Role of surgery along with antimicrobials in refractory skull base osteomyelitis-A prospective observational study.

INTRODUCTION: Study aimed to ole of surgery along with antimicrobials to improve clinical outcomes in treating refractory cases of skull base osteomyelitis (SBO). METHODS: A prospective observational study in a tertiary care centre with 70 SBO patients meeting eligibility criteria. The study population comprised 35 patients refractory to systemic antimicrobials of at least 4 weeks duration who later underwent surgery in addition to medication (surgical group). They were compared with a medical group that responded to medications alone. The outcome variables studied were the resolution of clinical features (pain, discharge, radiology, and inflammatory markers), culture yield, and total duration of treatment. RESULTS: According to our study, relief of pain was faster in the surgical group (1.66 against 4.57 months) with statistical significance (p < 0.001). Relief of symptoms (p < 0.001), radiological improvement (p = 0.001), and normalising of inflammatory markers (p < 0.001) were better in the surgical group than in the medical group. The duration of treatment was an average of 9.2 months in the surgical group compared to 11.3 months in the medical group (p = 0.019). Microbial culture from deep tissue sampling was positive in 24 surgical patients (68.57%). CONCLUSIONS: The treatment response in selected patients of refractory SBO who underwent surgery along with antimicrobials was better than the group who responded to antimicrobials alone. Surgery provided higher microbial yield resulting in culture-specific antimicrobials. The surgical group observed faster relief of symptoms, reduced hospital stay, and total treatment duration.

Exploring the utility of fibreoptic endoscopic evaluation of swallowing in young children- A comparison with videofluoroscopy.

OBJECTIVES/HYPOTHESIS: In adults, fibreoptic endoscopic evaluation of swallowing (FEES) has established its place in the assessment of dysphagia and aspiration vis-à-vis the current gold standard, videofluoroscopic swallow study (VFSS), almost at parity. However, in children with quite a different set of factors in play, its role is not certain. The primary objective was to measure the accuracy of FEES in young children with dysphagia, compared to VFSS. The secondary objective was to correlate other endoscopic findings with aspiration in videofluoroscopy. STUDY DESIGN: Prospective, observational. METHODOLOGY: Sixty-five children, aged 0.4-36 months with suspected oropharyngeal dysphagia and aspiration underwent FEES and VFSS. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and diagnostic agreement of FEES were calculated using VFSS as the gold standard. To test the statistical significance of the difference in two measurements, Mc Nemar's Chi-square test was used and to test the agreement between FEES and VFSS, Kappa value was calculated. To test the statistical significance of the association of endoscopic findings with VFSS findings, Chi-square test was used. RESULTS: FEES performed in young children was found to be less sensitive (50%) but more specific of aspiration (82%) with an accuracy of 77% in comparison with VFSS. The reverse was true of penetration (81%, 44% and 59% respectively). The agreement between FEES and VFSS in young children, on all parameters were low (k = 0.061-0.302). Endoscopic findings such as glottic secretions (P = 0.02), weak or diminished laryngeal adductor reflex (LAR) (P = 0.001) and penetration (P = 0.01) were significantly associated with aspiration in VFSS. Excessive secretions in the hypopharynx had a stronger correlation with oesophageal dysmotility (P = 0.02) than pharyngeal dysphagia (P = 0.05). CONCLUSION: FEES in young children appears to have a low agreement with VFSS unlike in adults. Aspiration observed in FEES is likely to be significant since specificity is high. FEES negative for aspiration may be interpreted taking into account, the aspiration risk of the subject and/or other endoscopic risk factors (penetration, weak/absent LAR & glottic secretions), if VFSS is not a viable alternative.

Observations from a pediatric dysphagia clinic: Characteristics of children at risk of aspiration pneumonia.

OBJECTIVES: The clinical variables that are predictive of aspiration pneumonia are not clear in the pediatric population. This study was conducted in order to identify the demographic, clinical, and radiological risk factors for the development of aspiration pneumonia in children referred to the dysphagia clinic. METHODS: A retrospective analysis of medical records of 88 children referred to the dysphagia clinic who had undergone videofluroscopic swallow study (VFSS). RESULTS: Oropharyngeal dysphagia was found in 61.3% (54 of 88). Incidence of aspiration pneumonia was 39.8% (35 of 88). CONCLUSION: Respiratory symptoms such as cough, choking, excessive secretions, and pharyngeal dysmotility other than aspiration in VFSS were not predictors of pneumonia. Infants and children with laryngotracheal anomalies, demonstrable aspiration in VFSS, and major cardiac illness are at risk of presenting with aspiration pneumonia. Whether gastroesophageal reflux disease (GERD) or esophageal dysmotility are causative of aspiration in the rest of the population needs to be investigated by future prospective studies. LEVEL OF EVIDENCE: 3b. Laryngoscope, 129:2614-2618, 2019.