHODS: The retrospective case-control analysis of a series analysed 271 surgical operations (2003-2022) for sialolithiasis performed at a hospital department of Otolaryngology-Head and Neck Surgery. The study compared two approaches: (1) pure endoscopic technique or pinpoint stone removal with Wharton's duct left intact and (2) transoral duct dissection or pinpoint stone removal technique, after which the duct was shortened. While choosing the surgical option, the size of the stone, the location of the stone, and the presence of multiple stones were taken into account. The rates of complications (lingual nerve paraesthesia, duct stenosis, drooling, and sialoadenitis), the incidence of foreign bodies, and the rate of recurrence during follow-up of ≥18 months were compared. RESULTS: 323 sialoliths were removed from 271 patients. Of these 323 calculi, 150 were removed by the first approach and 173 by the second approach. The calculi varied in diameter from 2 to 38 mm with an average diameter of 8.2 mm. For all 271 patients, the rate of recurrence was 4.8%, but 11 recurrent cases (8.7%) appeared after the first approach surgeries and 2 cases (1.4%) after the second approach surgeries (p = .03). Other variables did not show statistically significant differences. CONCLUSIONS: Surgical removal of the submandibular calculi, ending with shortening of Wharton's duct, reduces the recurrence rate for sialolithiasis but does not affect the rate of postsurgical complications.

The Safety, Tolerability, and Efficacy of DL-Lactic Acid Syrup (Tonsitin) in Children With Recurrent Tonsillitis: A Pilot Study.

To evaluate Tonsitin (10% DL-lactic acid) safety, tolerability, and efficacy, as a treatment for recurrent tonsillitis (RT) in children. This is a clinical prospective, randomized, double blind pilot study, to evaluate the safety, tolerability and efficacy of Tonsitin in healthy children with RT. Safety evaluated in terms of adverse events (AEs), tolerability in terms of compliance, and efficacy in terms of tonsils' size and frequency of tonsillitis, and quality of life. The study included 51 children. The treatment regimen was tolerable among the participants. Six children experienced AEs, but mostly mild. Tonsil size declined in both groups, but these results did not reach statistical significance. Tonsillitis episodes' frequencies were random and not significant. Tonsitin treatment was found to be feasible in the clinical setup and was well tolerated, and appears to be safe. Study efficacy results did not reach statistical significance.

An individual approach to intraoperative parathyroid hormone measurement during total thyroidectomy.

PURPOSE: Hypocalcemia is a common complication of thyroidectomy. Measurement of the intraoperative serum parathyroid hormone (PTH) levels became an established technique but it requires further improvements. We aimed to assess intraoperative PTH level testing results against the hypothesis that the PTH assay may be performed almost immediately after thyroid gland removal. METHODS: A retrospective cohort study. During total thyroidectomy surgery, the patients had PTH levels measured at the cutting time and again immediately after the thyroid gland is removed. Post-operatively, serial total blood calcium levels were obtained twice daily and recorded. RESULTS: Among 63 enrolled patients, 39 had multinodular goiter, 15 thyroid carcinoma, and nine had Graves' disease. The mean age was 59.8 ± 15.3 years, 43 females. The mean PTH level before surgery was 45.8 ± 22.0 pg/mL. Post-operatively, 11/63 patients developed hypocalcemia with serum calcium levels <8 mg/dL. Four patients with ≥50 % decrease in PTH concentration were normocalcemic a day after surgery and were discharged early. Four patients with ≥70 % PTH decrease were treated accordingly during prolonged hospitalization and did not suffer from permanent hypocalcemia. The cut-off value of 70 % decrease after the gland removal was able to predict postoperative hypocalcemia with a sensitivity of 100 %, specificity 82.9 %, PPV 60.0 % and NPV 100 %. CONCLUSION: Measurements of intraoperative PTH may not be performed at fixed time intervals but after 1-2 min after removal of the thyroid gland. Defining those not at risk would allow the majority of patients to be waived from post-operative blood calcium testing and safely discharged early after surgery.

The impact of eustachian tube function on intra-tympanic steroid administration.

OBJECTIVES: This study investigated the impact of eustachian tube (ET) function (ETF) on therapeutic success on candidates for intra-tympanic administration of steroids (ITAoS), due to idiopathic sudden sensorineural hearing loss (ISSNHL). METHODS: Medical chart review in two university-affiliated medical centers was performed. Included were consecutive adult patients diagnosed with unilateral ISSNHL between 2012 and 2019 who were treated with ITAoS due to incomplete or no recovery following systemic steroidal therapy. ETF was assessed by means tympanometry, before the initiation of ITAoS. The cohort was divided into an ET dysfunction group (ETD(+)) and a functioning ET group (control: ETD(-)). The audiologic response to treatment was recorded at the last follow-up. RESULTS: A total of 64 suitable patients [median (interquartile, IQR) age 49 (38-63) years] were enrolled. The ETD(+) group included 20 patients and the remaining 44 patients served as controls. Demographic and clinical parameters were not significantly different between the two groups at presentation. Hearing thresholds were improved significantly better, at frequencies 250, 500, 1, 2, 4, and 8 kHz (p = 0.001-0.040) in the ETD(+) group. CONCLUSION: ETD(+) is associated with better efficacy of ITAoS.

The association between Helicobacter pylori and chronic otitis media with effusion.

PURPOSE: Chronic otitis media with effusion (COME) is a common condition in children and a leading cause for hearing loss and ventilation tubes (VT) insertion. Among other risk factors, it is suggested that Helicobacter pylori (H. pylori) infection may have a role in the pathogenesis of COME. Previous studies have reached different results, and therefore, there is a need for further data on the relationship between H. pylori infection and COME development in children. Our objective is to investigate the presence of H. pylori in the middle-ear fluid (MEF) from children with COME. METHODS: A Comparative cross-sectional study. Children ≤ 18 years were included. The study group included children diagnosed with COME and required VT insertion. The control group included children with acute otitis media (AOM) who required myringotomy in the emergency room. Middle-ear fluid samples were sent for both culture and bacterial identification using polymerase chain reaction (PCR) testing. RESULTS: A total of 43 children were included. Eighteen with COME (median age 4 years, IQR 3-6), and 25 with AOM (median age 1 year, IQR 1-2). All samples were cultured for H. pylori. Twenty-two samples underwent H. pylori PCR testing of them, 12 samples from children with COME, and 10 from children with AOM. All cultures and PCR tests results were negative for H. pylori. CONCLUSIONS: Our results suggest that H. pylori does not have a role in the pathogenesis of COME. Future larger studies are needed to investigate whether H. pylori has a role in the pathogenesis of COME.

Caustic Ingestion in Children: The Otolaryngologist Perspective.

OBJECTIVES: Caustic ingestion in children is a significant cause of morbidity despite preventive measures. Upon arrival to the emergency department, these children are often initially seen by the otolaryngologist and later on by the gastroenterologist. This study aimed to determine which otolaryngological and gastrointestinal signs and symptoms can better predict abnormal findings on imaging, esophagogastroduodenoscopy (EGD), and complications development. METHODS: We performed a retrospective chart review of children 18 years or younger admitted because of caustic ingestion between January 2007 and November 2019. RESULTS: Forty-one children with a median age of 4.2 years (interquartile range, 1.7-16.7 years) were included; of them, 22 (53.6%) were males. Nineteen children (46.3%) underwent EGD, which revealed no pathology in 13 cases (68.4%). Most ingested substances were in the form of liquid (82.9%), accidentally ingested (82.9%), and with an alkaline pH (57.5%). Stridor, dyspnea, drooling, abnormal oral cavity findings, dysphagia, and vomiting were significantly associated with pathological findings on imaging and/or EGD and/or complications development ( P = 0.028, P = 0.028, P = 0.022, P = 0.02, P < 0.001, and P = 0.01 respectively). Laryngopharyngeal group of findings (dyspnea, stridor, hoarseness, sore throat, and/or drooling) predicted a higher risk for complications development than the gastrointestinal group (dysphagia, abdominal pain, vomiting, or abdominal swelling and/or tenderness) ( P = 0.011, P = 0.31 respectively). CONCLUSIONS: In children, after caustics ingestion, laryngopharyngeal signs and symptoms may predict a higher risk for complications development in comparison with gastrointestinal signs and symptoms. We therefore stress the importance of otolaryngological examination upon arrival to the emergency department.

Extended High Frequency Audiometry for Revealing Sudden Sensory Neural Hearing Loss in Acute Tinnitus Patients.

Introduction The measurement of extended high-frequency (EHF) audiometry has become more popular recently, mainly in connection with ototoxicity and noiseinduced hearing loss. New-onset tinnitus evaluation includes a standard hearing test that shows no pathology. Objective The aim of the present study was to evaluate the possibility that acute tinnitus is essentially connected to sudden sensory neural hearing loss (SSNHL), by utilizing EHF audiometry in cases in which standard audiometry for frequencies between 250 Hz to 8 kHz is within normal limits. Methods A retrospective study was conducted between January 2009 and May 2014 that included all patients presenting with acute tinnitus and normal standard audiometry. All patients underwent EHF audiometry and were treated accordingly. Results Thirty-two patients with acute tinnitus and asymmetric sensorineural hearing loss on EHF audiometry were identified. The average deltas between the ears were between 9.2 and 33dB (worse in the affected ear). Conclusion Extended high-frequency audiometry up to 20,000 Hz should be performed in all patients with acute tinnitus and standard audiometry within normal limits.

Clinical parameters predicting tonsillar malignancy.

PURPOSE: Tonsillectomy is indicated in unilateral tonsillar enlargement (UTE) to rule out malignancy, which eventually is found in about 1.4% of the patients. The aim of this study was to evaluate the presenting symptoms of patients who underwent tonsillectomy for UTE and identify parameters that are associated with an increased risk for malignancy, for better assessment and refinement of current management protocols. METHODS: A retrospective chart review of adult patients with UTE who underwent tonsillectomy between 1/1/2006 and 31/12/2016 was conducted. RESULTS: Forty-one patients with a median age of 53 years were included. There were 20 (49%) females and 21 (51%) males. Sixteen (39%) patients were diagnosed as having tonsillar malignancy. Patients with malignancy were older than those in the benign group (p = 0.001), had a previous malignancy (p = 0.006), and were less likely to present as an incidental finding (p < 0.001). Lymphadenopathy, throat pain, suspicious appearance of tonsillar mucosa, and hard consistency were also found to be statistically significant findings in the malignancy group (p = 0.017, p = 0.001, p = 0.01 and p = 0.018, respectively). Multivariable regression showed age, appearance and adjacent tissue involvement to be independently with malignancy. CONCLUSIONS: UTE alone, as an incidental finding, should not be regarded as an indication for tonsillectomy, as the risk for malignancy is low and the morbidity is significant. We suggest integrating the above-mentioned clinical parameters in the decision-making process, which were found to be significantly more frequent in the malignant group.

The yield of respiratory viruses detection testing is age-dependent in children with acute otitis media.

BACKGROUND: Studies of nasopharyngeal secretions serve as reliable surrogate to evaluate the involvement of viruses in acute otitis media (AOM) and upper/lower respiratory tract infections (URIs/LRIs). We explored nasopharyngeal viral studies from children with uncomplicated AOM and examined their cost-effectiveness in relation to their age. METHODS: We identified children aged 0-6 years admitted to our pediatrics department in a university-affiliated, secondary hospital with uncomplicated AOM and concurrent URI/LRI between 2012 and 2017, during October-April, when viral studies are performed. Studies were performed either using antigen detection tests, for respiratory syncytial virus (RSV) and influenza A/B (2012-2016) and for a variety of other common respiratory viruses, utilizing multiplex polymerase chain reaction assays (2017). RESULTS: A total of 249 children were included (median age: 15 months). In 88 (35%) children, viral studies were positive, most of them in children ⩽24 months (78, 89%). RSV was positive in 52 (59%) children, followed by influenza A and B, in 11 (13%) and 5 (6%) children, respectively. First year switch to a molecular assay, 4.5-fold more expensive, resulted in a statistically significant higher yield: 69% positive results in ⩽24 months, and 66% in those aged ⩽12 months (p < 0.05). In those ⩽24 months, US$23 and US$95 were spent for one positive test in the antigen detection years and the polymerase chain reaction year, respectively, whereas in those >24 months, US$83 and US$878 were invested for one positive test in the same year, respectively. CONCLUSION: In cost-effectiveness terms, the greatest benefit of nasopharyngeal studies was highest in children ⩽24 months.

High Dose of Intratympanic Steroids for Sudden Sensorineural Hearing Loss Salvage.

OBJECTIVE: Intratympanic (IT) steroid administration for sudden sensorineural hearing loss is offered as salvage to patients who failed systemic steroid treatment. Our objective was to study the audiometric and clinical outcomes of patients given salvage therapy with high-dose IT steroids instilled via ventilation tube. STUDY DESIGN: Retrospective case review. SETTING: Academic secondary medical center. PATIENTS: One hundred three patients >18 years of age with sudden sensorineural hearing loss who failed systemic steroids and received IT treatment between 2010 and 2018. INTERVENTION: Following ventilation tube insertion, 1 ml of 10 mg/ml dexamethasone was instilled, twice daily, for 7 days. OUTCOME MEASURES: Hearing assessment immediately before and after treatment. Tinnitus and vertigo complaints and risk factors were also retrieved. RESULTS: Tinnitus had improved in 53 (52%) patients, vertigo in 4 (4%), and aural fullness sensation in 56 (55%) (p < 0.001, p = 0.344, p < 0.001, respectively). The mean pure-tone threshold difference across frequencies following treatment was between 0 and 6 dB. A significant improvement was observed at 250, 500, 1000 Hz (p < 0.001 in all), and at 2000 Hz (p = 0.035). No significant difference was found at 4000 and 8000 Hz (p = 0.055, p = 0.983 respectively). Mean pure-tone average improvement of 4.5 dB was detected in 61 (59%) patients (p = 0.001). The mean speech discrimination score improved by 7% (p = 0.001). Four (22%) diabetic and nine (20%) hypertensive patients had pure-tone average ≥10 dB improvement (p = 0.759, p = 0.852 respectively). CONCLUSION: Although more than half of the patients improved clinically, the significance of the slight audiometric improvement should be weighed against the treatment protocol's complications.

Orbital complications secondary to acute rhinosinusitis in toddlers: A unique age group.

OBJECTIVES: To present the clinical course and management of pediatric orbital complications (OC) secondary to acute rhinosinusitis (ARS), focusing on subperiosteal orbital abscess (SPOA) in toddlers (<2 years). A secondary aim was to identify and evaluate unique variables in toddlers which distinguish them from the older age group. METHODS: A retrospective cohort study of all children with OC secondary to ARS admitted to a secondary medical center between 2005 and 2014 was conducted. Variables analyzed included age, gender, symptoms duration, previous antibiotic therapy, highest recorded temperature, physical and ophthalmologist's examination results, laboratory results and imaging findings. RESULTS: Of the 123 children with OC, 52 (42%) were toddlers. Of them, 30(58%) were boys, with a mean age of 1.4 years. Toddlers presented with higher fever measurements and leukocyte/lymphocyte counts than older children. 69% had Chandler's 1 stage vs 45% in older children (p = 0.015). Ophthalmoplegia was less common in toddlers, who were also less likely to develop late ophthalmoplegia, an important indicator for good treatment response. Eighteen (35%) toddlers underwent computerized tomography (CT) scans, compared to 50 (70%) in the older aged group. Of them, 16/18 (89%) had SPOA. Five (10%) toddlers underwent drainage (31% of Chandler's 3 in this age group) compared to 19 (27%) older patients who underwent surgical treatment (53% of Chandler's 3 in this age group). CONCLUSION: Toddlers with OC have a milder disease and better outcomes, measured in lower rates of delayed ophthalmoplegia, number of CT scans and SPOA rates, and with fewer surgical interventions.

Low-radiation of technetium-99m-sestamibi and single-photon emission computed tomography/computed tomography to diagnose parathyroid lesions.

We compared preoperative regular activity and low-activity radiology-based predictions with real surgical and pathological findings for parathyroidectomy surgery. The study retrospectively analyzed 54 consecutive cases (2009-2016) for benign tumor removal. Technetium-99m (Tc-99m)-sestamibi was used as a diagnostic radiopharmaceutical for diagnostic dual-phase parathyroid scintigraphy and single-photon emission computed tomography/computed tomography. We assessed images obtained with the radiation activity of 925 megabecquerel (MBq) and images obtained with the activity of 185 MBq. The study compared preoperative evaluation of tumor presence, multiplicity, location, and the type of pathology with actual data that were revealed during the operation and pathological investigation. The agreement between preoperative radiological prediction and actual location, number, and type of the parathyroid lesions was achieved in 98.4% (n = 61/62 lesions). The agreement between 925 MBq-based and 185-MBq based investigations was 100%. The agreement between radiological and pathological findings was 100% for both investigations. Our data suggest that the radioactivity of 185 MBq applied in the evaluation of the parathyroid glands provides results similar to the currently used 925-1110 MBq if used for diagnostic dual-phase parathyroid scintigraphy with Tc-99m-sestamibi. Such radioactivity may reduce the exposure to radiation of the patients and the staff without compromising results of the investigation.

Mandibular width as a novel anthropometric measure for assessing obstructive sleep apnea risk.

Craniofacial abnormalities are a known obstructive sleep apnea (OSA) risk factor, but still need to be better characterized. This study investigates the relationship between mandibular width and the risk of developing OSA.We retrospectively analyzed 3D reconstructions of head and neck computed tomography (CT) scans at our institution for mandibular width, neck circumference, neck fat volume (NFV), airway volume (AWV), and NFV:AWV ratio. Age, gender, and BMI were also documented. Patients were contacted to complete a STOP-BANG survey to assess OSA risk. Only patients with reconstructable scans and completed STOP-BANG questionnaires were included in the study. Survey results were analyzed to assess the correlation between mandible width and STOP-BANG. Mandible association was also compared to the associations of the other known risk factors.The final analysis included 427 patients with a mean age of 58.98 years (standard deviation = 16.77), 56% of whom were male. Mandibular width was found to positively correlate with STOP-BANG score (r = .416, P < .001). Statistically significant differences between mandible size for each risk group was seen (P < .001). After controlling for age and sex, mandible size was significantly different only for the low risk vs. high risk groups (odds ratio = 1.11; 95% confidence interval = 1.03-1.20; P = .007). Furthermore, when stratified according to mandible size, the small mandible group (<77.50 mm) predominantly consisted of low risk patients; the medium size mandible group (77.50-84.40 mm) was predominated by intermediate risk patients, and large mandible (>84.40 mm) was predominantly seen in high risk patients. Mandible width expressed a stronger association than NFV:AWV ratio, but neck circumference and NFV had stronger associations than did mandible width.In addition to previously documented OSA risk factors, mandibular width is positively correlated with OSA as an independent risk factor. Observation of a wide mandible (jaw) should raise awareness of OSA risk and increase screening methods when appropriate.

The significance of tissue biopsy for fungi in necrotizing otitis externa.

INTRODUCTION: The conventional treatment for necrotizing otitis externa (NOE) is prolonged anti-pseudomonas therapy, with surgical treatment in non-responsive patients. The aim of the present study is to describe the course of management of patients with non-responsive NOE undergoing hyperbaric oxygen therapy (HBOT), and to investigate the importance of tissue biopsy for fungi in this group of patients. MATERIALS AND METHODS: A retrospective study conducted between January 2010 and December 2013 at an Otolaryngology Head and Neck Surgery Department. Included were all 52 patients with NOE referred to our Medical Centre for further treatment including HBOT. RESULTS: Fifty-two consecutive patients, 29 men and 23 women, with a mean age of 70.6 years, were included in our study. Twenty seven (51.9%) underwent surgical debridement. No significant difference was found between the group having surgical intervention, and those who did not, with regard to sex, age, comorbidities, cranial nerve involvement or laboratory results. However, those who had surgical intervention had a statistically significant higher rate of fungal infection (P = 0.049). After completing 7 weeks of HBOT, a significantly lower WBC count was observed in the fungus-infected group (7000 vs 7.800, P = 0.03), and a tendency towards lower CRP levels in the fungus-infected group (16 vs 58, P = 0.087). CONCLUSION: Patients with NOE should have a comprehensive surgical intervention when delayed healing is observed, because proper fungal culturing might change the course of treatment and improve prognosis. LEVEL OF EVIDENCE: 4.

Evaluation and management of thyroid incidentalomas detected prior to the parathyroid surgery.

BACKGROUND: We investigated the management of thyroid incidentalomas associated with cases of parathyroid lesions in order to suggest a practical approach to their management from a surgical point of view. METHODS: 639 patients underwent radiological and ultrasound investigation of the thyroid area because of parathyroid disorders and parathyroidectomy and had at least three years of follow-up. All follow-up data for these cases were investigated from the moment the lesion was detected and up to the last report. RESULTS: Out of 639 cases, incidental or asymptomatic thyroid nodules were found in 179 patients (28%), of which, 22 patients were operated (parathyroidectomy + thyroidectomy) and 157 remained with the nodules. For these patients, the average period of follow-up was 7 years 5 mo. Following the results of the follow-up, 52 patients (33%) were suggested to have surgery of the thyroid gland and 49 were operated (16 total thyroidectomies and 33 hemithyroidectomies). The complications after the second surgery included recurrent laryngeal nerve palsy (n = 3), superior laryngeal nerve palsy (n = 1), permanent hypocalcaemia (n = 8), and surgical damage to the internal jugular vein (n = 1). All complications occurred at the previously operated side of the neck. CONCLUSION: While surgery remains the management of choice for malignant thyroid incidentalomas, for benign cases, if an asymptomatic thyroid nodule was detected inside the thyroid lobe on the side of planned parathyroidectomy and if the size of the nodule is ˃1.5 cm we suggest combined parathyroidectomy + hemithyroidectomy.

Low Concentration Intra-Tympanic Gentamicin Treatment for Menière's Disease: A Long-Term Follow Up.

BACKGROUND: Intra-tympanic injections of gentamicin (ITG), a known ototoxic agent, have been proven to be effective in controlling Menière's disease (MD) symptoms, in patients who did not respond to conservative therapy, although its safety was questionable. OBJECTIVES: To study whether low-concentration ITG, in refractory MD, had an effect on the ipsilateral hearing, in comparison to the contralateral ear, and to study the effectiveness of such treatment. METHODS: A comparative, retrospective cohort study was conducted between 2003 and 2015, and compared the change in the hearing level between the injected ear and the contralateral, untreated ear. OUTCOMES: In 20 of 27 patients (74.1%), one course of ITG treatment was considered as successful. In the short-term, there was improvement of hearing level at 1000 Hz (p = 0.014), and deterioration of hearing level at 8000 Hz (p = 0.039), both in comparison to the control ear. In the long-term and after confounders adjustment, we found there were no differences in the hearing levels between the treated ear and the untreated contralateral ear. CONCLUSIONS: A high success rates of treating vertigo attacks with low concentration ITG in refractory unilateral MD patients is herein reported, while a significant difference was not observed in the hearing threshold compared with the healthy contralateral ear.

Post-turbinectomy nasal packing with Merocel versus glove finger Merocel: A prospective, randomized, controlled trial.

Nasal packs are widely used after septoplasty and turbinectomy. We conducted a prospective, randomized, controlled clinical trial including 100 patients who underwent septoplasty with/or without turbinectomy randomized into two groups. In the first group (the Merocel group), a standard tampon was inserted at the end of surgery. In the second group (the glove finger group), the tampon was first placed inside a glove finger. The main outcomes measured were pain and bleeding during the postoperative period and during tampon removal. Consumption of pain killers and tranexamic acid were also recorded. The mean visual analog scale score 12 hours after surgery and during tampon removal in the Merocel group were 6.78 and 8.92, respectively, compared to 4.06 and 5.27, respectively, in the glove finger group (p < 0.001). A statistically significant difference in the bleeding rate and tranexamic acid consumption during tampon removal in favor of the Merocel group was shown (p < 0.001). The use of Merocel in a glove finger is significantly less painful, although a higher chance of bleeding is reported. The influence of the surgeon's experience in using this technique needs further investigation.

Indicators for imaging in periorbital cellulitis secondary to rhinosinusitis.

PURPOSE: Our objective was to identify the clinical indicators for subperiosteal orbital abscess (SPOA) among patients who present with periorbital cellulitis secondary to rhinosinusitis, and to evaluate the need for performing a computerized tomography (CT) scan. METHODS: A retrospective cohort study of all patients admitted to our tertiary care emergency department between 2006 and 2014 was conducted. Included were healthy patients with acute periorbital cellulitis secondary to rhinosinusitis. Variables analyzed included age, gender, duration of symptoms, previous antibiotic therapy, highest recorded temperature, physical examination findings, ophthalmologist's examination results, laboratory results, and interpretation of imaging studies, when performed. RESULTS: Of the 123 identified patients, 78 (63%) were males, with a mean age of 4 years (range 1-70). 68 patients were categorized as Chandler's 1 disease, 2 as Chandler's 2, and 53 as Chandler's 3. 68 patients underwent a CT scan, of those 53 had SPOA. Proptosis and ophthalmoplegia were strongly associated with the presence of an abscess (P < 0.001). However, 14 patients with no ophthalmoplegia or proptosis who underwent a CT scan were older (mean age, 10 years; P < 0.028), and had higher neutrophil count of 78 versus 59% (P = 0.01). This group of patients had a clinically rapidly progressive disease, receiving wider broad-spectrum antibiotics or had their antibiotic treatment replaced to broader spectrum antibiotics through their course of treatment (48.2% compared to only 6.1%). CONCLUSIONS: We confirmed that patients with proptosis and/or limitation of extraocular movements are at high risk for developing SPOA, yet many do not have these predictors. Other features can identify patients who do not have proptosis and/or limitation of extraocular movements but do have significant risk of SPOA, and in these cases performing an imaging study is strongly suggested.

Conservative Management for Subperiosteal Orbital Abscess in Adults: A 20-Year Experience.

OBJECTIVE: Orbital complications (OC) secondary to acute rhinosinusitis (ARS) in adults are less common than in children, with assumed worse outcome. MATERIALS AND METHODS: Adults with OC secondary to ARS between 1994 and 2014 were reviewed retrospectively. Parameters recorded included age, gender, clinical symptoms and signs, computed tomography (CT) scan findings, duration of hospitalization, treatment before and during admission, cultures, and outcome. RESULTS: Thirty-seven adults with a mean age of 34.6 years, 27 males and 10 females, were diagnosed with OC, 19 (51.3%) with subperiosteal orbital abscess (SPOA), and none with orbital abscess/cellulitis or cavernous sinus thrombosis. Twelve patients with SPOA were managed conservatively with Amoxicillin-Clavulanate in most cases, and only 7 (36.8%) underwent surgery. A CT scan was performed in 27 cases revealing rhinosinusitis in all patients, including frontal involvement in 19 (51.3%) patients and sphenoid sinus in 16 (43.2%). CONCLUSIONS: A shift toward conservative treatment in cases of SPOA has long been integrated in the management protocols, mainly in children under 9 years old. The presumed worse prognosis in adults is not supported in our study, and a conservative treatment is urged to be considered in this group of patients albeit the more extensive radiologic involvement of their sinuses.